University of Kentucky / UK HealthCare Policy and Procedure. Policy # A01-025

Transcription

1 University of Kentucky / UK HealthCare Policy and Procedure Policy # A Title/Description: Patient Complaints and Grievances Purpose: To establish a process for prompt resolution of patient grievances. Policy Definitions Complaint Staff Present Grievance Grievance Submissions Procedure Provision of Patient Rights & Responsibilities Addressing Patient Complaints Addressing Patient Grievances Resolution of Grievances Role of the Grievance Committee Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates Policy UK HealthCare Patients shall have reasonable expectations of care and services. Patients may voice complaints and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care. In accordance with the Centers for Medicare & Medicaid Services (CMS) Condition of Participation: Patient s Rights, 42 CFR482.13(a)(2), UK HealthCare addresses those expectations, complaints and recommendations in a timely, reasonable, and consistent manner. The University Health Care Committee of the University of Kentucky Board of Trustees, as the governing body of UK HealthCare, including without limitation the University of Kentucky Hospital (Chandler Hospital) and UK HealthCare Good Samaritan Hospital, by written action taken December 12, 2006, established a Grievance Committee and delegated to such committee the responsibility for the effective operation of the grievance process for UK HealthCare, including the review and resolution of patient grievances. The Grievance Committee is comprised of: 1. The Chief Administrative Officer 2. The Chief Medical Officer 3. The Chief Nursing Executive 4. The Director of Strategic Marketing

2 5. The Director of UK HealthCare Risk Management 6. The Chief Revenue Officer (formerly director of Revenue Management) 7. The Enterprise Director of Pharmacy Services, 8. The Physician in Chief of Kentucky Children s Hospital, and 9. An appointee from the Board of Directors of the College of Medicine Faculty practice organization, currently Kentucky Medical Service Foundation, Inc. UK HealthCare Office of Service Excellence, in collaboration with UK HealthCare clinical faculty, staff, and administration, shall operate and maintain the UK HealthCare complaint and grievance process while maintaining a record of complaints and grievances. Data collected regarding patient grievances is incorporated into the UK HealthCare Center for Enterprise Quality and Safety performance improvement plans. Definitions Complaint A complaint is a patient complaint that can be addressed and resolved at the bedside and at the time of the complaint by staff present. Staff Present Staff present includes any UK HealthCare employee and any member of the Medical Staff present at the time of the complaint or who can quickly be at the patient s location (i.e. nursing administration, customer service representative ( CSR ), physicians, etc.) to resolve the patient s complaint. A written response is not required in response to a complaint. Grievance A grievance is a patient complaint that: 1. Cannot be resolved at the time of the complaint by staff present, 2. Is postponed for later resolution, 3. Is referred to other staff for later resolution, 4. Requires investigation, 5. Requires further actions for resolution. and/or 6. Involves allegation of abuses, neglect, or exploitation. Grievance Submissions 1. A written complaint is always considered a grievance. This includes written complaints from an inpatient, an outpatient, or a released/discharged patient regarding the patient care provided, abuse or neglect, or the Hospital s compliance with the CMS Conditions of Participation. 2. An or fax is considered a written complaint and meets the definition of a grievance, as defined above. 3. Oral complaints, including communication following hospital discharge or clinic visit regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are grievances.

3 However, post-hospital oral communications regarding patient care that would routinely have been handled by staff present if the communication had occurred during the stay or visit are not required to be defined as a grievance. 4. If a patient or the patient s representative requests that a complaint be handled as a formal complaint, it is considered a grievance. 5. Any patient grievance shall be handled following the resolution process outlined in this policy. 6. In general, information obtained from patient satisfaction surveys does not meet the definition of a grievance. (a) However, if an identified patient writes or attaches a written complaint on the survey and requests resolution, then the complaint meets the definition of a grievance. (b) If an identified patient writes or attaches a complaint to the survey but has not requested resolution, UK HealthCare may treat this as a grievance if the specific complaint were usually treated as a grievance. 7. Any issue of whether a complaint constitutes a grievance is resolved by the a co-chair of the Grievance Committee in consultation with Office of Service Excellence. Billing complaints are not usually considered a grievance for the purposes of the CMS requirements. However, a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489 is considered a grievance. A complaint or grievance is considered resolved when the patient is satisfied with the actions taken on the patient s behalf. There may be situations where UK HealthCare has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance and the patient or the patient's representative remains unsatisfied with such actions. In these situations, UK HealthCare may consider the grievance closed for the purposes of this policy. Procedure Provision of Patient Rights & Responsibilities Upon admission, the patient shall be given a Your Rights & Responsibilities as a UK Hospital Patient brochure as part of the Authorizations and Agreements that outlines the patient s rights, responsibilities, and a method to express concerns about the care and services the patient receives. Addressing Patient Complaints All UK HealthCare employees and members of the Medical Staff shall actively invite or encourage the patient to share his or her concerns or complaints at the point of service. All such individuals are expected to address concerns in a timely, reasonable and consistent manner as a part of their daily job responsibilities. Complaints involving situations or practices that place the patient in immediate danger shall be resolved immediately and to the extent possible. Complaints or concerns shall be addressed at the point of service by staff present using the following steps: 1. Listen patiently without interrupting. Do not argue or get defensive.

4 2. Offer an appropriate, blameless 1 apology. 3. Ask questions to understand fully the service failure. 4. Discuss options available to address the service failure; utilize the service recovery process when appropriate. 5. If a reasonable option does not satisfy the patient, engage the assistance of the manager of the area, the patient s medical team, or the Hospital service (i.e., Dietary, Environmental Services, etc.) for assistance. 6. Reach a mutually agreeable (patient and staff present) resolution to the complaint. 7. Thank the patient for speaking up and for allowing you to improve our care/service. 8. Follow through with the resolution to the complaint as soon as possible. 9. Reassess the patient to ensure the concern or complaint has been addressed to the patient s satisfaction. Patient complaints resolved at the point of service that are not otherwise considered grievances (abuse, neglect, patient harm, or hospital compliance with CMS requirements) do not require documentation in the Office of Service Excellence complaint database. Addressing Patient Grievances If staff present is unable to resolve the patient s complaint, the complaint becomes a grievance. Staff present shall promptly notify Office of Service Excellence, providing date the complaint was received, the patient name and medical record number, description of the grievance, including any documentation relating to the grievance, the contact person and description of efforts made and options offered to investigate and resolve the complaint. The CSR, under the direction of the Office of Service Excellence manager and/or director of Office of Service Excellence, shall investigate the circumstances giving rise to the grievance. Grievances involving situations or practices that place the patient in immediate danger shall be resolved immediately. The CSR shall communicate with the patient and/or the patient s representative as soon as possible. When a written complaint (grievance) is received by any UK HealthCare employee or member of the Medical Staff, such person shall immediately forward the writing to Office of Service Excellence for investigation. Upon receipt, the CSR will: 1. Contact the complainant by phone or in person if presently a patient, and 2. Within seven days of receipt of the written complaint, send a letter to the complainant acknowledging the complaint and informing the complainant of the steps taken or to be taken to investigate and resolve the grievance. The letter shall include the date when the complainant will be notified of the results of the investigation as well as information on how to contact the CSR by telephone. If the patient has a complaint regarding quality of care, disagrees with a coverage decision or wishes to appeal a premature discharge, the CSR shall also notify the patient in writing that the patient may contact the appropriate (Medicare or other) quality improvement organization to lodge 1 Examples of blameless apologies include: I m sorry your bedding needs to be changed. Casting blame: I m sorry [person s name] didn t change your bed. Blameless: I m sorry you don t like the food. Casting blame: I m sorry Dietary didn t serve you the right food.

5 a complaint. Office of Service Excellence shall notify the organization if requested by the patient to do so. Resolution of Grievances UK HealthCare shall respond to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance. The CSR shall use the following guidelines to resolve grievances that cannot be resolved at the point of service: 1. The CSR shall contact the manager or staff member caring for the patient at the time of the complaint and obtain the following information for the patient complaint database: (a) Date grievance was received; (b) The patient name and medical record number; (c) Description of the grievance, including any written documentation relating to the grievance; (d) Name of the Hospital contact person; and (e) Description of efforts made and options offered to investigate and resolve the complaint. 2. The CSR shall facilitate communication between the principals to resolve the problem. 3. The CSR shall remain in contact with the complainant regarding the status of the grievance via phone and written correspondence. 4. The CSR shall maintain records of activities and correspondence related to complaints and grievances in the patient complaint database. 5. The CSR shall provide written acknowledgment at closure providing additional avenues of recourse. 6. If a grievance involves abuse, neglect, exploitation, or patient safety, Office of Service Excellence shall notify the social worker assigned to the appropriate service and Risk Management. If a grievance involves quality of care issues, Office of Service Excellence shall notify UK HealthCare Risk Management and coordinate communication with the complainant. 7. Any grievance unresolved after seven days is reviewed by the manager of Office of Service Excellence and/or director of Office of Service Excellence. Cases remaining unresolved after seven days are reviewed every 14 days by the manager of Office of Service Excellence and/or director of Office of Service Excellence until the patient is satisfied with the actions taken on their behalf. 8. If it is determined that the situation cannot be satisfactorily resolved at the level of Office of Service Excellence, the manager and/or director of Office of Service Excellence shall refer the matter to the UK HealthCare Chief Medical Officer and the UK HealthCare Chief Nursing Executive to facilitate resolution. Role of the Grievance Committee If the above steps do not result in resolution of the grievance to the satisfaction of the complainant, the UK HealthCare Grievance Committee shall be convened within 10 working days to review and resolve. The committee shall hear the results of the investigation, render an

6 opinion or decision, and shall notify the complainant within 30 days following receipt of the grievance. Resolution of grievances shall not exceed 90 days. Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children s Ambulatory Department Policies Replaced Chandler HP01-35 Good Samaritan 050 Kentucky Children s CH Ambulatory KC Other Effective Date: 12/2008 Review/Revision Dates: 05/20/2013 Approval by and date: Name Angie Lang, Review Team Leader Name Jonathan Curtright, Chief Operating Officer, Ambulatory Services Name Anna L. Smith, Chief Administrative Officer Name Michael Karpf, Executive Vice President for Health Affairs Date Date Date Date