How to Prevent a Complaint From Becoming a Lawsuit

Kathryn Moghadas, RN, CHBC, CLRM

Disclosures

March 09, 2012

Your Office's Grievance Process

  1. Develop a policy (see sample below) that designates a contact individual (practice administrator, quality or compliance officer, or risk manager) for complaints or grievances.

  2. Educate all staff members on the policy and the process. This may include signage changes at the front desk.

  3. Provide a complaint form that is readily available to patients (see sample below).

  4. If a complaint or grievance occurs, process forms or verbal complaints with documentation.

  5. Investigate the root cause.

  6. Identify corrective actions.

  7. Report the findings.

Are You Doing Enough to Prevent Grievances?

While it's crucial to have an official grievance process, it's also wise to avert patient dissatisfaction.

The most common reasons for patient grievances are: (1) failure to communicate; (2) failure to fulfill expectations for examination and treatment; (3) prolonged wait time; (4) rudeness; and (5) inappropriate behavior related to billing.

The first 2 common complaints have remained consistent for the last 30 years. They constitute 2 of the most common reasons for patient grievances.

Poor communication skills and failure to fulfill expectations for examination. In recent years, medical school training has changed from using a biomedical model to a patient-centered approach. The training shift is intended to help new doctors improve their communication skills and improve health outcomes, patient compliance, and patient satisfaction.

Physicians -- even established physicians -- may need more feedback or a refresher regarding the medical interview process and its 3 essential functions: information gathering, relationship building, and patient education.

Long waits and rudeness. Doctors and the practice managers need to provide proper oversight of their personnel as well as their scheduling. There are times when the physician will run behind schedule for various reasons, but that should be the exception rather than the rule.

Generally, the practice staff should be mindful of the physician’s schedule, the type of visit scheduled, the number of rooms available, the correct preparatory workup, and the appropriate staffing levels. These are all practice management considerations when attempting to develop the scheduling template.

When the doctor is running behind schedule, it's wise to update the waiting patients about the delay, and also phone patients who have not arrived yet and give them the option to delay or reschedule. This communicates that the practice values the patients' time commitment.

In a complaint regarding rudeness, intervention on behalf of the practice administrator to council the offending staff member is one of the proper actions to take. If the administrator has trouble accomplishing this, the physician may need to step in.

The last of the most common reasons for patient grievances, inappropriate behavior related to billing, can stem from patient misunderstanding of correct billing practices. Clear and simple billing policies explained at the time of registration can help. The checkout clerk should explain which charges will be submitted to the patient's insurance and which are considered part of the patient's deductible or not allowed. With Medicare patients' financial informed consent, the rules are simple. Charges not covered by Medicare must be authorized by the patient prior to delivery of the service, otherwise the patient cannot be billed.

Sample Patient Grievance Policy

POLICY

It is the policy of __________________ to ensure that all complaints related to care or services provided are handled courteously, consistently, and as expeditiously as possible. If the initial efforts of the (practice administrator, quality or compliance officer, or risk manager) fail to amicably resolve complaints, it is the policy of ___________ to utilize this grievance procedure to make reasonable efforts to resolve patient grievances as quickly as possible.

A Patient Complaint is a verbal or written complaint regarding patient care received that is resolved at the time of the complaint by a staff member present. A complaint is considered resolved when the patient or the patient’s representative is satisfied with the actions taken.

A Patient Grievance is a verbal or written complaint by a patient or patient representative regarding patient care received that occurs after the visit, is presented to ___________, and requires further action or resolution.

PURPOSE

To provide a system whereby patients or their representatives may present concerns and recommend changes freely, without subject to coercion, discrimination, reprisal, or unreasonable interruption of care.

PROCEDURE

Notice of Right to File Grievance

The practice will make available a sign posted in a prominent position that notifies patients and their representatives of the practice’s goal to provide the best quality patient care possible. Should there be a concern that the patient feels has not been resolved, the patient may request a grievance form from the receptionist or contact the designated officer.

INITIAL RESPONSE TO THE COMPLAINANT

Nonsupervisory personnel who receive a Patient Complaint from a patient or a patient's family member or representative, either written, by phone, or in person, will refer the complaint to the ________________________.

The ____________ will attempt to gather the salient facts of the encounter and resolve the matter with the complainant immediately, unless additional action needs to be taken by the __________ to gather additional information. By the end of the meeting with the complainant, the _________ will determine a mutually agreed-upon time to reconvene, either in person or by phone, to report the investigation’s findings. This investigational time should not exceed seven (7) working days. All these actions and conversations should be documented on the Complainant form.

NOTIFICATION OF INVESTIGATION RESULTS

Upon completion of the investigative process, the __________ should contact the complainant with the results of the investigation. The notification should be in the form of disclosure of actions taken, findings, actions recommended, and changes or no changes made in the practice processes. In instances where the complaint is against a specific employee, the results of actions taken will remain confidential. The complainant will learn only that appropriate action was taken to remedy the complaint.

RESOLUTION

A patient’s grievance is considered resolved when the patient or patient’s representative is satisfied with the action taken.

There may be times where the practice has taken appropriate and reasonable action to resolve the grievance and the patient or patient’s representative remains dissatisfied. In these cases, the practice will close the file for purposes of this policy.

Additional action might need to be taken, such as discharging the patient from the practice, notification of the

Sample Patient Complaint Form

Patient Complaint Form
  Date:        
Please describe any problem you experienced:  
 
How can we help resolve it?  
 
Name of Patient: ________________________________________________________
Information Provided/Taken by: ____________________________________________
Referred to: ___________________________________________________________
Resolved by: ___________________________________________________________
Patient Notified of Action: _________________________________________________
Date: _________________________________________________________________

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