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Grievances, Complaints, and Patients’ Rights

Accreditation Monthly

March 9, 2010

Simply put, CMS defines a grievance as a written or verbal complaint by a patient or patient's representative regarding care or services, abuse or neglect, or potential violations of the Conditions of Participation (CoP). CMS is very specific in the Patient Rights chapter of the CoP (§482.13, A-0118–A-0123) regarding the expectation of prompt resolution to grievances in both the inpatient and outpatient areas.

The Joint Commission has aligned its requirements to CMS in this area by mandating that a complaint resolution process be in place in the Rights and Leaderships chapters.¹ Staff must be able to demonstrate understanding of your organization's policy related to complaint resolution. For example, it's great for staff to know that patients can call The Joint Commission with complaints, but it is not so good if they can't provide the number or know how to direct the complainant to the accrediting body.

In general, we find that outpatient staffs are vulnerable to being less familiar with the hospital's written grievance process. It's a good practice to review the information published in patient handbooks regularly and make it accessible for staff if necessary.

Aside from demonstrating that your policy and your practices are in compliance with the requirements, you must show that they have been approved by your governing body. Items to consider in the review of your process include whether:

  • You are responding to complaints and grievance in writing within seven days. If not, has the patient or patient's representative been informed that you are still working on the issue and provided with a new timeframe for potential resolution?
  • The response is composed in a manner that can be understood, including incorporating language or cultural sensitivities into the resolution process.
  • Complaints and your response to the matter being tracked so you can demonstrate compliance with the regulations and your own policy.
  • Grievance data are evaluated and considered in your organization performance improvement plans.

It is the expectation that quality and safety issues are being managed by leadership, which includes the involvement of your governing body.

¹The Joint Commission Hospital Accreditation Manual (RI.01.07.01, EPs 1–2, 4, 6–7, 10, 18–20; LD.01.03.01, EP 1–3; LD.04.01.07, EP 1–2).

Laure Dudley, Consultant, March 2010

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