Joint Commission Gets Serious About Patient Grievance

If you've been following the changes taking place within the Joint Commission during the past year or so, you know that the healthcare accreditor has been updating standards to more closely align with the Centers for Medicare & Medicaid's (CMS) Conditions of Participation (CoPs).

HcPro posted an article on their site back in March that nicely outlines several recently released changes to the Joint Commission hospital accreditation standards. This article focuses on one particular addition to the 2009 standards.

For Compliance, Ombuds, Quality, Risk Management, Marketing/Patient Experience, and Medical Staff: 

Joint Commission has added considerable language to the 2009 hospital standards pertaining to patient rights and specifically, responding to patient grievances in a timely manner:

RI.01.07.01

EP 1: The hospital establishes a complaint and grievance resolution process.

EP 2: The hospital informs the patient and his or her family about the complaint and grievance resolution process.

EP 4: The hospital reviews and, when possible, resolves complaints and grievances from the patient and his or her family.

EP 6: The hospital acknowledges receipt of a complaint or grievance that the hospital recognizes as significant and notifies the patient of follow-up to the complaint or grievance.

EP 7: The hospital provides the patient with the phone number and address needed to file a complaint or grievance with the relevant state authority. (See also MS.09.01.01, EP 1)

EP 10: The hospital allows the patient to voice complaints or grievances and recommend changes freely without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care.

EP 17: The governing body reviews and resolves grievances unless it delegates this responsibility, in writing, to a grievance committee.

EP 18: In its resolution of grievances, the hospital provides the individual with a written notice of its decision, which contains the following:

• The name of the hospital contact person
• The steps taken on behalf of the individual to investigate the grievance
• The results of the process
• The date of completion of the grievance process

EP 19:The process for resolving grievances includes a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the Quality Improvement Organization (QIO).

EP 20: The governing body approves the complaint and grievance resolution process.

Impact:These standards are new to the Joint Commission but not CMS. The hospital must now have a procedure, approved by and overseen by the governing body. It will be necessary to track the steps of the process.

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I have a particular interest in the standards pertaining to patient rights and grievance as I've spent considerable time recently updating the Patient Comment & Grievance Tracking Database from Simple Data Solutions.   If you need to develop or improve your patient complaint and grievance tracking process, please take a look at this product to see whether it meets your needs.  It is specifically designed for smaller hospitals, ambulatory surgery centers, dialysis centers, home health agencies, and durable medical equipment suppliers.  There is a free 30 day trial download available from the Simple Data Solutions web site, as well as comments from some current users.

Responding well to patient grievances does more than comply with standards, it improves patient safety, patient satisfaction, and often preserves the organization's valuable financial resources.

 

Comments

[Nurse Line]

This is quite a comprehensive and informative posting on the Joint Commission’s take on the grievances of patients. I think the patient rights should be laid down more clearly.