Grievance Policy

St. Vincent General Hospital District

St. Vincent Health

Leadville, CO 80461

Statement of Policy:

Patients of St. Vincent Health (SVH), his or her representative, family member, employee, or appointed advocate, have the right to voice a concern or grievance about an unresolved or safety issue concerning their care, or any other concern that arises from their experience with the hospital, without fear of retribution or changes in their care. They can expect the hospital to respond and work towards resolution, when possible, in a timely manner.

It is the policy of this facility to support each patient’s right to voice grievances and to ensure that after a grievance has been received, the facility will actively work to resolve the issue and communicate the resolution’s progress to the patient and/or patient’s family in a timely manner. The Patient Advocate will work with the patient and staff to resolve the issue. All grievances are investigated, and the outcomes documented.

SVH will inform the patient and/or the patient’s legal guardian/representative of the internal grievance process, including whom to contact to file a grievance. As part of its notification of patient rights, SVH will inform the patient in the resolution letter that he/she may submit a grievance with the State agency (the State agency that has licensure survey responsibility for SVH) directly, regardless of whether he/she has first used SVH’s grievance process.

SVH will provide the patient or the patient’s representative a phone number and address for submitting a grievance to the governing State agency below:

Colorado Department of Public Health and Environment
HFEMSD-A2 Attention: Hospital Complaint Intake
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530
303-692-2827 www.cdphe.state.co.us

SVH will refer Medicare ​beneficiary concerns to the hospital’s assigned Quality Improvement Organization (QIO) at the beneficiary's request if they have a grievance regarding quality of care, disagree with a coverage decision, or they wish to appeal premature discharge; additionally, SVH will inform all beneficiaries of this right and supply the QIO contact information below at their request:

Area 3 - KEPRO
Beneficiary Helpline 844-430-9504
http://www.keproqio.com/

Procedure:

Information on filing a grievance will be supplied at the time of all patient registrations and admissions.
The Board of Directors delegate the grievance responsibilities for effective operations of the grievance process to the Patient Advocate Policy Committee. The Policy Committee has appointed the Patient Advocate to ultimately handle and be responsible for the resolution of all grievances. When a patient wants to voice a grievance the receiving staff member will immediately notify the Patient Advocate, who will meet with the patient. If the Patient Advocate is not available at the time of grievance, the staff member will relay the patient’s medical record number and HIPAA compliant message to the Patient Advocate and Patient Advocate backup – who will make contact with the patient within 48 hours. The Patient Advocate will document and track the grievance on the hospital’s company shared Patient Complaint folder in a Quality Assurance and Disciplinary Procedures (QADP) excel spreadsheet.

Regardless of the nature of the grievance, the Patient Advocate will work with staff members to research the grievance and make sure the substance of each grievance is responded to by identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance.

A written response will be mailed for the initial acknowledgement of the grievance (which may or may not include the resolution) within the timeframe of 7 to 10 calendar days. SVH will follow-up with another written response stating the resolution when it is determined (if not resolved upon mailing the first letter).

Not all complaints must be in writing if SVH is addressing a relatively minor request from a patient and it can be immediately resolved. When appropriate, the grievance resolution will be noted in the grievance log and letter.

The letter will include:
• Identification of SVH’s contact person
• Steps taken to investigate each part of the grievance
• Results of the grievance process
• Date of completion

The Patient Advocate will supply a monthly grievance report to the Quality Management Team one week prior to their monthly meetings. The Patient Advocate will respond to any questions from the Quality Management Team that arise from the report.  

DEFINITIONS: 

Patient’s Representative:  

A person who is named on a patient’s HIPAA form as a point of contact with signature of patient, or the patient’s legal guardian or Power of Attorney for Healthcare. 

Complaint: 

A “patient complaint” is a patient care issue presented by a patient, or the patient’s representative, that can be can be resolved immediately by staff present. “Staff present” includes any hospital staff present at the time of the complaint or staff who can quickly be at the patient’s location (i.e., nursing, administration, nursing supervisors, patient advocates, etc.) to resolve the patient’s complaint.  
If a complaint: cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff (like a patient advocate or hospital management) for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements.  

Grievance:  

A “patient grievance” is a formal or informal written or verbal grievance that is made to SVH by a patient, or the patient’s representative, when a patient issue cannot be resolved promptly by staff present.  
Patient Advocate:  
SVH’s Patient Advocate is the person that formally receives and responds to all patient concerns. The Patient Advocate follows a process of listen, investigate, respond, and resolve for patient grievances and concerns for the patient and/or the patient’s representative. 

REFERENCES AND SOURCES OF EVIDENCE: 

NIAHO Grievance Guidelines  

POLICY VIOLATION: 

Any SVH employee who fails to abide by this policy may be subject to disciplinary action, up to and including termination.