Responding to Complaints: An Ounce of Cure, a Pound of Prevention

The impact of a single complaint or grievance reaches far beyond the individual concerned—this is as true in a health care setting as it is anywhere else. Although people tend to underreport unhappiness with their health care, they do tend to talk about it with friends and family.¹ As reported by the Agency for Healthcare Research and Quality (AHRQ), marketing studies indicate that while only 50% of unhappy customers complain to the service provider, 96% will tell at least 9 or 10 others about their bad experience.² Considering the ubiquity of online ratings for providers and facilities, this "grapevine effect" can potentially spread the impact of a single complaint far and wide, including to prospective patients or residents.²

Organizations must address complaints and grievances in order to comply with federal regulations and accreditation standards, as well as to protect patients (and their caregivers/families) and reduce liability. The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation require that organizations have effective processes for addressing grievances, and CMS has published interpretive guidelines for various settings on this topic. Although these requirements apply to individuals in specific Medicare- or Medicaid-funded care settings, they are also appropriate recommendations for handling complaints and grievances from all individuals served—regardless of payment source or care setting.

The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities' complaint resolution standards also require that accredited facilities address and resolve complaints from patients, residents, and their families. In addition, facilities using Joint Commission accreditation for CMS-deemed status purposes must establish a mechanism for timely referral of complaints regarding the quality of care to the appropriate CMS-contracted quality improvement organization upon request by a Medicare beneficiary.

Still, effectively integrating these standards into practice can be challenging; it involves developing not only easily accessible methods for people to submit complaints but also internal workflows to evaluate and address the feedback received. There are several key areas to focus on to successfully address complaints from patients, residents, caregivers, and others.

Organizations should establish a multidisciplinary team to resolve complaints and grievances. The team may include administration, resident relations staff or advocates, risk and quality managers, the compliance officer, legal counsel, and nurses or other staff with direct resident contact. The team should review all individual grievances, complaints, and resolutions in addition to aggregated data.

Because complaints and grievances may be received by a variety of staff (eg, clinical, risk management, or administrative), clearly defined terms and procedures are essential for the submission of verbal or written grievances to ensure that they are effectively managed and forwarded promptly to the designated grievance committee for investigation and follow-up.³

Patients and residents should also be notified of their legal rights upon admission to the facility, including that they have the right to file complaints or grievances regarding their care; that their decision to file complaints or grievances will not compromise the care they will receive; and that all information will be kept confidential. In addition, they should receive information regarding how to file a grievance or complaint and to whom they should address such concerns.

In an effort to promote transparency and reporting, organizations often publish this information on their websites or in written materials provided upon admission; they should periodically review these materials to ensure that the language is clear and easily understandable. Facilities should provide versions in other languages or offer document translation or interpreter services for residents or patients with limited English proficiency.

Organizations must actively solicit feedback to capture—and resolve—all complaints and grievances,1 which allows organizations to identify patterns and opportunities for service recovery, identify at-risk providers, and improve patient satisfaction (Box 1).

Box 1. Strategies for Sustained Improvement in Complaint Capture¹ 

• Promote the availability of advocates;
• Publish articles about grievance policies in print and online communications;
• Place flyers with telephone numbers for clinical emergencies and resident relations in highly visible locations in every room;
• Use "same-day feedback" cards; and
• Ask individuals served whether all their needs are being met—and, if the answer is no, what the staff or facility could do better.

Developing well-articulated policies and procedures—including formal definitions for complaints and grievances—will facilitate consistent treatment of all complaints and grievances and lay the groundwork for quality improvement initiatives.

Organizational policy should detail the principal steps in a grievance investigation, which may include the following³:

• Interviewing the individual served;
• Interviewing the complainant (if different from the individual served);
• Reviewing relevant medical records;
• Interviewing staff who may have knowledge of the situation;
• Researching applicable laws, regulations, policies, and procedures; and
• Identifying measures, including those already taken, to resolve the problem.

In addition, documentation of complaints and grievances, as well as their resolution, is important not just for CMS compliance but also for quality improvement and risk management purposes. Organizations should consult with legal counsel in designing forms and systems for such documentation to ensure they take advantage of all available legal protections while complying with applicable state and federal laws for peer-review processes and treatment of patient safety work products.

Although CMS regulations for aging services providers (eg, home health agencies, skilled nursing facilities) do not require a written response to the patient or resident, providing one is nevertheless a suggested risk-management practice.

In addition, because written responses may be used as evidence in court, organizational policies should recommend that staff prepare responses objectively and state only the facts. Copies of written responses should be sent to the risk-management department, and reports on all grievances and actions taken should be submitted to the governing board or grievance committee.

All staff, especially nurses, physicians, and others with direct contact with residents, should receive education on the facility's grievance process and how to direct grievances to appropriate personnel.

Education should emphasize the value of effective communication skills, such as listening without becoming defensive, being empathetic, handling emotion, solving problems, and following through.²

Formal training should be ongoing and include meaningful strategies to develop both individual and organizational skills in conflict resolution and active listening. Training should include understanding human reactions and how different personality types complain, as well as focusing on the problem rather than the delivery and distinguishing the personality from the problem.⁴

Resources for advocacy across the aging services continuum include patient and resident advocates (staff or volunteer), ombudsmen, resident councils, and family councils.

Organizations may consider using advocates as their liaisons with individuals served when a potential claim arises. The advocate will ideally have established trust and rapport with the individuals served and, therefore, will be the ideal candidate for explaining the facility's procedures for handling claims.

Skilled nursing facilities must post contact information, including name, address, and telephone number information for advocacy resources, which include state survey agencies, state licensure offices, state ombudsman programs, and Medicaid fraud control units.⁵

Service recovery is a process that organizations can use to "recover" the trust of dissatisfied individuals by identifying and addressing the problem or otherwise making up for failures in clinical operations or customer service.

According to AHRQ, "Many staff know immediately which situations or patients will end up in the [chief executive officer's] office,"2 emphasizing the value of staff's proactive communication with leadership to facilitate a swift resolution—ideally before the individual files a formal complaint (Box 2).

Box 2. Best Practices for Service Recovery Best practices for basic service recovery have been articulated using the mnemonic "HEARD," representing the following steps⁶:

• Hearing the concern;
• Empathizing with the individual raising the concern;
• Acknowledging appreciation for the person's coming forward and apologizing as warranted;
• Responding to the concern with a time frame and expectations for follow-up; and
• Documenting the concern.

Create an infrastructure that allows staff to respond to complaints.⁶ By empowering staff to respond to smaller concerns expeditiously, organizations can prevent them from becoming larger issues.

In order to manage some complaints autonomously, staff need the following²:

• Straightforward direction regarding the extent of their authority to act on complaints without getting approval from managers;
• Clear protocols to address the most frequent complaints;
• A minimum of bureaucratic roadblocks; and
• A clear system of resource people, lines of authority, and backup systems for addressing difficult situations or situations with financial, legal, or ethical implications.

Analyzing complaints and grievances in aggregate yields a wealth of data that is a powerful tool for quality improvement.³

One way to formalize this process is to conduct an annual written analysis of all formal complaints to determine trends, areas in need of improvement, and actions to be taken, with a goal of delivering better service and improving outcomes.

Organizations should capture and categorize information on grievances and complaints and use the data as part of their quality assessment or performance improvement programs. For example, the organization may identify recurring complaints or electronically organize data by category (eg, setting, service, physician) to determine trends. Several options are possible for cataloging member complaints that enable tracking by typologies, which link complaints to related quality-improvement activities, such as the Consumer Assessment of Healthcare Providers and Systems composite.²

Overall, it is important to ensure all staff are well trained and well equipped to receive complaints and grievances from patients and their families. This includes clear processes and procedures for reporting, acting on, and resolving such feedback. As with all quality improvement initiatives, ongoing management of complaints and grievances requires constant vigilance and monitoring to ensure they are effectively managed and addressed.

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