Executive Summary

Emphasis on patient-centered care has increased, as have calls for transparency of patient satisfaction data. These trends in healthcare make seeking and responding to patient feedback increasingly important components of risk management and patient safety programs. Patients have the right to file complaints and grievances with the organization when they are unsatisfied with the treatment received, and healthcare organizations should have processes in place for handling both in a timely manner. In addition, tracking and trending of patient complaints and grievances may call attention to systems or individual performance problems and suggest quality improvement opportunities. For example, patient complaints are associated with both clinical complications and increased risk of malpractice litigation.

Healthcare organizations must develop processes for addressing patient complaints and grievances in order to comply with federal regulations and accreditation standards, as well as to protect patients and reduce liability. Complaints stem from minor issues that can typically be resolved by staff present at the time the concern is voiced, while grievances are more serious and generally require investigation into allegations regarding the quality of patient care. The Centers for Medicare and Medicaid Services (CMS) outlines requirements for addressing grievances in its Conditions of Participation (CoPs) and has published interpretive guidelines on this topic. Although these requirements apply to patients receiving Medicare and Medicaid funding, they are also appropriate recommendations for handling complaints and grievances from all patients—regardless of payment source.

The Joint Commission and other accreditors' complaint resolution standards also require that accredited facilities address and resolve complaints from patients and their families. In addition, facilities using Joint Commission accreditation for CMS deemed-status purposes must establish a mechanism for timely referral of patient complaints regarding the quality of their care or premature discharge to the appropriate CMS-contracted quality improvement organization (QIO) upon request by a Medicare beneficiary.

Although CMS regulations and interpretive guidelines, as well as accreditation standards, for managing patient complaints and grievances are well established, calls for transparency of patient satisfaction—or lack thereof—have evolved significantly in recent years. Formal online reviews, whether captured by the organization or by an independent entity (e.g., a commercial physician rating site), are ubiquitous and have become part of how many patients choose providers. Informal information sharing about customer service experiences through social media is also commonplace; this includes comments about healthcare providers and organizations. This digital environment, in combination with fierce competition for patients, means that healthcare organizations need to proactively avoid patient complaints and grievances; or failing that, to quickly and effectively "right" what patients reasonably perceive as "wrongs."

This guidance article distinguishes between complaints and grievances, discusses best practices for proactive customer service, provides strategies on how to effectively manage grievance processes and ensure compliance with applicable regulations, and explains how grievances and complaints can be used for quality improvement activities.

Action Recommendations

  • Design a process to capture and address all complaints and grievances.
  • Ensure the involvement of the organization's governing body or its designated grievance committee.
  • Implement policies, procedures, and processes for investigation and resolution of patient complaints and grievances.
  • Educate all physicians and staff on grievance processes.
  • Train all staff to listen effectively and manage patient and family expectations.
  • Use dedicated staff to solve small problems before they escalate.
  • Employ a proactive approach to customer service.
  • Empower frontline staff to act as the first line of defense against complaints.
  • Track complaints, grievances, and patient satisfaction surveys and implement improvement initiatives to address trends identified.
  • Verify that the grievance process is effective.

Who Should Read This

Accreditation coordinator, Administration, Corporate compliance, Ethics committee, Legal counsel, Nursing, Patient safety officer, Quality improvement, Social services, Staff education

 

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Ready, Set, Go: Know Your Risks

The Issue in Focus

Distinguishing between Complaints and Grievances

Although it is important to address both complaints and grievances in a timely and effective manner, recognizing the difference between the two is a critical foundation for any grievance resolution process. Complaints, as defined by CMS, are patient issues that can be resolved promptly or within 24 hours and involve staff who are present (e.g., nursing, administration, patient advocates) at the time of the complaint. Complaints typically involve minor issues, such as room housekeeping or food preferences. (CMS)

Most complaints will not require that the facility send a written response to the patient. However, even if a patient's complaint is addressed quickly and informally, the facility should document the complaint and the actions taken to resolve it and maintain the records for quality improvement activities. (CMS)

Common complaints of hospitalized patients include the following (Pronovost):

  • Difficulty sleeping due to overnight noise, blood draws, and vital sign assessments
  • Poor communication—staff who do not listen or explain, whiteboards that are not updated
  • Environmental concerns such as messy rooms and lost personal belongings
  • Lack of courtesy such as staff who do not knock before entering a room and staff who act unprofessionally

Healthcare organizations should always try to resolve patient complaints or concerns immediately and informally whenever possible. However, small issues can escalate, and patients (or their family members or representatives) who feel that their complaints have not been resolved or who have a more in-depth concern may file a formal grievance.

According to CMS interpretive guidance, a grievance "is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS . . . CoPs, or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489." (CMS)

Grievances may be submitted in the course of care or after the patient is discharged, and may occur by virtue of a patient's request for response. All written complaints are considered grievances. (CMS)

Examples of grievances include the following (Vukson and Turvey):

  • Failure to meet the patient's care expectations
  • Failure to notify the physician of the patient's concern
  • Failure to protect patient confidentiality
  • Failure to obtain informed consent
  • Premature discharge
  • Allegations of abuse, neglect, or other unethical behavior

Grievances encompass a wide range of concerns. Considering the broad language of CMS interpretive guidance, many patient concerns may fall into the category of grievances. For example, "patient care" encompasses many aspects of service, including but not limited to medication administration, provision of personal care, and timeliness responding to requests for assistance. If staff are in doubt as to whether a complaint is a grievance, best practice is to err on the side of caution and label the complaint a grievance. (Venn)

Grievances are also legitimized by meeting the definition set forth by CMS interpretive guidance. Therefore, if a patient perceives "neglect" or "abuse," despite immediately apparent evidence to the contrary, the patient's concern should be treated as a grievance. An organization that defines "grievance" too narrowly not only risks regulatory sanction for failing to respond in accordance with CoPs but may also miss an opportunity to investigate, identify, and address underlying systems issues. (Venn)

Complaints and Grievances in Healthcare

The impact of a patient complaint or grievance reaches far beyond the individual concerned. Unfortunately, although patients tend to underreport unhappiness with their healthcare, they do tend to talk about their unhappiness (Levin and Hopkins). As reported by the Agency for Healthcare Research and Quality, marketing studies indicate that while only 50% of unhappy customers complain to the service provider, 96% will tell at least 9 or 10 others about their bad experience. Considering the ubiquity of online ratings for providers and facilities, this "grapevine effect" can potentially spread the impact of a single complaint far and wide, including to prospective patients of whom organizations are not even aware. (AHRQ) See Patient Feedback: What Do We Do With It? for more information.

Individuals from minority populations and underserved communities often avoid complaining even when they experience significant problems with care delivery. In the healthcare context, many people—even those not typically considered "vulnerable"—fear that complaining could jeopardize the quality of the clinical care they receive. (AHRQ) It is also common for patients and families to avoid complaining for fear of retaliation (NCAL). Cultural norms can play a role as well; for example, an individual whose culture discourages questioning authority may have difficulty raising a concern.

Patient complaints range from the seemingly trivial to those that appear likely to trigger a malpractice lawsuit (McMullin). Similar to other businesses, healthcare organizations are often judged, at least in part, by how they handle dissatisfied customers. Patients and families, who are already in a vulnerable position, expect organizations to address their concerns as quickly as possible. Prompt attention to patient concerns is not only excellent customer service, it may also prevent adverse events from occurring in the organization. (Joint Commission)

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Patient Feedback: What Do We Do With It?

Healthcare organizations typically respond to patient complaints and grievances with service recovery efforts aimed at mitigating frustration, addressing concerns, and retaining patient and community loyalty. However, not all organizations look for patterns of systems failures and individual performance issues that emerge from these reports; the true value of patient complaints and grievances lies in what organizations do with the lessons learned. (Pichert et al.)

Indicators for Quality, Safety, and Litigation Risk

Patient complaints on clinical matters, "a proxy for risk of lawsuits" (Pichert et al.), are neither random nor circumstantial. Rather, they involve a minority of providers and are indicative of variations in professional practice and performance. Complaints are associated with complications of surgical procedures and, accordingly, physicians' risk of being sued for malpractice.

One study found that patient complaints about physicians were associated with lawsuits or events identified as potentially leading to lawsuits against those physicians; a physician's risk of being sued was higher when patients complained about the treatment received while under his or her care (Hickson et al.). In a study of surgical cases, patient complaints were associated with surgical complications (Murff et al.).

Patient Perspective

Viewing complaints and grievances from the patient perspective is critical: regardless of whether a concern appears legitimate on its face, if the patient feels the concern sufficiently to raise it, the complaint should be taken seriously and treated accordingly. Complaints carry a certain validity simply by virtue of being the perception of the patient or family member (NCAL).

Sometimes, patients and family members take issue with something tangential to the care provided. However, if the issue is coloring their perspective on their overall interaction with the organization, it is worth the time to get to the bottom of the issue and attempt to make the problem right in the eyes of the patient or his or her representative, if at all possible. Given the anxiety and heightened emotions that naturally accompany many healthcare encounters, this may require skillful listening to determine what the patient or family member is truly upset about. As stated in CMS interpretive guidance, "a grievance is considered resolved when the patient is satisfied with the actions taken on [his or her] behalf."

There is no substitute for feedback from the individual receiving care; organizations may find that encouraging patients to be "the eyes and ears" of individual and team performance yields a rich source of quality improvement data and opportunities for risk prevention (Hayden et al.).

Corporate Compliance Perspective

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Fraud and Abuse Laws

Effective management of patient complaints and grievances is also imperative from a corporate compliance standpoint, not only because of CMS CoPs, and private accreditation standards, but also because individual patient concerns often bring to light larger systems issues, such as quality of care, Medicare billing, and research compliance. Additionally, before instituting well-intentioned responses to patient grievances, such as giving gifts or writing off copays, organizations should consult legal counsel to determine whether doing so would violate federal or state fraud or abuse law. See Fraud and Abuse Laws for more information. Furthermore, because unhappy patients may take their business elsewhere, complain to payers, or take legal action, unresolved patient concerns pose a clear financial risk. (Venn)

Regulations and Standards

CMS requires hospitals and other providers such as ambulatory surgical centers, facilities for patients with end-stage renal disease, and home healthcare agencies to establish patient grievance programs. Although CMS CoPs do not uniformly apply to every care setting and payer source, an effective patient grievance program is a best practice for risk management throughout the continuum of care. (Venn) Indeed, truly patient-focused organizations distinguish themselves from others by handling complaints in such a way that unhappy patients feel that their concerns have been addressed and that they are valued by the organization (AHRQ).

Many common themes emerge among CMS regulations and those of private accrediting agencies. When examined collectively, these requirements can be framed as best practices for management of complaints and grievances.

Centers for Medicare and Medicaid Services

CMS requirements for managing patient grievances are outlined in the Medicare CoPs for patient rights and are further described in an August 2005 letter to state surveyors providing interpretive guidance on this particular CoP and others. CMS's State Operations Manual for hospital surveyors also outlines these requirements.

As part of CMS's CoPs, hospitals must inform all patients or their representatives of the rights patients have during care. Included in these is the right to express grievances or concerns about care. Although these requirements apply to patients whose care is funded by Medicare and Medicaid, the recommendations are appropriate for any healthcare organization in handling patient complaints and grievances. The following section of the CMS CoPs addresses patient grievances (42 CFR § 482.13):

(a) (2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital's governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum:

(i) The hospital must establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital.

(ii) The grievance process must specify time frames for review of the grievance and the provision of a response.

(iii) In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

CMS CoPs further explain the "reasonable time frame" required for resolution of grievances with the following information (§482.13[a][2][ii]):

  • Hospitals must attempt to resolve all grievances as soon as possible.
  • Grievances about situations that could endanger a patient (e.g., neglect, abuse) should be reviewed immediately.
  • Typically, a response time of seven days is appropriate; most grievances should be resolved within that amount of time.
  • If an investigation cannot be completed or a grievance cannot be resolved within seven days, the patient or the patient's representative should be informed that the process is ongoing and that he or she will receive a written response within a specified time period according to organizational policy.

CMS interpretive guidance clarifies that the following scenarios are always considered grievances (CMS):

  • All written complaints, including those submitted via e-mail or fax
  • Complaints that accompany a patient satisfaction survey and request a resolution
  • Telephone calls to the hospital with a complaint about the patient's care
  • All verbal—including via telephone call—or written allegations of abuse, neglect, or noncompliance with CMS requirements
  • Requests by a patient or his or her representative for a response from the hospital
  • Requests by a patient or patient's representative that his or her concern be treated as a formal complaint or grievance

The Joint Commission

Joint Commission standard RI.01.07.01 partially mirrors CMS CoPs by requiring hospitals to establish a complaint resolution process under the responsibility of the governing body unless otherwise delegated, and by requiring hospitals to inform patients and families about the complaint resolution process. The Joint Commission also requires hospitals to do the following (Joint Commission standard RI.01.07.01 element of performance 4,6,7):

  • Review and—as possible—resolve complaints from patients and families.
  • Acknowledge receipt of complaints that cannot be resolved immediately and notify the patient of follow-up to the complaint.
  • Provide patients with telephone numbers and addresses required to file a complaint with the relevant state authority.

DNV GL

Det Norske Veritas's (DNV) standards require hospitals to implement a formal grievance procedure that includes the following (DNV):

  • A list of whom to contact
  • Review and resolution of grievances by the governing body, or written delegation of this function to an appropriate individual or committee
  • A process to refer quality-of-care issues for quality management oversight
  • Delineation of reasonable time frames for review and response to grievances

DNV also requires that grievance resolutions be made in writing and directed to the patient, and include the following:

  • Hospital contact person
  • Investigative steps taken
  • Results of the grievance process
  • Process for escalation of unresolved complaints
  • Date of completion

Action Plan

Implement a Centralized Grievance Resolution Process

Action Recommendation: Design a process to capture and address all complaints and grievances.

Action Recommendation: Ensure the involvement of the organization's governing body or its designated grievance committee.

Because patient grievances may be received by a variety of staff (e.g., finance, risk management, legal), clear definitions and clearly defined procedures for submission of verbal or written grievances are essential so that all grievances are effectively managed and organized. Regardless of which department originally receives the grievance, it must be forwarded promptly to the designated grievance committee for investigation and follow up. (Venn)

Governing Body Oversight

CMS and accrediting organizations require that hospitals' governing bodies approve and oversee the grievance process unless they assign these duties in writing to a grievance committee. Facilities should organize a multidisciplinary team of individuals when developing or revising grievance policies; this team may include administration, patient relations staff or patient advocates, the risk manager, the quality manager, the compliance officer, legal counsel, and nurses or other staff with direct patient contact.

Notification of Patient Rights

Patients should be notified of their legal rights upon admission or as soon as possible after admission to the facility. Patients should be informed that they have the right to file complaints or grievances regarding their care; that their decision to file complaints or grievances will not compromise the care they will receive; and that all information will be kept confidential. In addition, patients should receive information regarding how to file a grievance or complaint and whom they should contact with such concerns. Some facilities have posted signs in patient rooms with the name and phone number of the individual whom patients can contact in the event of a complaint or grievance.

Healthcare facilities must also inform patients of their right to file grievances with regulatory agencies (e.g., local licensing and certification office, state agencies, QIOs). The facility should provide patients with the addresses and phone numbers of these agencies and should inform patients that they may directly contact the state agency that has licensure survey responsibility for the hospital, even if they have not filed a grievance with the healthcare facility.

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Culturally and Linguistically Competent Care

Facilities often provide this information on their websites or in written materials provided to patients on admission and may want to review these materials to ensure that the language is clear and easily understandable. For patients with limited English proficiency, facilities should provide versions in other languages, document translation, and/or interpreter services. See Culturally and Linguistically Competent Care for more information. Patients should sign a form to acknowledge that they were informed about their rights and that they received information on the grievance process.

Staff should also interview patients and their family members or other representatives to determine whether they understand the grievance process, including how to submit grievances and whom to contact.

Complaint Capture

Strategies for Sustained Improvement in Complaint Capture

  • Promoting the availability of patient representatives
  • Providing a patient complaints brochure, translated into four languages, with ample space to write comments
  • Publishing articles about grievance policies in print and online communications
  • Placing flyers with telephone numbers for clinical emergencies and patient relations in highly visible locations (e.g., across from patients' beds) in every patient room
  • Using "Same Day Feedback" cards in the emergency department and inpatient units
  • Asking patients whether all of their needs are being met—and, if the answer is no, what the staff or facility could do better

Source: Levin CM, Hopkins J. Creating a patient complaint capture and resolution process to incorporate best practices for patient-centered representation. Jt Comm J Qual Patient Saf 2014 Nov;40(11):484-92. PubMed.

Organizations can only address complaints of which they are aware. Healthcare organizations must take a proactive approach and actively solicit feedback in order to capture—and resolve—all patient complaints and grievances. (Levin and Hopkins) Capturing patient complaints allows organizations to identify patterns and opportunities for service recovery, identify at-risk providers, and improve patient satisfaction.

Such efforts also require effective systems that encourage customers to complain when warranted; this may include consistently asking patients and family members for feedback and frequently encouraging them to share any concern they might have (AHRQ; NCAL).

Collaboration among various departments such as compliance, risk management, quality assurance, and patient safety is necessary to quickly and efficiently move patient concerns through the process. However, staff may find it difficult to know what to do—and when to do it—when presented with a concern. For example, before one organization introduced a streamlined patient complaint capture and resolution process (discussed below), an assessment suggested that staff were uncertain about when to transfer complaints to the appropriate department, how much collaboration was required, and when to consider a file closed.

The Patient Representative Department at Stanford Health Care, a 613-bed general medical and surgery facility in California, undertook an 18-month "mission" to develop robust processes for monitoring and addressing patient feedback using service recovery techniques, with the goal of improving customer service and patient care, safety, and satisfaction.

Initially, the Stanford patient representation and service quality teams identified many existing repositories of patient comments and concerns, including letters, e-mails, walk-ins, telephone calls to various staff and executives, complaints entered into the electronic health record, comments made to clinical staff and managers, and written entries on patient satisfaction surveys and "Same Day Feedback" cards.

The project team then centralized the process for complaint capture, effectively bringing all patient feedback data into one tracking system. Staff were made aware through management meetings and new employee orientation that all patient complaints should be referred to the patient representative department. Once these efforts were consolidated, the project team reported, complaint data became more accurate, reliable, and easier to act on.

Stanford Health Care achieved and sustained a 50% increase in annual complaint capture (Levin and Hopkins). See Strategies for Sustained Improvement in Complaint Capture for some of the organization's methods.

Develop Policies and Procedures

Action Recommendation: Implement policies, procedures, and processes for investigation and resolution of patient complaints and grievances.

Development of well-articulated policies and procedures—including formal definitions for complaints and grievances—will facilitate consistent treatment of all complaints and grievances, and will lay the groundwork for quality improvement initiatives that follow.

Investigation

Initial acknowledgment. The patient or family member should receive notification that the grievance has been received, that it will be investigated, and that he or she will receive follow-up once the issue has been resolved.

Gathering of facts. When staff members are unable to resolve a complaint during the initial contact, an interview process should commence to determine the scope of the problem. All parties involved in the situation should be interviewed in order to uncover the root of the problem. (NCAL)

Organizational policy should detail the principal steps in a grievance investigation, which may include, but are not limited to, the following (Venn):

  • Interviewing the patient
  • Interviewing the complainant (if different from the patient)
  • Reviewing relevant medical records
  • Interviewing staff with potential knowledge of the situation
  • Researching applicable laws, regulations, policies, and procedures
  • Identifying measures, including those already taken, to resolve the problem

It is important that staff understand that the investigative process is focused not on blame but on resolution and improvement; this can make a substantial difference in staff's willingness to report complaints and assist in their resolution. Staff may be able to offer solutions based on their frontline perspective, and those who are invited to participate in the process are more likely to be invested in making the resolution successful. (NCAL) When investigation reveals problems with systems, processes, or human performance, managers and executive leaders should redesign or reassign them as appropriate. (AHRQ)

Interviewing the patient is important not only to gain understanding of his or her perspective about the situation, but also to ensure the patient's eventual satisfaction, which determines the resolution of the issue. Therefore, it is critical to understand the patient's desired outcome at the outset of the investigation. (Venn)

Use of templates. Organizations may wish to work with legal counsel to develop templates for the documentation of patient concerns, as well as all interviews and written responses. In addition to facilitating a reliable internal record, templates will also help staff follow procedures, ascertain all required information, and remain focused during what could be a difficult conversation.

The Stanford Health Care project included introduction of new templates for patient representatives' notetaking in interviews with patients, whether in person or over the phone. Templates were also created to obtain assistance and feedback from physicians and staff regarding patient concerns. (Levin and Hopkins) See Resource List for more information.

Resolution

Time frame for response. Healthcare organizations should include specific time frames for responding to grievances in their policies. Grievances concerning situations that may endanger the patient (e.g., neglect, abuse) should be given highest priority and should be addressed immediately.

Organizations should track and document time frames for responding to grievances so that this information can be provided to surveyors if necessary. Risk managers should also ensure that timelines for responding to grievances are clearly explained to patients.

Documentation

Documentation of complaints and grievances, as well as their resolution, is important not just for CMS compliance but also for quality improvement and risk management purposes. Documentation of investigations and results is also typically of interest to surveyors (Venn).

Organizations should consult with legal counsel in designing forms and systems for such documentation to ensure that they take advantage of all available legal protections while complying with applicable state and federal laws for peer review processes and treatment of patient safety work product.

Written Responses

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Mix-and-Match Phrases for Grievance/Complaint Response Letters

Responding to concerns is the "hallmark of service recovery"; assuring the individual that the situation will never happen again is a critical component of resolution. (Levin and Hopkins; AHRQ)

Organizations may wish to develop templates to be used as a framework for written response that can be customized for individual situations. Sample phrases for response letters, provided by Wesley Healthcare, appear in Mix-and-Match Phrases for Grievance/Complaint Response Letters.

When the grievance is resolved, CMS regulations require that the organization send the patient a written response that includes a description of the actions taken to investigate the grievance, the results of those actions, the date of completion of the grievance process, and the name of a contact person. Written responses should be sent even if appropriate staff members meet with the patient and family members and resolve the grievance during the discussion. The response should be written in clear and easily understandable language, should include specific information about what actions will be taken to resolve the issue, should avoid making promises for other staff members, and should reflect only actions that will be taken.

In addition to satisfying applicable regulatory and accrediting requirements, sending follow-up correspondence is simply good customer service. When specific information cannot be provided because of confidentiality issues, the response letter may read "appropriate action has been taken." If a healthcare organization receives a grievance by e-mail, the written response may be sent by e-mail as well. (Venn)

Because written responses may be used as evidence in court, hospital policies should recommend that staff prepare responses objectively and state only the facts. Copies of written responses should be sent to the risk management department, and reports on all grievances and actions taken should be submitted to the governing board.

According to CMS regulations, a grievance is considered resolved when the party who filed the grievance is satisfied with the response, or when the healthcare facility has taken "appropriate and reasonable" actions to resolve the grievance even if the patient or patient's family is unsatisfied with the response.

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Sample Policy on Patient Complaints and Grievances

In certain circumstances, risk managers may wish to waive portions of a patient's hospital bill after a grievance has been investigated. However, many legal and regulatory issues, including compliance with fraud and abuse laws, as well as insurance coverage issues, are involved in waiving a patient's bill. Healthcare facilities should proceed with guidance from both the facility's legal counsel and its malpractice insurance carrier.

See a sample policy on patient complaints and grievances from Wesley Healthcare (Wichita, Kansas), as well as Resource List for an additional sample policy.

Educate All Physicians and Staff

Action Recommendation: Educate all physicians and staff on grievance processes.

Action Recommendation: Train all staff to listen effectively and manage patient and family expectations.

Education

Patients may complain or submit grievances to any staff member; therefore, all staff, especially physicians and others who have direct contact with patients, should receive education on the facility's grievance process, how to differentiate between complaints and grievances, and how to direct grievances to appropriate personnel.

Education should emphasize that staff must communicate calmly with patients and show empathy for their concerns. Physicians and other staff members may instinctively rush through discussions with patients who exhibit dissatisfaction; however, it is important to treat patients who are complaining or upset calmly in order to relieve their dissatisfaction and prevent lawsuits.

Educate providers who receive a high number of complaints. It is beneficial for all physicians to understand the frequency of complaints against them relative to their peers. Those with unusually high numbers of complaints can leverage this insight to address personal and practice-related issues that increase individual and organizational claims risk, thereby improving patient safety and satisfaction. Colleagues with lower risk, and organizational partners, should support high-risk physicians in efforts to address their status. (Pichert et al.)

Organizations may therefore wish to undertake a specific educational campaign directed at providers who are the subject of unusually high numbers of complaints.

The Center for Patient and Professional Advocacy at Vanderbilt University in Tennessee designed a peer messenger process that was tested with 373 physicians identified as high risk for unsolicited patient complaints over a four-year period at 16 community and academic medical centers across the United States. Peer messengers from within the high-risk physicians' medical groups made the physicians aware of their standing with respect to their peers; most participating physicians responded professionally and received "substantially fewer" unsolicited complaints after the intervention. (Pichert et al.)

Communication

The value of effective communication skills in managing patient complaints and grievances cannot be overstated. It is critical that staff have essential skills such as the ability to listen without becoming defensive, be empathetic, handle emotion, solve problems, and follow through. (AHRQ)

Physicians and staff should be instructed to stop what they are doing and give the person expressing concern their full attention, maintain eye contact, and avoid negative body language such as crossing the arms or shifting weight back and forth. (NCAL) See Table. Good Listening Skills for more information.

Table. Good Listening Skills

Stop all activity and make eye contact when someone approaches you. If you are unable to stop what you are doing, explain this kindly, set a mutually agreeable time to talk, and fulfill the commitment.
If at all possible, sit down with the individual expressing concern.
Speak in a quiet space with as few distractions as possible.
Maintain positive body language, leaning slightly forward and avoiding crossing your arms.
Repeat back the concern to ensure that you have understood.
Present yourself as a partner and avoid defensiveness.
Focus on mutual points of agreement.
Project confidence and the ability to effect a change by using good posture, maintaining consistent eye contact, and addressing the other person by name.
Do not avoid stressful encounters.

Offer a solution and follow through.

Source: National Center for Assisted Living (NCAL). Turning complaints into compliments. 2005 [cited 2016 Jul 5].

 

Expectation Management

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Informed Consent

Communication

Failure to recognize and manage patient expectations can be a root cause of patient complaints. By helping patients and families develop realistic expectations for treatment and prognosis at the outset, physicians and staff can avoid many complaints in the longer-term. (McMullin; NCAL)

Informed consent is a critical aspect of expectation management, one that has evolved into "the most crucial event" in managing a patient's care (McMullin). Skilled evaluation of the patient's understanding of treatment processes, risks, and expected results lays the foundation for managing any complaints that follow. (McMullin) See Informed Consent for more information.

Formal training in communication, active listening, and expectations management begins at orientation but should also be ongoing. Training should include understanding human reactions and the ways people with different types of personalities complain. Staff should be trained to focus on the problem rather than the delivery, and to distinguish the personality from the problem. (NCAL) See Communication for more information.

Use Patient Advocates

Action Recommendation: Use dedicated staff to solve small problems before they escalate.

Patient advocates, or patient representatives, are hospital employees (or occasionally volunteers) whose specific function is to help patients cope with the often complex and frightening process of hospitalization and to help resolve any problems the patient might face during his or her stay. The patient advocate performs a valuable risk management function by solving small problems before they become large ones and by helping patients feel that they are being treated fairly by the healthcare facility.

In some hospitals or healthcare facilities, the patient advocate is the risk manager, a nurse, or another employee, while in other facilities, a separate individual is hired to perform this role. Some patients choose to hire their own private patient advocate (Foreman). The patient advocate may or may not have medical training, and currently, no regulatory body licenses or regulates the profession.

Healthcare organizations considering implementing a patient advocate program should organize a committee to determine the scope of the program and get support from administration and staff members. In addition, healthcare organizations should consider whether patient advocates will be part of the risk management program or whether their role in supporting patients will be considered a separate function.

Healthcare facilities may consider using patient advocates as their liaisons with patients when a potential claim arises. The patient advocate will ideally have established trust and rapport with the patient and, therefore, will be the ideal candidate for explaining the facility's procedures for handling claims. If an incident occurs, for instance, the patient advocate may introduce the risk manager to the patient with a word of explanation about the facility's risk management program.

Use Service Recovery Techniques

Action Recommendation: Employ a proactive approach to customer service.

Action Recommendation: Empower frontline staff to act as the first line of defense against complaints.

Proactive Service Recovery

Best Practices for Service Recovery

Best practices for basic service recovery have been articulated using the mnemonic "HEARD," representing the following (Hayden et al.):

  • Hearing the concern
  • Empathizing with the individual raising the concern
  • Acknowledging appreciation for the person's coming forward and Apologizing as warranted
  • Responding to the concern with time frame and expectations for follow-up
  • Documenting the concern

The Agency for Healthcare Research and Quality (AHRQ) has published information and resources for healthcare organizations wishing to use service recovery techniques as part of their quality improvement efforts. Service recovery is a process that organizations can use to "recover" dissatisfied patients by identifying and addressing the problem or otherwise making up for failures in clinical operations or customer service.

AHRQ posits that when patients experience repeated breakdowns in service, they naturally lose confidence in the care they receive and question how an organization that cannot get the "small things" correct can be trusted to master the complicated processes integral to the delivery of high-quality healthcare. Service recovery can therefore be instrumental in restoring patients' trust and confidence in the organization's ability to "get it right."

"Many staff know immediately which situations or patients will end up in the [chief executive officer's] office," states AHRQ, emphasizing the value of staff's proactive communication with leadership to facilitate a swift resolution—ideally before the individual files a formal complaint. (AHRQ) See Best Practices for Service Recovery.

Empower Staff

Effective service recovery requires healthcare organizations not only to learn about negative perceptions and experiences sooner rather than later, but also to create an infrastructure allowing staff to respond (Hayden et al.). By empowering staff to respond to smaller concerns expeditiously, organizations can prevent them from becoming larger issues.

In order to be able to handle some complaints autonomously, staff need the following (AHRQ):

  • Straightforward direction regarding the extent of their authority to act on complaints without getting approval from managers
  • Clear protocols to address the most frequent complaints
  • A minimum of bureaucratic roadblocks
  • A clear system of resource people, lines of authority, and backup systems for addressing difficult situations or situations with financial, legal, or ethical implications

Analyze Data

Action Recommendation: Track complaints, grievances, and patient satisfaction surveys and implement improvement initiatives to address trends identified.

Action Recommendation: Verify that the grievance process is effective.

Tracking and Trending

Effective resolution of patient grievances and complaints is, of course, critical for delivery of high-quality care and customer service for individual patients. However, when complaints and grievances are analyzed in aggregate, the process also yields a wealth of data that is a powerful tool for quality improvement. (Venn)

Healthcare organizations should capture and categorize information on patient grievances and complaints and use the data as part of their quality assessment or performance improvement programs. For example, the organization may identify recurring complaints or electronically organize data by category (e.g., service, physician) to determine trends. Several options are possible for cataloguing member complaints that enable tracking by typologies linking complaints to quality improvement activities, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) composite (AHRQ).     

Facilities may also perform failure mode and effects analysis on issues patients complain about or use root-cause analysis to assess complaints or grievances ("Effective"). The governing board should review data related to grievances on a quarterly basis (Vukson and Turvey).

Verify Efficacy

ECRI RESOURCES  

Self-Assessment Questionnaire: Managing Patient Complaints and Grievances.

As with all quality improvement initiatives, ongoing management of patient complaints and grievances requires constant vigilance and monitoring to ensure efficacy. For example, the Stanford Health Care project, which was initially quite successful, experienced modest deterioration following some leadership changes and staff turnover. However, having instituted a process for monitoring data, the organization was able to detect and reverse the deterioration. (Levin and Hopkins)

Among many other data points, CMS suggests monitoring whether concerns are addressed in a timely manner; whether individuals expressing concern are informed of any resolution; and whether the organization applies lessons learned.

For a detailed examination of program efficacy, see Self-Assessment Questionnaire: Managing Patient Complaints and Grievances.

Glossary

Bibliography

References

42 CFR § 482.13 (2006).

Agency for Healthcare Research and Quality (AHRQ). Service recovery programs. 2015 Jul [cited 2016 Jul 6]. http://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html

Centers for Medicare and Medicaid Services (CMS). State Operations Manual. Appendix A—survey protocol, regulations and interpretive guidelines for hospitals. 2015 Nov 20 [cited 2016 Jun 29]. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

DNV GL Healthcare. Standard, interpretive guidelines and surveyor guidance for hospitals. Version 3.2. 2014 Aug [cited 2016 Jun 30]. https://www.dnvgl.com/Images/DNV-GL-DS-HC102_tcm8-8434.pdf

Effective patient grievance policy can be vital tool for improvement. Healthcare Benchmarks Qual Improv 2004 Apr;11(4):37-41. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/15285473

Foreman J. For when a doctor and nurse just aren't enough. Boston Globe. 2006 May 1 [cited 2016 Jul 8]. http://archive.boston.com/news/globe/health_science/articles/2006/05/01/for_when_a_doctor_and_a_nurse_just_arent_enough

Hayden AC, Pichert JW, Fawcett J, Moore IN, Hickson GB. Best practices for basic and advanced skills in health care service recovery: a case study of a readmitted patient. Jt Comm J Qual Patient Saf 2010 Jul;36(7):310-8. http://www.ncbi.nlm.nih.gov/pubmed/21226384

Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002 Jun 12;287(22):2951-7. http://jama.jamanetwork.com/article.aspx?articleid=195008 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/12052124

Joint Commission. Standard RI.01.07.01. In: 2016 Comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission Resources; 2016.

Levin CM, Hopkins J. Creating a patient complaint capture and resolution process to incorporate best practices for patient-centered representation. Jt Comm J Qual Patient Saf 2014 Nov;40(11):484-92. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/26111366

McMullin L. The hidden risks in patient complaints. Becker's Hospital Review. 2015 May 5 [cited 2016 Jun 29]. http://www.beckershospitalreview.com/hospital-management-administration/the-hidden-risks-in-patient-complaints.html

Murff HJ, France DJ, Blackford EL, Grogan EL, Yu C, Speroff T, Pichert JW, Hickson GB. Relationship between patient complaints and surgical complications. Qual Saf Health Care 2006 Feb;15(1):13-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564001 PubMed: http://www.ncbi.nlm.nih.gov/pubmed/16456204

National Center for Assisted Living (NCAL). Turning complaints into compliments. 2005 [cited 2016 Jul 5]. https://www.ahcancal.org/ncal/operations/documents/complaints_compliments.pdf

Pichert JW, Moore IN, Karrass J, Jay JS, Westlake MW, Catron TF, Hickson GB. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf 2013 Oct;39(10):435-46. http://www.jointcommissioninternational.org/assets/1/7/Journal_0ct_2013-pichert_436-446.pdf PubMed: http://www.ncbi.nlm.nih.gov/pubmed/24195197

Pronovost P. The patient wish list. 2015 Oct 15 [cited 2016 Jul 18]. U.S. News Health & World Report. http://health.usnews.com/health-news/patient-advice/articles/2015/10/15/the-patient-wish-list 

Venn L. Solving patient complaints while avoiding compliance snares. Health Care Compliance Association national conference. 2010 [cited 2016 Jun 29]. http://www.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2010/508handout.pdf

Vukson R, Turvey J. Grievance is NOT just a complaint. Presented at: American Society for Healthcare Risk Management 2006 Annual Conference & Exhibition; 2006 Oct 31; San Diego (CA).

Topics and Metadata

Topics

Accreditation; Laws, Regulations, Standards; Quality Assurance/Risk Management

Caresetting

Hospital Inpatient

Clinical Specialty

 

Roles

Clinical Practitioner; Healthcare Executive; Legal Affairs; Nurse; Quality Assurance Manager; Risk Manager

Information Type

Guidance

Phase of Diffusion

 

Technology Class

 

Clinical Category

 

UMDNS

SourceBase Supplier

Product Catalog

MeSH

ICD9/ICD10

FDA SPN

SNOMED

HCPCS

Disease/Condition

 

Publication History

​Published August 17, 2016