Greivance Policy

Purpose

The purpose of this policy is to protect patient rights and to establish a process for the resolution of Grievances. The Network encourages open communication between local providers of ESRD healthcare services (dialysis and kidney transplant) and CKD / ESRD patients. Effective communication; as presented in the Decreasing Patient Provider Conflict (DPC) Toolkit, combined with patient education are keys to the avoidance of complaints in the ESRD setting. In the event that resolution of problems cannot be reached at the provider level, the Network serves as an objective arbiter of Grievances under authority of Centers for Medicare and Medicaid Services (CMS) federal contract.

The Network cannot and will not retaliate, discriminate against, intimidate, coerce or otherwise reprise patients or patient advocates who file Grievances.

Standards

The Network will require, in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations, that all ESRD healthcare providers establish and implement polices and procedures that address patients’ rights and responsibilities and encourage patients to understand and exercise those rights and responsibilities. All New England ESRD healthcare providers must establish, maintain and offer an internal patient complaint process for the resolution of problems at the provider level. This policy and its’ procedures must be made known to the patients being cared for in that facility. The ESRD healthcare provider must also post the Network Grievance Notification card in a prominent place, so that all patients have fair and equal access to the Network toll free patient telephone line. If a patient has complained at the facility level without satisfaction, the patient will be referred to the Network. If the patient does not wish to complain at the facility level, they may address their concerns directly to the Network.

The Network Medical Review Board (MRB) will establish and maintain a standing Sub-Committee for consult and review of Grievances; this committee with be the Network Grievance Committee. The Network Board of Directors will appoint members of the Network Grievance Committee. Each member will serve an unspecified term of office, with membership representing professional and demographic diversity.

This Network Grievance policy, a Network Grievance Notice placard and a copy of “Your Health - A Shared Responsibility” will be distributed to New England ESRD healthcare providers as part of the New Facility Starter Kits.

Contacts, inquiries, problems, complaints and Grievances may be addressed to the Network for review and resolution by patients, patient family members and patient advocates. Reported issues should relate to experiences or problems in dialysis facilities, transplant centers, or acute dialysis facilities (hospitals). Grievances may also be addressed to other agencies or regulatory bodies with jurisdiction over ESRD healthcare providers.

All Grievances are private, confidential and protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines. Patient identity is confidential and cannot be released without the expressed permission of the patient. Access to information, or documents regarding a Grievance will be restricted to appropriate Network professional staff. Records related to Grievances will be stored in a secure location either in hard copy or electronic format. The Network will number Grievances as assigned by the Systematic Information Management System (SIMS) in order to track and monitor status of the Grievance. If the Grievance creates a conflict of interest for Network staff, the Network Grievance Committee, or either of the Networks Boards (MRB, BOD), the nature of the conflict will be declared as soon as recognized. The member will remove himself or herself from the Grievance process coincidental to declaration of conflict.

To maintain an effective and efficient Grievance Policy, procedure and process the Network will periodically self evaluate its system of addressing Grievances. Any resulting changes in policy, procedure or process will be brought before the Network Board of Directors for approval and implementation. The policies and procedure described herein are also subject to revision in accordance with CMS requirements.

Procedures

In order to assess a situation that has resulted in a Network Grievance the details should be submitted in writing by the reporting person and should be signed or marked (witnessed). Upon receipt of a Grievance the information noted by phone or written document will be numbered according to SIMS and kept in a separate, secure, identifiable location. All related materials will also be kept in this file. If the Grievance is of a life threatening nature the State Department of Public Health and the CMS Region 1 Project Officer will be immediately notified. Upon receipt of a Grievance the Network will undertake CMS prescribed steps to establish lines of communication with all involved parties and begin the process of inquiry into the matter. The Network will employ methods of inquiry including telephone interviews, electronic communications by e-mail or FAX, request and review of records and on-site visits as indicated. Throughout the sequential process of review, inquiry, findings and recommendations the Network will adhere to timelines for completion as prescribed by CMS. The Network Patient Services staff member (PSC) will be first point of contact for Grievances, if the presenting issues involved are primarily clinical in nature, the Grievance will be referred to the Network Medical Quality Manager. The Network Executive Director will be consulted throughout the process. A phone call, letter of inquiry, or both will notify the ESRD healthcare provider that a Grievance has been filed naming their facility. The ESRD healthcare provider will be advised that they must respond within ten working days from receipt of the Grievance notification. If a satisfactory solution cannot be mediated between the patient and provider as a first remedy, the Network will intervene by making recommendations and could require a monitored corrective plan of action to be undertaken by the ESRD healthcare provider. The Network Grievance Committee will be consulted at the discretion of the Network ED. When review of the Grievance is concluded the person reporting the matter and the ESRD healthcare provider involved in the Grievance will be sent letters explaining the Network’s findings. If the patient or patient designee is dissatisfied with the Network’s recommendations, a series of referrals will be triggered as follows: the Network Grievance Committee, the Network Medical Review Board, the Network Board of Directors, the CMS Region 1 Project Officer and as a last referral the State Department of Public Health. The Network staff, Grievance Committee and Boards may decline, after consultation with CMS, to review a situation for which legal action is pending.

Time Frame

Within fifteen (15) calendar days of receipt of a Grievance, a letter confirming receipt will be sent to the patient or patient designee. Within one month (30 days) the patient or patient designee will be advised of the course of action to be taken by the Network. Within ninety days (3 months) all Network activities, including but not limited to: communication, mediation, education, recommendation, referral and resolution will be concluded.

Follow-Up

If an ESRD healthcare provider has been required to implement a corrective action plan as the result of a Grievance, the Network will monitor progress on the plan for an appropriate period of time.

Documentation

All Network contacts, including Grievances, will be documented and tracked in the Standardized Information Management System (SIMS) computer program. All Grievances will be documented and filed in hard copy format (paper records).

This policy and evidence of Network activity resulting from this policy will be presented at the Network’s onsite evaluation conducted by CMS Region 1 Project Officer. This policy is established in the interest of patient rights and is in compliance with Network Goals and Objectives.

NOTE: The above policies incorporate HCFA interim grievance instructions (10/89). Network policy and procedures are on file in HCFA/HSQB as of 2/90.

Distribution: June 1990

Amended: The changes in this policy incorporate the new language in the final HCFA grievance guidelines effective 7/91. Amended policy approved by Board of Directors: 9/26/91.

Distribution: October 1991

Amended: Procedure clarified at request of project officer 6/93 regarding the network seeking consultation with HCFA on grievances involving pending legal action. In matters that are life threatening the network will refer and assist the regional office in seeking resolution. 6/93.