In any healthcare system, the rights and responsibilities of patients/clients and their families are vital. One critical aspect of this is the ability to voice concerns and have them addressed in a timely and effective manner. The Joint Commission Hospital and Behavioral Health Care manuals, along with CMS, DNV, CHIQ, ACHC, and CARF manuals all outline specific standards regarding patient/client complaints and their resolution. All accreditors have aligned their standards that crosswalk to the COPs, to include the CMS requirements. Let’s delve into the principles behind these standards and their significance in ensuring quality care.  We will also uncover some of the common findings driving standard non-compliance findings during surveys from the accreditors and regulatory agency. 

The Right to Complaint Resolution

This requirement emphasizes the patient/client and their family’s right to have their complaints reviewed by the organization. It is not just about having the right; it is also about ensuring that hospitals, psychiatric hospitals, behavioral health care, and human services organizations have robust processes in place to address these concerns promptly and effectively.

Establishing Complaint Resolution Processes

Establishing a complaint resolution process and informing patients/clients and their families about it is paramount. Transparency is key here. Patients/clients should be aware of how they can voice their complaints and what steps will be taken to address them. However, surveyor observations reveal instances where organizations failed to inform patients/clients about the complaint resolution process or where the responsibility was not delegated to a committee as required for Medicare Certified providers.

Reviewing and Resolving Complaints

Providers are expected to actively review and, when possible, resolve complaints from patients/clients and their families. It is not enough to have a process in place; action must be taken to address the concerns raised. Unfortunately, some organizations have been found lacking in this aspect, with evidence of unaddressed complaints dating back a year.

Acknowledging and Notifying Patients/Clients

The importance of acknowledging receipt of a complaint that cannot be immediately resolved and notifying the patient/client of follow-up steps is imperative. Patients/clients need to know that their concerns have been heard, even if resolution takes time. However, instances were found where organizations failed to communicate or notify patients when complaints could not be immediately resolved.

Providing Written Notice of Decisions

Medicare certified organizations must notify patients/clients with written notice of decisions regarding their complaints. This notice should include details such as the steps taken to investigate the complaint, the results of the process, and the date of completion. Unfortunately, some organizations fell short in providing this essential communication, leading to noncompliance.

Setting Time Frames for Complaint Review and Response

Accreditors and CMS highlight the importance of setting time frames for complaint review and response. While there is no requirement for a specific policy or documentation, compliance is determined by evaluating the organization’s process. Adherence to these time frames ensures timely resolution of complaints and demonstrates a commitment to patient satisfaction.

Referral of Patient Concerns to Accrediting Bodies and Regulatory Organizations

The requirements emphasize the need for a process to refer patient/client concerns about quality of care or premature discharge to the quality improvement organization. This ensures that systemic issues are addressed to prevent recurrence and improve overall care quality.

In conclusion, while these standards outline the rights of patients/clients and their families to have their complaints addressed, they also highlight the responsibilities of health care organizations to have effective complaint resolution processes in place. Compliance with these standards is essential for upholding patient/client rights and ensuring the delivery of quality healthcare services. As patient/client advocates, it is crucial for hospitals, psychiatric hospitals, behavioral health care, and human services providers to be aware of and uphold these rights.

Barrins & Associates Consultation

At Barrins & Associates we can assist you to develop a comprehensive and compliant grievance process in adherence to the TJC, DNV, ACHC, CIHQ, CARF and CMS standards for psychiatric hospitals and community behavioral health and human services providers.  Inquire today about our consulting services. We continue to support your journey toward accreditation and regulatory compliance.

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