A Growth Mindset Approach to Managing Grievances

By: Shannon Roberts, RN

Senior Clinical Compliance Educator

Posted: August 5, 2025

A grievance or complaint is a formal statement, either verbal or written, from a service recipient, advocate, or staff member expressing dissatisfaction. Complaints often focus on issues related to quality of care or services, safety, service recipient rights, and/or mistreatment or abuse. From an accreditation perspective, dealing with a grievance is not just a matter of addressing an individual problem, it involves establishing and implementing tools to track the responsive corrective actions. The goal is to minimize the potential recurrence by improving overall service quality, safety, and client/staff satisfaction.

But can you prove it?

During an ACHC Accreditation survey, behavioral health providers are expected to demonstrate compliance with multiple standards related to grievances and complaints. Organizational compliance must be convincing to the surveyor. The evidence will fall into one or more categories: direct observation, response to interview, and written documentation.

Let’s take a close look at ACHC Behavioral Health Accreditation Standards and the associated evidence that your organization is meeting the requirement.

Standard BH2-2A includes two service recipient rights regarding voicing and investigating and grievances/complaints that must be listed on a Rights and Responsibilities statement provided to each client.

The evidence used to demonstrate compliance with this standard includes:

• Written policies and procedures.
• The statement of service recipient rights and responsibilities.
• Service recipient records.
• Response to interview.
• Observation of procedures in action (as applicable).

Standard BH2-4A describes the requirement to inform each service recipient or their representative, at the initiation of service, about how to report a complaint and how complaints are investigated and resolved.

The evidence of compliance for this standard includes:

• Written policies and procedures.
• A log of complaints/grievances received.
• Governing body meeting minutes, if applicable.
• Response to interview.

Standard BH2-4B includes providing, at the time of admission, the service recipient or their representative with written information about how to contact the organization, appropriate state agency, and ACHC with a complaint.

The source of evidence for compliance includes:

• Service recipient records.

Standard BH2-5A states that the organization will provide the service recipient/responsible person with a process to appeal in the event that they are not satisfied with the outcome of the organization’s complaint investigation.

Surveyors look for evidence of compliance in:

• Written policies and procedures.
• Observation.

Standard BH6-3D requires that performance improvement (PI) reports include at least quarterly review of all grievances/complaints to detect trends and an action plan to decrease occurrences.

The evidence for this standard focuses on:

• Performance improvement reports.

Standard BH6-3J expects ongoing monitoring of service recipient grievances/complaints and the PI actions taken to resolve complaints and improve services.

The evidence required for this standard should be present in:

• Performance improvement reports.

Each form of evidence serves to validate that the organization is meeting the standard, but you may note that most standards require written documentation: a policy or procedure, documentation in a service recipient’s record, personnel files, audit tools, training records, formal observations of care/service.

ACHC Standards are structured in a Plan-Do-Study-Act (PDSA) quality cycle. Policies and procedures often represent the starting point—(Plan, or what you intend to do)—then we look for documentation of how you implement your policies (Do). When complaints come, as they inevitably will, ACHC wants to know that you’ve looked for trends and patterns (Study) and that your corrective actions (Act) are documented as activities reflecting the results of your analysis.

Making it matter

Accreditation, whether mandated or voluntary, is an important achievement for a behavioral health organization. Compliance with standards related to grievances/complaints, can be another box to check OR a strategic tool. By embracing a growth mindset – so appropriate to this type of setting, your organization will be:

• Prioritizing service recipient’s rights.
• Driving continuous improvement in care/services.
• Building strong relationships by fostering open communication.
• Minimizing potential risks and liabilities.