Transcript Burn Intensive Care Unit PI-LDP PROJECT December 7, 2007

Fine Tuning the Patient
Complaint Process for MUHS
PI-LDP Project
February 19, 2010
Kay Steward - Manager of Guest Relations
Nancy Jones - Department Manager - Nursing
Myra McCoig - Risk Management Coordinator
Laura Hirschinger – Clinical Improvement Specialist
Advisors:
John Hornick Director of Nursing Services
Carey Smith Manager of Regulatory Affairs
Executive Sponsors:
Les Hall
Chief Medical Officer
Dennis Stambaugh Chief Quality Officer
Initial Focus Area and Aim
9/9/09- Global Aim Statement:
We aim to improve the methods for addressing and
resolving complaints.
The process begins with the initial patient complaint.
The process ends with patients and family
acknowledgement that they have been heard, they receive
feedback and the issue has been addressed.
By working on this process we hope to improve coordinated
effort, timeliness, and efficiency of response to patient and
family and meet regulatory requirements.
It is important for us to work on this now because we want
our customers to feel their concern was acknowledged,
investigated, and that they have received feedback in a
timely manner.
UMHC Strategic Goals and
Columns of Excellence
Acknowledging and answering patient’s questions and complaints
contributes to each of the Columns of Excellence. Patient
satisfaction includes:
•
•
•
•
•
•
Evaluation of how we handle complaints
Indicator of quality of care
Validation of billed charges
Empowering of staff for service recovery
Retention of patients and customers for continued growth
Continue to strive as employer and provider of choice
4
Service ~ Quality ~ Finance ~ People ~ Growth ~ Community
Key Words…
• Complaint - Any verbal expression of
dissatisfaction with a process or person, which is
generally resolvable at the department level by
staff present or refer to appropriate chain of
command.
• Grievance - A grievance is a substantive
quality of care issue or a perceived
violation of a patient's rights.
submitted in writing or is unable to be
resolved during the inpatient stay or
outpatient visit,
All written complaints, unless written as
a comment on a patient satisfaction
form.
Verbal complaints expressed after the
patients discharge or visit may be
determined to be a grievance
First
at Complaints…
The Challenges
EDUCATION ROLES
OF THE AND
RESPONSIBILITIES
ROLES AND
COMPLAINT/GRIEVANCE
RESPONSIBILITIES
Physicians
PROCESS
LACK OF COORDINATION
LACK OF COORDINATION
Varied entry points of compaint
Email
Administration Guest Varied entry points of compaint
Written
policy
Attendings
Department
ServicesEmail Administration Guest
does not match
Residents Chairs
Attendings
Department
practice at this
Services
Residents
Chairs
time
Managers
Receipt
of
complaint
DATA OUTCOMES
Managers
Receipt of complaint
Multiple Departments Input Needed to
Nursing Ancillary
Lack of understanding
of the process required
Named
Multiple
Departments Input Needed to
Nursing Ancillary
Concerns
ResponsibilityReconcile
by regulatory agencies
Named
Guest Services
Reconcile Concerns
to track complaints
Complaints
Grievances
Guest Services
Begining
Administration
Resolution Regulatory
Administration
Compliance
Resolution of the complaint
Patient
Accounts
Duplicate
Uneducated front line staff
Resolution of the complaint
Patient Accounts
Administration Guest Managers
Who to direct
Quality of care complaints
Guest Managers
How to resolve
Services
Administration
Quality of care complaints
to for resolution
Services
Ability to pull
Risk Management
information together
Patients
often receive
Risk Management
for trends and
patterns
Patients often receive
Different conception of how complaints are
conflicting information
Patient advocacy
conflicting information
entered and resolved
Patient advocacy
Reporting
ofDocumentation
PSN
submitted
to
Lack
of
Guest
Staff
SOM
Department
Administration
PSN submitted to
complaint activity to
Lack of Documentation
wrong department
Services
Managers Members
wrong department
management group
Physicians
Urgency perceived by
Administrative support staff to
resolve complaints
immediately
Same complaint
Who handles
simple comes
resolutions?
Do ineffective
up multiple times but
resolutions lead to
gets reworked by a
grievance level?
Who is the
responsible
party
different
person or
area
for the overall complaint?
Define Define
Complaint
Complaint
Process
Process
Who handles simple resolutions?
Who is the responsible party
for the overall complaint?
Poor communication
Unclear
coordination
TIMELINES
When should complaints be
Disruptive
of
triaged tobehavior
Administration?
person complaining
Who is the lead for theWhen should complaints be
grievance process?
triaged to Risk Management?
Department managers unsure
of resolution, documentation,
Tracking problem
and communication
issues?
patients/families
Where is the repository for the
grievance documentation?
Nursing managers being
asked to resolve
physician complaints?
Unclear how grievances
are reported to
PATIENTS/FAMILIES
Departments do
not
Administration?
have the resources
WITH UNREALISTIC
“manpower”
EXPECTATIONS
GRIEVANCES
InvestigateResolve
Timely
Timely
RESOLUTION
When should complaints be
triaged to Administration?
When should complaints be
triaged to Risk Management?
Department managers unsure
of resolution, documentation,
and communication issues?
Nursing managers being
asked to resolve
physician complaints?
Departments do not
have the resources
“manpower”
InvestigateResolve
Timely
Timely
RESOLUTION
CMS Rules
CMS Requirements for Complaint
Resolution
 The patient should have reasonable expectations of care and
services and the facility should address those expectations in a
timely, reasonable, and consistent manner
 If the complaint will not be resolved within 10 days, the hospital should
inform the patient /representative that the hospital is still working to
resolve the complaint. Communication will occur every 10 days until
resolved.
 A complaint is considered resolved when the patient is satisfied with
the actions taken on their behalf.
Stakeholders
•
•
•
•
•
•
Guest Relations
Regulatory Affairs
Risk Management
Patient Safety
Administration
Department Managers
•
•
•
•
•
•
•
UH Physicians
School of Medicine
Frontline staff
Patients
Visitors
Family
Community
Going to the Key Players…
Survey Monkey Results
Facility
N= 95
CRH
9%
Clinics
17%
UH
59%
MRC
12%
MUPC
SOM 2%
1%
Survey Monkey Results
Role
Department
Administrator
5%
Director or
Above
10%
Assistant
Manager
25%
Supervisor
16%
Manager
44%
Survey Monkey Results
The current resolution process for complaints is effective.
60.0%
50.0%
40.0%
Strongly Disagree
30.0%
Disagree
Neither
20.0%
Agree
Strongly Agree
10.0%
0.0%
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Survey Monkey Results
The current process allows for the resolution of complaints and
grievances in a timely manner.
60.0%
50.0%
40.0%
Strongly Disagree
30.0%
Disagree
Neither
20.0%
Agree
Strongly Agree
10.0%
0.0%
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Survey Monkey Results
When more than one department is selected for resolution, who is
the person responsible for resolving the complaint?
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Guest Services
OCE
Hospitality Coordinator
Department where patient is
located
Service complaint is about
Survey Monkey Results
When more than one department is selected for resolution who
should be responsible for resolving the complaint?
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Guest Services
OCE
Hospitality Coordinator
Department where patient is
located
Service complaint is about
What is the greatest STRENGTH of
the complaint process in PSN?
• A good tracking system.
• Allows feedback and communication from the
different departments.
• Gets all departments involved and working
together to solve the problem and come to an
appropriate solution.
• Brings accountability and recognizes
weaknesses in a process or specific area.
What is the biggest CHALLENGE of
the complaint process in the PSN?
• No accountability for actual resolution
• One dept cannot affect change on another
department and the frivolous reports often take so
much attention that the real issues never get
addressed.
• Limited loop closure by the responsible party with
those seeking direct follow-up.
• No routine reports are shared that trend complaint
types by service, or number of days to resolve,
etc.
Evolution of Aim Statement
To define the process of addressing complaints
throughout the University of Missouri Health Care
System to establish a consistent and efficient
method which clearly defines the roles of
stakeholders to provide appropriate resolution by
March 31, 2010 through the implementation of new
algorithms outlining the process and educating
staff on the process and regulatory requirements.
Interventions Considered
1. Education to all staff
on role
3. Revise PSN System
for ease of
documentation
4. Revision of policy
Resources
2. Provide an executive
report
Impact
Low High
1, 3
High
Low
4
2
Next Steps
1. Create a systemic definition of how all
complaints would be processed regardless
of point of entry—Define Algorithms
2. Determine how we will educate on the
new process
3. Develop a Patient Safety Leadership
Team report
4. Work with IT on PSN revisions
Establishing Ownership
Executive Sponsors
Executive Committee Of Medical Staff
Department Chairs
Division Directors
Senior Leadership
Managers
Defining the
Process
All Written Complaints
Updated 2/3/10
ALL written documents (i.e. email or letters) entering the
health system go to Guest
Relations
* Excludes written comments
on Press Ganey, Your Opinion
Counts, and/or Solicitted
comments
Guest Relations sends
confirmation letter to
patient in one business
day
Guest Relations
clarifies the issues of
the grievance
including checking
IDX for patient
service
Guest Relations Generates
a PSN comment report &
designates as a grievance
coordinating the response
Guest Relations
assigns to
departments for
review
Department must
submit response in
PSN System in 5
business days.
If no response in 5
business days Guest
Relations will notify
Clinic/Hospital/SOM
Director
If unable to resolve within
5 business days Guest
Relations sends a written
progress report to patient
Reference: Response to Patient complaints “Grieve Algorithm”
Guest Relations responds with formal written
resolution per policy based on departments
PSN response
Patient Complaints About Physicians
Current Inpatient
Last updated 2/3/10
Patient
complaints
about
physicans
Guest
Relations
acknowledges
& listens to
concern
Guest
Relations
identifies
immediate fix
Guest Relations
Restates concern
Guest Relations
Follow-up with Patient
Guest Relations
Check IDX for
patient service
Guest Relations is
unable to fix &
needs to forward
to the appropriate
department
Guest Relations
provides contact
materials to
patient/family
member
Guest Relations
Calls Department
to gather
information
Guest
Relations Calls
Attending
Physician
Department facilitates
resolution
If unable to resolve let
the physician know that
a response is needed in
one business day for
service recovery while
patient is still inhouse
If Attending is able to resolve
immediately the PSN comment
report is generated by Guest
Relations for tracking purposes
Guest Relations
Generates a PSN
report (Goals are
outlined in this
report)
Guest Relations
waits for a
response from the
SOM
If no response in one
business day notify
Chief Medical Officer
SOM resolves
with patient (this
should be
documented in
PSN)
Guest Relations will make a
follow-up contact with patient
for final resolution
SOM unable to resolve
with patient & asks
Guest Relations to
facilitate resolution
Guest
Relations
resolves
PSN
Guest Relations will make a
follow-up contact with patient
for final resolution
Patient Complaints About Physicians
Outpatient
Last updated 2/3/10
Patient
complaint
Guest Relations
acknowledges &
listens to
concern
Guest Relations
Restates concern
If no follow-up is
requested by patient/
family, Guest Relations
generates a PSN
Comment
Clinic/Hospital/SOM
provide resolution in the
PSN System
Guest Relations
provides contact
materials to patient/
family member
Guest Relations
Check IDX for
patient service
Guest Relations is
unable to resolve &
needs assistance
from the appropriate
department
If Clinic/Hospital/SOM is able to
contact the patient they can resolve
the PSN Comment immediately.
Guest Relations
Generates a PSN
Comment (Goals
are outlined in this
report)
Guest Relations
waits for a response
from the responsible
department
If no response in one
business day notify
Chief Medical Officer
SOM unable to resolve
with patient & asks
Guest Relations to
facilitate resolution
Guest
Relations
resolves
PSN
Guest Relations will make a
follow-up contact with patient
for final resolution
Guest Relations
sends reminder email
to Clinic/Hospital/
SOM (this is noted in
the PSN Comment)
Clinic/Hospital/SOM
contacts patient and
resolves (this should
be documented in
PSN)
If unable to resolve to
patient’s satisfaction Guest
Relations will document in
the PSN System.
Clinic/Hospital/SOM
contacts patient and
resolves (this should
be documented in
PSN)
Guest Relations will make a
follow-up contact with patient
for final resolution
Billing Complaints
Updated 2/3/10
Billing Issues
Guest Relations
acknowledges &
listens to concern
Guest Relations
restates concern &
ask if they have
spoken with
Patient Accounts
If they have already
spoken with Patient
Accounts Guest
Relations checks IDX
for patient service
Guest Relations
Generates a PSN
Comment
Guest Relations
submits to Patient
Accounts
If they have not spoken with
Patient Accounts the call is
transferred to them for resolution
Patient Accounts
contacts patient
and resolves
comment report in
PSN System
Guest Relations oversees to ensure
Patient Accounts has contacted patient
and resolved report appropriately.
Lost Item complaints
Updated 2/3/10
If this is an essential
item like: hearing aids,
glasses, or dentures
the following steps are
taken and will be
replaced if not found
Lost Items
reported to
Guest Relations
Security
Department
Searches
Guest Relations
generates a
PSN(Goals are
outlined in this
report)
Guest Relations takes
notes
(this is explained to
patient and a reconnect date is
provided
If this is a nonessential item- Guest
Relations confirms
the condition of
service form for
signature
Dietary Searches
Hospitality
Searches
Lost Medications
Linen Services
Seaches
Returns
Medications to
Patient
Clinical Unit/
Department
Searches
Notify patient
unable to locate
medications
Housekeeping
Searches
Security files a
report
Guest Relations
Awaits Response
Notify Risk
Management &
Insurance
Management
(Claim maybe
submitted for >$1,000)
Guest Relations follows up
with patient with response
Anticipated Return
Compliance with External Requirements Grid:
This initiative improves compliance with external requirements in any of the following ways.
Type of Strategic or Market Effect
No
Effect /
NA
(Check)
Directly
Improve
(+) or
Worsen (-)
Indirect
Improve
(+) or
Worsen (-)
Measure(s) Used
Strategic Impact
 Supports Strategic Vision/Mission
 Retention of patients and
+
customers for continued growth
 Continue to strive as employer
and provider of choice
Market Impact
 Increases volumes
√
 Increases market share
√
+
1. Evaluation of how we
handle complaints
2. Retention of patients and
consumers for continued
growth
Measurement Data /
Description:
Projected/Actual Changes
Over Specific Time Period
Next Phase
•
•
•
•
•
•
•
Guest Relations informational card – March 2010
Guest Relations report at bi-weekly – March 2010
Continuing education of process – March 2010
PSN changes – June 2010
Education on new PSN revisions- June 2010
Post survey – August 2010
Continuous Monitoring!!
Lessons Learned
• Required vigilance
• Required clarification of roles and
responsibilities
• A process taken for granted without
functional understanding or direction
Team Dynamics
– blending of experiences and backgrounds
Team Function
•
•
•
•
•
•
Discursive Discusser – Myra McCoig
Wordsmith – Nancy Jones
Organizer – Laura Hirshinger
Badger – Kay Steward
PI LDP Experience Guide - John Hornick
Politician - Carey Smith