COMMUNICATION & RELATIONSHIP BETWEEN RISK MANAGEMENT AND THE MEDICAL STAFF OFFICE

1. CAMSS 43rd ANNUAL EDUCATION FORUM May 7, 2014 COMMUNICATION&RELATIONSHIP BETWEEN RISK MANAGEMENT AND THE MEDICAL STAFF OFFICE Caroline J. Swinton, RN, MSN Director, Patient Relations & Risk Management COMMUNITY HOSPITAL OF SAN BERNARDINO

2. OBJECTIVES Explain the Crosswalk between CMS-TJC (Center for Medicare/Medicaid Services – The Joint Commission) for complaints and grievances. Provide specific strategies to assist with resolution of issues, complaints and grievances involving the Medical Staff. Describe approaches to reduce vulnerabilities of receiving an indirect/direct impact or deficiencies. Explain the importance of collaboration and working relationships between the Medical Staff and Risk Management.

3. PATIENT RIGHTSGRIEVANCE AND COMPLAINT MANAGEMENT

4. Welcome to the crosswalk…

5. Crosswalk – TJC CMS Why is it important to focus on the Crosswalk? • Guidance in developing processes to provide the highest level of care, treatment and services. COMPLIANCE

6. “In the confrontation between the stream and the rock, the stream always wins — not through strength but by perseverance.” Jackson Brown

7. GRIEVANCE/COMPLAINT • A patient grievance is a formal or informal written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient’s representative, regarding the patient’s care, abuse or neglect, issues related to the hospital’s compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations.

8. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2) TAG: A-0118 The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care, treatment, and services. EP 1 - The governing body defines in writing is responsibilities. LD.04.01.07 The hospital has policies and procedures that guide and support patient care, treatment and services. EP 1 – Leaders review and approve policies and procedures that guide and support patient care, treatment, and services (See also NR.02.03.01, EP 1; RI.01.07.01, EP 1)

9. NOTIFICATION TO PATIENT/FAMILY UPON ADMISSION If you want to file a grievance with this hospital, you may do so by writing or by calling the Patient Relations department at (909) 806-1256. The Grievance Committee will review each grievance with a written response. The written response will contain the name of a person to contact at the hospital, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process. Concerns regarding quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Improvement Organization. File a complaint with the State of California Department of Public Health regardless of whether you use the hospital’s grievance process. The California Department of Public Health’s phone number and address is: State of California Department of Public Health (Licensing and Certification Program) 464 W. 4th Street, Suite 529 San Bernardino, CA 92401 (909) 383-4777. The patient has the right to contact The Joint Commission if patient safety has been compromised or not met accepted quality of care standards. The Joint Commission’s phone number and address is: The Joint Commission One Renaissance Blvd., Oakbrook Terrace, IL 60181 (800) 994-6610

10. Medicare Requirements Joint Commission Standards & Elements of Performance TAG: A-0118 The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. RI.01.07.01 The patient and his or her family have the right to have complaints reviewed by the hospital. EP 1 - The hospital establishes a complaint resolution process. (See also LD.04.01.01.07, EP1; MS.09.01.01, EP1) Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee. EP 2 – The hospital informs the patient and his or her family about the complaint resolution process. (See also MS.09.01.01, EP 1) EP 4 – The hospital reviews and, when possible, resolves complaints from the patient and his or her family.

11. EXAMPLE OF PATIENT/FAMILY NOTIFICATION COMPLAINT/GRIEVANCE ASSISTANCE Should you encounter any concerns or dissatisfaction with the care or services received at Community Hospital of San Bernardino; these concerns may be communicated to: Patient Relations Director (909) 887-6333 Ext. 1256 My signature below indicates that I have been provided information of my Rights & Responsibilities as a patient at Community Hospital of San Bernardino and received a copy of the information above. Signature:________________________________________ Date:_______________________ Relationship:__________________________________________________ Please indicate relationship if signed by person other than the patient.

12. SAMPLE OF GRIEVANCE FORM

13. Medicare Requirements Joint Commission Standards & Elements of Performance TAG: A-0118 The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. RI.01.07.01 – cont… EP 6 - The hospital acknowledges receipt of a complaint that the hospital cannot resolve immediately and notifies the patient of follow-up to the complaint. (See also MS.09.01.01, EP1) EP 7 – The hospital provides the patient with the phone number and address needed to file a complaint with the relevant state authority. (See also MS.09.01.01, EP 1) EP 19 – For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital determines time frames for complaint review and response.

14. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2) – cont… TAG: A-0119 [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. LD.01.03.01 - The governing body is ultimately accountable for the safety and quality of care, treatment, and services. EP 1 - The governing body defines in writing its responsibilities. LD.04.01.07 – The hospital has policies and procedures that guide and support patient care, treatment, and services. EP 1 – Leaders review and approve policies and procedures that guide and support patient care, treatment, and services. (See also NR.02.03.01, EP1; RI.01.07.01, EP1)

15. RESPONSIBILITY/PROCEDURE • (example of statements) • The Board of Directors is responsible for the effective operation of the Grievance process. • Coordination and management of all significant unresolved grievances is delegated to the Grievance Committee. • Upon admission all patients are notified of the process to invoke the patient grievance system. The patient’s signature is requested on the notification form, and a copy of the form is retained in the patient's medical record. Information on the form includes the name, address and phone number of the Department of Public Health Services. • Patients who are unable to receive information regarding the patient grievance system upon admission or whose responsible party receives that information on their behalf will be referred to the Patient Relations Department for follow up. The Patient Relations Department will ensure that information is provided to the patient should the patient be able to receive and acknowledge that information later in his/her hospitalization. • Any written or verbal complaints relating to the professional competency/conduct of a member of the medical staff or allied health professional will be forwarded to the Medical Staff Administration for review by the appropriate medical staff leader.

16. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2) – cont… TAG: A-0119 [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. RI.01.07.01 – the patient and his or her family have the right to have complaints reviewed by the hospital. EP 1 - The hospital establishes a complaint resolution process. (See also LD.04.01.07, EP 1; MS.09.01.01, EP1) Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee. EP 6 – The hospital acknowledges receipt of a complaint that the hospital cannot resolve immediately and notifies the patient of follow-up to the complaint. (See also MS.09.01.01, EP 1)

17. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2) – cont… TAG: A-0120 [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: RI.01.07.01 – the patient and his or her family have the right to have complaints reviewed by the hospital. EP 6 - The hospital acknowledges receipt of a complaint that the hospital cannot resolve immediately and notifies the patient of follow-up to the complaint. (See also MS.09.01.01, EP 1) EP 20 – For hospitals that use Joint Commission accreditation of deemed status purposes: The process for resolving complaints includes a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the quality improvement organization (QIO).

18. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2)(i) TAG: A-0121 [At a minimum:] (i) The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. RI.01.01.03 – The hospital respects the patient’s right to receive information in a manner he or she understands. EP 1 - The hospital provides information in a manner tailored to the patient’s age, language, and ability to understand (See also PC.02.01.21, EP 2; PC.04.01.05, EP 8; RI.01.01.01, EPS 2 and 5) RI.01.07.01– The patient and his or her family have the right to have complaints reviewed by the hospital. EP 1 – The hospital establishes a complaint resolution process. (See also LD.04.01.07, EP1; MS.09.01.01, EP 1) Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee. EP 2 – The hospital informs the patient and his or her family about the complaint resolution process. (See also MS. 09.01.01, EP 1)

19. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2)(ii) TAG: A-0122 [At a minimum:] (ii) The grievance process must specify time frames for review of the grievance and the provision of a response. RI.01.07.01 – The patient and his or her family have the right to have complaints reviewed by the hospital. EP 19 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital determines time frames for complaint review and response.

20. COMPLAINTS/GRIEVANCE • The Grievance Committee will review any grievance received within 72 hours of receipt of the grievance. • An email is generated to the Grievance Committee with specifics of the grievance. • All complaints will be reviewed within 24-48 hours by Directors and Managers.

22. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2)(iii) TAG: A-0123 [At a minimum:] (iii) In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. LD.01.03.01 – The governing body is ultimately accountable for the safety and quality of care, treatment, and services. EP 1 - The governing body defines in writing its responsibilities. LD.01.04.07 – The hospital has policies and procedures that guide and support patient care, treatment, and services. EP 1 - Leaders review and approve policies and procedures that guide and support patient care, treatment, and services. (See also NR.02.03.01, EP1; RI.01.01.01, EP1)

23. SAMPLES OF GRIEVANCE LETTERS

24. Medicare Requirements Joint Commission Standards & Elements of Performance CFR NUMBER §428.13(a)(2)(iii) TAG: A-0123 [At a minimum:] (iii) In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. RI.01.07.01 – The patient and his or her family have the right to have complaints reviewed by the hospital. EP 6 - The hospital acknowledges receipt of a complaint that the hospital cannot resolve immediately and notifies the patient of follow-up to the complaint (See also MS.09.01.01, EP 1) EP 7 - The hospital provides the patient with the phone number and address needed to file a complaint with the relevant state authority. (See also MS.09.01.01, EP1) EP 18 – For hospitals that use Joint Commission accreditation for deemed status purposes: In its resolution of complaints, 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 complaint • The results of the process • The date of completion of the complaint process

25. CASE STUDY • “My Doctor was not nice or communicated with me, did not want to prescribe me any meds even though I was in pain and not eating. I am being discharged without still not being able to eat and no meds for nausea or pain when discharged. Did not even ask me how I was feeling. He seen I was sweating, shaking in pain and still discharged me. I always gave good credit, but this doctor was horrible.” • Next step(s)?

26. CASE STUDY • “I have been in the Emergency Room since 2:17 pm, it is now 8:20 pm. I have not spoken with a doctor. I came in for pain and vomiting and yet nothing has been done about it. I have been asking for something to relieve my pain and yet no one seems to care. I myself think that it is wrong. Everyone who walk in after me has been seen. I don’t think that’s right at all. I keep getting excuses why I have not been seen.” • Next step(s)?

27. case study • “My Doctor is rude and never makes eye contact which me when he is communicating with me. He always seems to rush when giving me information. Whenever I asks a question he tells me that I am the Doctor not you, just listen to me. I want a new Doctor because I can’t take it anymore.” • Next Step(s)?

28. CASE STUDY • “I am very concerned about my Doctor. He got very upset with one of the Nurses. I heard him screaming and telling the Nurse that she didn’t know what she was doing. When my Doctor came to visit me, all he talked about was how stupid the Nurses are at this hospital. I want to be transferred to another hospital.” • Next Step(s)

29. Importance of communication & relationship • Effective communication – Critical • Building a relationship • Meetings regularly • Agenda items: Review monthly activity reports, compliance, TJC & CMS requirements, patient experience feedback from rounding, surveys, grievances and planning education programs. • Utilizing this approach will reduce the vulnerabilities for regulatory/accreditation deficiencies.

30. After the survey has been completed CELEBRATION!

31. Thank YouQUESTIONS?Caroline.Swinton@DignityHealth.org(909)806-1256