PATIENT CARE POLICY III.

Transcription

1 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 policy is to provide and describe a uniform mechanism for managing all patient complaints/grievances regarding care and services received at Northwestern Memorial Hospital (NMH). Depending on the nature and severity of the complaint/grievance different processes may be required for review and resolution. II. III. IV. POLICY: The hospital provides the opportunity for all patients to express their concerns about the quality of care or service they have received through a complaint/grievance mechanism. The hospital has established a process for the prompt review and resolution of patient complaints and grievances and has identified who is to be contacted to file a complaint/grievance, and discloses the name of the State agency to which the patient may take their grievance. At NMH, the Patient Representative department (PRD) has been designated to address and coordinate investigation of patient complaints and grievances. PERSONS AFFECTED: This policy applies to all employees, physicians and others involved in caring for or interacting with patients and/or their families. DEFINITIONS: A patient complaint is a minor, time-limited, immediate issue which can be addressed without extensive investigation. Examples include, but are not limited to: lost property, incorrect or late meal, lengthy wait time, perceived rude behavior, lack of communication with house staff or attending physician, billing error, etc. A complaint is further defined as a patient concern that is resolved within 24 hours of notification of patient issue, or post-hospital verbal communication which could have been handled the same day if staff had been made aware of the complaint at the time of the incident. A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, when a patient issue cannot be resolved promptly by the staff present. Grievances also include concerns raised regarding the patient s care, abuse or neglect or concerns raised regarding the hospital s compliance with the CMS Hospital Conditions of Participation (CoP) which cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further actions for resolution. Staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patient s location, such as nursing, administration, nursing supervisors, physicians, and patient advocates, to resolve patient s concern. V. PROCEDURE/RESPONSIBILITIES: See Appendix I Summary of Procedures If a patient expresses a complaint, if at all possible, it should be resolved by the staff present. If the complaint requires additional investigation, the Patient Representative Department (PRD) is responsible for managing the process.

2 COMPLAINT AND GRIEVANCE MANAGEMENT 2 of Any NM staff member who becomes aware of a patient complaint or grievance which cannot be resolved locally should communicate with the local manager and, as appropriate, escalate to the Patient Representative Department for investigation and resolution. A. HOSPITAL-RELATED COMPLAINTS 1. NMH Patient Representatives Department The PRD manager or designee will review and manage or refer patient complaints or grievances if the incident occurred in the hospital or involved hospital services. PRD will manage patient complaints and grievances involving the hospital which are not directly related to a practitioner s clinical practice or judgment, allegations of harm or injury, or physician behavior, conduct, or impairment. As relevant, PRD will share information about the complaint or grievance with a practitioner and his/her practice employer (if applicable), Chief of Staff, Office of the President, Senior Vice President of Medical Affairs, Senior Management, and any other individuals or departments, as necessary, to complete the review and to determine if further investigation, disposition, or action is warranted. The manager or designee will be the contact person with the complainant during the review process except as otherwise noted below. PRD will involve and request support from Risk Management, Clinical Quality, Billing Inquiry Unit, Privacy Officer, and other support departments as needed. PRD will refer complaints to other areas for ongoing management and accountability as follows: Billing issues to Billing Inquiry Unit Physician behavior, conduct, impairment, clinical judgment: Medical Staff Office. Requests for compensation and/or threats to engage in legal action: Claims and Litigation. For complaints or grievances occurring while the complainant is an inpatient, the review will be initiated within the next business day of the receipt of notice. For complaints or grievances received from an outpatient, discharged patient, or a patient s representative, an acknowledgement of the complaint or grievance will be provided typically within two business days, by telephone. For all complaints: Communication with the patient or patient s representative regarding complaints will be made via telephone, unless the patient specifically requests a written response. For all grievances: Once the investigation of a grievance is completed, the investigator will provide the patient or their representative with a written notice of any relevant findings, actions taken to conduct the investigation, date of completion, and the name of the contact person for any follow-up. If NM is unable to resolve the grievance within 7 days from receipt, the PRD will contact the patient or the patient s representative by phone to provide an update, and every 2 weeks thereafter, until resolved. A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf. However, there may be situations where the hospital has taken appropriate actions on the patient s behalf in order to resolve the grievance and the patient or patient s representative remains dissatisfied. Per CMS Conditions of Participation, in these situations the hospital may consider the grievance resolved for the purposes of this requirement. The PRD will maintain appropriate documentation.

3 COMPLAINT AND GRIEVANCE MANAGEMENT 3 of Annually, the PRD will provide a report to the Administrative Quality Committee and the Professional Standards Committee of the Board of Directors outlining the volume and nature of the complaints and grievances managed through the PRD during the previous year. 2. NM Clinical Quality Management/Risk Management Department Issues identified as an unusual incident or occurrence reported per NM policy 5.08 and the Northwestern Memorial Quality Management and Performance Improvement Plan: The Risk Management staff will act as a resource for cases where clinical practice, clinical judgment, or allegations of harm or injury have been alleged or identified. Clinical Quality Management will review and refer the complaint/grievance to the appropriate QM Committee according to clinical quality management protocols. All complaints/grievances will be documented and tracked. Final results will be reported to the Chief of Staff and respective clinical department chairs according to clinical quality protocols. Annual reports by practitioner will be forwarded to NMH Medical Staff Office and Northwestern Memorial HealthCare Corporation for inclusion in credentialing files. 3. NM Medical Staff Office All NM medical staff-related patient complaints/grievances are to be forwarded to the NM Medical Staff Office. The Chief of Staff will review all cases that allege aberrant or inappropriate behavior, ethical, immoral or illegal conduct, or issues related to impairment. The Chief of Staff or designee will be the contact person with the complainant during the review process. The complaint/grievance will be managed according to applicable hospital policies and the NM Medical Staff Organizational Documents using the appropriate quality structure. The Chief of Staff or Medical Staff Office Manager will communicate with the practitioner, clinical department chairman, Senior Vice President of Medical Affairs, Office of General Counsel, Senior Management, and/or any other individuals or departments, as necessary, to complete the review and to determine if further investigation, disposition or action is warranted. B. PRACTICE-RELATED COMPLAINTS Affiliated Practitioners The PRD will forward all complaints/grievances to the appropriate Practice designee. The Physician or the Practice designee is responsible for all cases that occur at an NM Affiliated Practitioner s office practice site. Complaints involving behavior, conduct or impairment will also be forwarded to the NM Medical Staff Office (see # A.3). VI. VII. RELEVANT REGULATORY REFERENCES: The Joint Commission (TJC), Comprehensive Accreditation Manual for Hospitals, RI.2.90, RI Center for Medicare and Medicaid Services (CMS): Hospital Conditions of Participation. Patient Rights 42 CFR POLICY UPDATE SCHEDULE: This policy will be reviewed every three (3) years or more frequently as necessary.

4 COMPLAINT AND GRIEVANCE MANAGEMENT 4 of VIII. KEY WORDS AND CROSS REFERENCING: Complaints, grievances, communication, risk management, patient representatives, quality, adverse events. PC: 5.01 PC: 5.07/1.11 PC: 5.08 PC: 5.24 PC: PC: 5.33 PC: 5.90 Patient Rights and Responsibilities Integrated Code of Ethics: Patient Care and General Administration Risk Management Incident and Event Reporting Documentation: Medical Record Patients Rights: Protected Health Information (PHI) Consent of Patients Medical Ethics Consultation

5 COMPLAINT AND GRIEVANCE MANAGEMENT 5 of RESPONSIBLE PARTIES: Erma Clark Manager, Patient Representatives Jennifer Rauworth Director, Patient Services REVIEWERS: Office of the General Counsel Claims and Litigation Chief of Staff COMMITTEES: Patient Care Committee, May 15, 2008 Medical Executive Committee, June 9, 2008 APPROVAL PARTIES: Daniel J. Woods Vice President, Operations Electronically Approved: 6/27/08 Dean M. Harrison President and CEO Northwestern Memorial Hospital Electronically Approved 7/1/08

6 COMPLAINT AND GRIEVANCE MANAGEMENT 6 of APPENDIX I PROCESS TO LODGE COMPLAINT The following delineates the approach patients may take in lodging a grievance or complaint to Northwestern Memorial Hospital. The Patient Representative Department (PRD) has been designated as the responsible party to solicit and receive patient complaints/grievances: It is staffed during normal business hours Monday-Friday. A complaint or grievance can be lodged verbally or in written form. The PRD is located in the Feinberg Pavilion at , via the NM web site, or in writing at the following address: Patient Representative Department Northwestern Memorial Hospital 251 E. Huron Street, Suite Chicago, Illinois For complaints requiring management immediately during evening and weekend hours, the Hospital Operations Administrator (HOA) will take responsibility for managing the complaint or grievance until it can be referred to the PRD the next business day. PROCEDURE FOR RESOLUTION OR ESCALATION Summary of Processes Managers and Staff: Recognize PRD as the resource for escalation of patient complaints/grievances regarding NM care and service, which cannot be resolved locally. Refer the complainant to PRD, or contact PRD directly for assistance. Patient Representative Department NM Medical Staff Hospital Related NMH Billing Related Practice Related Acknowledge Complaint Evaluate/Investigate Involvement of Risk/CQM Evaluate/Investigate Level of case Involvement of Risk/CQM Refer to Billing Inquiry Unit if issue is limited to billing Evaluate/Investigate/ Resolve locally Alert Risk / Quality As appropriate Alert Risk / Quality As appropriate Alert Director at Manager discretion Provide follow-up to patient when resolved Resolve with patient and manager and other leadership as appropriate Provide follow-up to patient when resolved Patient Representative Department provides updates to patients every 2 weeks until close Patient Representative Department will provide written response to patients when applicable.