One aspect of providing care that is truly patient-centered is giving patients confidence that their preferences, concerns, and, yes, complaints will be heard and acted upon.
This is such an important concept within patient rights that it is addressed in specific requirements for ACHC Acute Care and Critical Access Hospital Accreditation. (Patient grievance standards are found in Chapter 15 for acute care hospitals and Chapter 6 for critical access hospitals.)
Complaint or grievance?
A complaint is a voiced issue that can be immediately resolved to the patient’s satisfaction. Examples of complaints might include issues with food choices, bedding changes, or housekeeping.
A complaint escalates to the category of grievance when it cannot be resolved in the moment. Additionally, any written complaint—including those received by fax or email from an inpatient, outpatient, a released or discharged patient, or a patient’s representative—is considered a grievance.
Grievances are typically triggered by issues with care received, or expected but not received. Allegations of abuse or neglect are always grievances, as are verbal or written complaints that tie to CMS Conditions of Participation, including billing concerns that touch on a specific Medicare beneficiary right. For example, not receiving a required notice, such as the “Important Message from Medicare” or being billed for something that should have been billed to Medicare, is a grievance. A concern like, “My bill is too high” or “I don’t understand this charge,” is not a grievance addressed by accreditation standards.
In most cases, the test isn’t the topic; it’s whether the complaint is easily resolved. Resolution is achieved when the patient or patient representative is satisfied with the actions taken on their behalf.
Managing grievances
Hospital policies and procedures begin addressing complaints and grievances at the time of admission, when the hospital must provide each patient with information about the right to communicate a grievance.
This information must explain how to submit a verbal or written grievance, including who to contact with a formal complaint and how to file a grievance with the hospital's state licensing agency. (The hospital must inform each patient of their right to contact the state agency regardless of whether they follow the hospital’s grievance process.)
Patients must also be informed of their right to have a grievance referred to a Quality Improvement Organization. QIOs are CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting.
Hospital policies should include the following:
■Process for documenting complaints and grievances across all locations.
■Timeline for investigations.
◦Seven days is the standard, on average.
◦If the grievance is complex and will not be completed within seven days, the procedure should require that the patient be informed within the seven-day period that work is still being done to resolve the grievance and that they can expect a written response within a stated number of days. The number of days is defined in the policy.
◦Complex grievances are those that may require medical record review by a physician or multidisciplinary team, or an extensive investigation or root-cause analysis.
◦The extended period is a policy decision that is best made by the leadership, risk management, and compliance teams. Hospitals should set a realistic policy interval that allows for prompt resolution. (A range of 15 to 30 days is common.)
■Written response to the patient that, at the minimum, includes the following elements:
◦Steps taken to investigate the grievance.
◦Hospital’s decision or outcome of the investigation.
◦Date on which the grievance investigation was completed.
◦Name of the hospital’s contact person.
■Mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate QIO, at the beneficiary’s request.
◦This CMS requirement does not mandate that hospitals automatically refer each Medicare beneficiary’s grievance to the QIO; however, the hospital must comply with a request for a QIO review.
■A means to incorporate grievance data in the QAPI Program.
■Acknowledgment that the hospital’s governing body is responsible for approval of an effective grievance process. Additionally, it must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.
Best practices
■Standardize intake and tracking.
◦Use a single log/system to capture every complaint and grievance, regardless of the channel and which department receives it.
◦Start the timeline at the moment a complaint isn't resolved by staff present.
◦Build in automatic flags when a deadline (e.g., 7 days) is approaching.
■Train on the complaint vs. grievance distinctions.
◦If the response to a complaint sounds like, “I’m just a nurse/aide/food service attendant and don’t know about that,” the door has been opened to escalate a complaint to a grievance.
◦Create a process for follow-through. Staff members must proactively pass the complaint to someone who can address it and communicate to the patient that this is what they will do.
◦Calls going to a “patient advocacy” line should be managed similarly, with timely call back and response/resolution.
◦Follow-up after a conversation. At times, staff or leadership feel the issue was resolved during an initial conversation, but the patient is not satisfied with the actions taken or the response. Then, days later, it becomes a grievance that triggers a more complex process.
■Build a response letter template.
◦A standardized template with all four required elements (decision, contact name, investigative steps, completion date) reduces the risk of omitting an element.
◦The written response must be in the language the patient understands. Avoid medical terminology or process improvement terms. Use simple language such as, "a review of the medical record" and "an interview with staff who cared for you."
■Create an escalation path for urgent grievances.
◦Abuse/neglect/harm allegations go to leadership the day they are received.
■Provide proactive interim communication.
◦Standardize a “still working on it” letter for any grievance not resolved by day 5-6 to meet the initial seven-day communication period.
◦Include the new expected resolution date, per policy.
■Refresh patient rights materials regularly.
◦Audit admission packets, website, and posted notices annually for correct state agency contact info and QIO language.
◦Confirm information is provided in the patient's preferred language and is simple to understand.
■Tie grievance data to QAPI.
◦Plan monthly or quarterly trend reviews: Categorize grievances by type, unit, or root cause.
◦Feed patterns (e.g., repeated complaints about a specific unit or process) into performance improvement projects.
◦Document the link to PI projects explicitly. Surveyors often check for the connection, not just the raw data.
■Conduct internal mock surveys/chart audits.
◦Periodically pull closed grievance files and audit against all four written response elements and time frame compliance.
◦If a grievance escalates to a state agency, review the grievance process for that patient to look for opportunities for improvement.
■Define leadership oversight and accountability.
◦Designate a clear owner (e.g., patient advocate or risk manager) for process compliance.
◦Report regularly to hospital leadership/board on grievance volume, resolution times, and trends.
■Review policy for policy-practice alignment.
◦Compare the written grievance policy against actual practice.
