Lakeview Hospital Patient/Family Complaints ADM-151 Approval Body: Director of Quality Resources Effective Date:

Size: px

Start display at page:

Download "Lakeview Hospital Patient/Family Complaints ADM-151 Approval Body: Director of Quality Resources Effective Date:"

Homer Atkinson
7 years ago
Views:

1 approval: Policy Statement: The complaint/grievance process underscores Lakeview Hospital s commitment to honoring patient rights. Regardless of the type of concern, patients have the right to voice complaints/grievances and recommend changes in policies and services. This policy and procedure defines the process for patient complaints and grievances, in accordance with state and federal regulations. Objective: To provide a centralized and recognized systematic process for responding to a complaint or grievance filed by a patient or patient s representative in a manner which is fair and equitable, allowing Lakeview Hospital to identify areas and processes needing improvement. Scope: This policy applies to all members of the workforce who have contact with patients and their representatives, (including active employees, students, interns, residents, volunteers and physicians) of any units, departments, clinics or facilities under the management of Lakeview Hospital, as well as patients and their representatives. Page 1 of 6

This policy and procedure defines the process for patient complaints and grievances, in accordance with state and federal regulations.

2 approval: Definitions: 1. Complaint: An allegation or dissatisfaction expressed verbally regarding the patient s care and/or the services provided that could be promptly resolved by informal means. This does NOT include allegations of abuse, neglect or harm. A verbal complaint does not require, but may receive, a written response to the patient. 2. Grievance: a. Any verbal complaint, when not resolved at the time of the complaint by staff present or, is postponed for later resolution, requires investigation and/or requires further action for resolution. b. Any written complaint regarding the care of the patient or the hospital s compliance with the CMS Hospital Conditions of Participation (CoPs). c. Any complaint, verbal or in writing, with an allegation of abuse, neglect or patient harm. d. A verbal complaint made via telephone after the patient has been discharged, regarding the care of the patient or the hospital s compliance with the CoPs. NOTE: Post-hospital verbal communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the hospital stay are not considered a grievance. Page 2 of 6

Any verbal complaint, when not resolved at the time of the complaint by

3 approval: Definitions (continued): e. Any complaint where the patient or their representative has requested that the complaint be treated as a formal complaint or grievance, or has requested a written response from the hospital. f. A grievance requires a written response to the patient or representative within a timely manner. NOTE: Electronic communications sent by a patient or their representative will be considered written for the purposes of this policy. 3. Patient Representative: The patient s representative is someone who, in accordance with state law, may speak for the patient. This would include, but is not limited to: Legal guardian, Medical Durable Power of Attorney for Healthcare, family members (spouse, adult child, parent, adult sibling, and grandparent). The representative may also be someone whom the patient has indicated may speak for them. If the patient is unable to communicate this information, it will be assumed that anyone coming forward with a complaint is acting on behalf of the patient and will be considered a patient representative. 4. Staff present Includes any hospital staff present at the time of the complaint or who can quickly be at the patient s location (i.e. nursing, administration, department managers, nursing supervisors, patient advocates, etc.) to resolve the patient s complaint. Exceptions to Provisions/Procedure /Special Instructions: The following will not be considered grievances, and therefore are excluded from the provisions of this policy: 1. Reports of lost/stolen belongings. 2. Billing issues. 3. Concerns reported by patients or their representatives solely for the purpose of alerting Lakeview Hospital to actual/potential patient safety issues. Page 3 of 6

rmal complaint or grievance, or has requested a written response from the hospital. f. A grievance requires a written response to the patient or representative within a timely manner.

4 approval: Procedure or Special Instructions: 1. Lakeview Hospital encourages patients to express complaints/grievances to facilitate resolution of the complaint, and/or improvement of future service to patients. 2. Lakeview Hospital expects employees to address complaints and grievances at the time of the occurrence in an effort to resolve the issue. Employees will attempt to resolve patient complaints/grievances using available resources. See Service Recovery, ADM-149. If a problem cannot be resolved, the employee will contact the nursing department manager, or, if appropriate, administrative supervisor. 3. The nursing department manager/administrative supervisor will attempt to resolve the complaint/grievance (See Service Recovery, ADM-149): a. If the issue is resolved, and the complainant is satisfied, no written follow-up is necessary. b. If complainant is not satisfied, contact the hospital Patient Representative to try and resolve issue with the patient. c. If the complainant remains dissatisfied provide the patient with a Patient Complaint/Grievance Form (Addendum A). The Complaint/Grievance Form outlines the patient s options for voicing his/her complaint. Review the options with the patient. Encourage the patient to submit his/her complaint to Lakeview Hospital s Patient Representative for investigation and follow-up. Complaints may be submitted to the hospital Patient Representative verbally or in writing. 4. The hospital Patient Representative is responsible for: a. acknowledging the complaint/grievance within 2 working days; b. investigating the complaint/grievance; c. referring quality of care or premature discharge grievances to the appropriate internal review process; d. referring individual grievances regarding violation of patient privacy rights to Lakeview s Chief Privacy Officer; 5. Complaints/grievances not adequately addressed are referred to Lakeview Hospital s Performance Improvement Committee, as appropriate. Page 4 of 6

Lakeview Hospital expects employees to address complaints and grievances at the time of the occurrence in an effort to resolve the issue.

5 approval: 6. Complainants who are dissatisfied with Lakeview Hospital s complaint/grievance response may, at any time, direct complaints regarding medical treatment or patient rights to: Minnesota Board of Medical Practice Office of Ombudsman for Older Minnesotans 2829 University Avenue SE., Suite 500 PO Box Minneapolis, MN St. Paul, MN (612) or (800) or (800) TTY: (800) Fax: TTY: (800) Minnesota Office of Health Facility Office of Quality Monitoring Complaints The Joint Commission PO Box One Renaissance Boulevard St. Paul, MN Oakbrook Terrace, IL (651) or (888) (800) TTY: (651) Fax: (630) complaint@jointcommission.org 7. Complaints regarding privacy may be directed, at any time, to: Department of Health & Human Services Office of Quality Monitoring HHS Privacy Advocate The Joint Commission ASPE Room 434E One Renaissance Boulevard 200 Independence Avenue SW Oakbrook Terrace, IL Washington, DC (800) (202) Fax: (630) complaint@jointcommission.org 8. Complaints and grievances will be collected and trended by the Quality Resources Department. Identified trends will be forwarded to the appropriate department manager for action. A summary of complaint/grievance findings will be presented regularly to Administration and Committees, as appropriate. 9. Lakeview Hospital s governing board has designated Department Managers to: a. communicate patient complaint/grievance rights and procedures to staff and patients. b. address complaints regarding specific employees through hospital performance appraisal and disciplinary action processes, including appropriate sanctions for failure to comply with Page 5 of 6

Medical Practice Office of Ombudsman for Older Minnesotans 2829 University Avenue SE., Suite 500 PO Box 64976 Minneapolis, MN 55414-3246 St.

6 approval: privacy policies and procedures. c. use patient complaints/grievances to identify and implement service improvements through active involvement of staff. 10. Lakeview Hospital s governing board has designated the Quality Resources Department to: a. investigate and respond to complaints/grievances through active involvement of department managers. b. maintain a record of all complaints and responses. c. report analyzed trends to appropriate committees, staff members and departments who can take appropriate performance improvement action. 11. Lakeview Hospital s governing board has designated the Performance Improvement Committee to: a. review individual complaints/grievances referred to the committee at the request of the complainant or the Quality Resources. Department. b. analyze complaint/grievance summaries and trends to initiate quality improvement efforts relative to any deeper, systemic problems identified through the complaint/grievance process. References: None Considerations: 1. Service Recovery ADM149 Addendums: 1. Patient Complaint/Grievance Form 2. Complaint/Grievance Flowchart Page 6 of 6

c. report analyzed trends to appropriate committees, staff members and departments who can take appropriate performance improvement action. 11.

PATIENT CARE POLICY III.

PATIENT CARE POLICY III. PATIENT CARE POLICY Subject: PATIENT CARE ADMINISTRATION Title: COMPLAINT AND GRIEVANCE MANAGEMENT Page: 1 of 6 Revision of: 08/09/06 Policy # 5.42 Effective Date: 07/01/08 I. PURPOSE: The purpose of this