Effective Management of Complaints and Grievances

Effective

Management of

Complaints and

Grievances

Jennifer Comerford, MJ, OTR/L, CHC, HEM

Senior Risk Management Analyst

October 7, 2016

My Own Experiences

Provider

Manager

Family

member

True or False???

Complaints are valid by the fact of their existence

Clinical Framework

Continuumof

care

•Homecare

•Shortstay

•Long‐termcare

• Hospice

Individuals

served

• Clients

•Patients

• Residents

• Families

Nomenclature

• Complaints

• Grievances

• Issues

•Concerns

Common

themes

•Risk

• Opportunity

Regulatory Framework

Source:NJDCA

Learning Objectives

1. Distinguish between a complaint and a grievance

2. Describe risk management implications of complaints

3. Describe methods to capture and investigate complaints

4. Recall strategies for complaint resolution and response

Learning Objective #1

Distinguish between a complaint and a grievance

True or False?

 Complaints are smaller issues and grievances are more

significant

Distinguishing Between Complaints and

Grievances

 Complaints

 Minor issues

 Quickly resolved

 Handled by staff present

 Grievances

■ Significant issues

■ Cannot be resolved

immediately

■ Allegations involving

patient care

Source:CMSSOM

Examples of Complaints and Grievances

 Complaints

 Cold food

 Lost personal belongings

 Environmental concerns

 Grievances

■ Unmet patient care

expectations

■ Breach of confidentiality

■ Lack of informed consent

■ Premature discharge

■ Allegations of abuse,

neglect

Sources:CMSSOM;VuksonandTurvey

Failure to Respond to

Customer Service Issues

Dietaryerrors

Equipmentindisrepair

Environmentalconcerns

Lostpersonalitems

Complaints

Sources:AHRQ;Myers

Attention

todetail

Excellent

customer

service

TRUST

Learning Objective #2

Describe risk management implications of complaints

True or False?

 Long-term care loss rates are increasing by 5% annually

Source:AonRiskSolutions

Claims Trends: Long-Term Care

Severityis

increasingby

2%annually

Frequencyis

increasingby

3%annually

Lossrates

are

increasing

by5%

annually

Source:AonRiskSolutions

Forecasted 2016 Claims Activity

Lossrate:$2,150/bed

Frequency:0.99claims/100beds

Severity:$217,000/claim

Source:AonRiskSolutions

Common Complaints in Nursing Facilities

 Issues surrounding discharge

 Failure to answer requests for assistance

 Lack of respect for residents

 Quality-of-life issues

 Problems with medication administration

Source:AdministrationonAging

Postacute Patients: Special Concerns

High

expectations

No“bankof

trust”

Clinical

complexity

Failureto

meet

expectations

Unresolved

complaints

Regulatory Requirements and

Accreditation Standards—Brief Survey

 Centers for Medicare and Medicaid Services (CMS) for

long-term care facilities

 CMS for home health agencies

 Commission on Accreditation of Rehabilitation Facilities

(CARF)

 The Joint Commission

 State regulations

Sources:CARF;CMSHHA,LTC;

TheJointCommission

Organizational Policy and Procedure

 Clearly defines “complaint” and “grievance”

 Delineates procedures for investigation and response

 Informs patients, residents, and families of their rights

 Specifies timeframes for response

 Provides information regarding resources for advocacy

 Ensures multidisciplinary oversight

Sources:CARF;CMSHHA,LTC,SOM;

TheJointCommission

Dissatisfied Customers:

How Many Complain to the Service Provider?

Source:AHRQ

Dissatisfied Customers:

How Many Complain to Family and Friends?

Sources:AHRQ;LevinandHopkins

Complaints and Grievances in Healthcare

 People underreport unhappiness with their healthcare

due to fear of:

■ Retaliation

■ Jeopardizing the quality of care

Source:NCAL

Emotional Harm Resulting from Disrespect

 Respect has been defined as “the actions taken towards

others that protect, preserve, and enhance their dignity.”

 Examples of emotional harms

 Event types

■ Communication

■ Environment of care

■ Care after death

Source:Sokol‐Hessneretal.

Emotional Harm:

Implications for Aging Services

 Theme of care after death

 Impacts on other residents

Source:Sokol‐Hessneretal.

Learning Objective #3

Describe methods to capture and investigate complaints

True or False?

 Organizations can only address the complaints of which

they are aware

Complaint Capture

 Proactive approach: actively solicit feedback

 Identify

■ Patterns and opportunities

■ At-risk staff, and improve resident satisfaction

Case Study: Complaint Capture

 Identified repositories of

patient concerns:

 Letters

 E-mails

 Walk-ins

 Telephone calls

 Electronic health record

 Clinical staff and managers

 Patient satisfaction surveys

 Centralized the process

for complaint capture

■ Single tracking system

 Trained staff

 Increased use of

complaint data

Source:LevinandHopkins

Strategies for Sustained Improvement in

Complaint Capture

 Use of patient liaisons

 Brochures in multiple languages

 Visible telephone numbers for concerns

 Asking patients if all of their needs are being met

Source:LevinandHopkins

It’s Free to Have an Open Door

Methods to Capture Complaints

 Ask for feedback

 Encourage candor

 Ensure nonretaliation

 Collaborate among staff

 Designate a single repository

Preliminary Investigation

Becomeawareof

complaint

Initial

acknowledgment

Document

complaint

Begintogather

facts

Source:NCAL

Steps in a Grievance Investigation

Reviewmedical

records

Interview

patient

Interview

complainant

Interviewstaff

Research

applicable

authority

Identify

resolution

Sources:AHRQ;NCAL;Venn

Learning Objective #4

Recall strategies for complaint resolution and response

True or False?

 Many staff know immediately which situations or patients

will eventually end up in the CEO’s office

Source:AHRQ

Critical Themes of Complaint Resolution

Proactive

follow‐up

Respect

Nonretaliation

Addressing

theconcern

Staff Education and Training

Problem

Delivery

Source:NCAL

Good Listening Skills

 Stopallactivityandmakeeyecontact

 Sitdown

 Maintainpositivebodylanguage

 Restatetheconcern

 Presentyourselfasapartner

 Focusonmutualpointsofagreement

 Projectconfidenceandtheabilitytoeffectachange

 Donotavoidstressfulencounters

 Offerasolutionandfollowthrough

Source:NCAL

Proactive Service Recovery

 A process to “recover” dissatisfied patients

 Demonstrate the ability to “get it right”

 Restore trust and confidence

Source:AHRQ

“HEARD” for Service Recovery

H

• Hearthe

concern

E

•Empathize

withthe

individual

A

•Acknowledge

appreciation

•Apologizeas

warranted

R

•Respondto

concern

D

•Document

the

concern

Source:Haydenetal.

Empowering Staff to Respond

 Straightforward direction

 Clear protocols

 Minimal bureaucratic roadblocks

 Clear system of resources and lines of authority

 Backup systems for addressing complex situations

Sources:AHRQ;Haydenetal.

Setting Realistic Expectations

Earntrust

Facilitate

understanding

Prevent

complaints

Sources:McMullin; Myers;NCAL

Setting Realistic Expectations: Examples

 Examples:

■ Weight loss

■ Contracture

■ Fall precautions

■ Terminal prognosis

Source:Myers

Resolutions and Responses

for Postacute Patients

Nursing

Social

work

Written Response

 Acknowledge risks of writing, and of not writing

 Develop templates with legal counsel

 Define a process

 Respond thoughtfully and skillfully

Postresponse Analysis

 Review findings

 Discuss recommendations

 Educate as appropriate

 Failure mode and effects analysis, root-cause analysis

Tracking and Trending

 Categorize data

 Analyze in aggregate—powerful tool for quality

improvement

 Share with:

■ Leadership

■ Multidisciplinary oversight committee

■ Staff

Sources:CARF;Venn

References

42 CFR § 482.13 (2006).

Administration on Aging (AOA). Long-term care ombudsman program. 2014 Oct 7. [cited 2016 Jul

22]. http://www.aoa.gov/AoA_programs/Elder_Rights/Ombudsman/index.aspx

Agency for Healthcare Research and Quality (AHRQ). Service recovery programs. 2015 Jul [cited

2016 Aug 4]. http://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-

for-improving/customer-service/strategy6p-service-recovery.html

Aon Risk Solutions. Long term care general liability and professional liability actuarial analysis.

2015 Nov [cited 2016 Jul 26]. http://www.aon.com/attachments/risk-

services/Aon_2015_Long_Term_Care_Liability_Actuarial_Analysis_full.pdf

Centers for Medicare and Medicaid Services (CMS).

Home health agencies (HHA). 2005 Aug 12 [cited 2016 Jul 22].

https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/homehealth.html

Long term care facilities (LTC). 1989 Feb 2 [cited 2016 Jul 22].

https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/LTC.html

State Operations Manual (SOM). Appendix A—survey protocol, regulations and

interpretive guidelines for hospitals. 2015 Nov 20 [cited 2016 Aug 4].

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

References, continued

Commission on Accreditation of Rehabilitation Facilities (CARF). Continuing care retirement community

standards manual. Section 1.K.3-4. 2016 [cited 2016 Jul 22].

http://www.carf.org/WorkArea/DownloadAsset.aspx?id=23968

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 re-admitted patient. Jt Comm J Qual Patient Saf 2010

Jul;36(7):310-8. PubMed: http://www.ncbi.nlm.nih.gov/pubmed/21226384

The Joint Commission. Standard RI.01.07.01. In: 2016 comprehensive accreditation manual for nursing

care centers. 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

Myers B. Navigating the litigation quagmire. Provider (Long Term and Post-Acute Care). 2015 Sep [cited

2016 Jul 25]. http://www.providermagazine.com/archives/2015_Archives/Pages/0915/Navigating-

The-Litigation-Quagmire.aspx

References, continued

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

New Jersey Division of Consumer Affairs (NJDCA). Patient bill of rights. 2015 Jul 7 [cited 2016

Jul 29]. http://www.njconsumeraffairs.gov/bme/Pages/Patient-Bill-of-Rights.aspx

Sokol-Hessner L, Folcarelli P, Sands KE. The practice of respect. NEJM Catalyst 2016 Jun 23

[cited 2016 Jul 25]. http://catalyst.nejm.org/the-practice-of-respect-improving-patient-

experience/

Venn L. Solving patient complaints while avoiding compliance snares. Health Care Compliance

Association national conference. 2010 [cited 2016 Jul 29]. http://www.hcca-

info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2010/508ha

ndout.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).

Questions?

Please contact Jennifer Comerford, Senior Risk

Management Analyst at (610) 825-6000 x5165 or

jcomerfor[email protected]

Thank you