This webinar will cover in detail the CMS requirements for hospitals to help prevent the hospital from being found out of compliance with the grievance regulations. This webinar will also discuss the Joint Commission standards on complaints and how these cross walk to the CMS grievance interpretive guidelines. Staff should be aware and follow the hospital grievance and complaint policy. This webinar will cover what is now required to be documented in the medical record. This is a must attend for any hospital.

Webinar Objectives:

• Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on grievances. (This is true whether the hospital is accredited by Joint Commission, AOA, CIHQ, DNV Healthcare or not)
• Identify that the CMS regulations under grievances includes the requirement to have a grievance committee
• Discuss that the Joint Commission has complaint standards in the patient's right (RI) chapter
• Recall that in most cases the patient must be provided with a written notice that includes steps taken to investigate the grievance, the results, and the date of completion
• Recall that AHRQ is proposing a consumer reporting system for patient safety events

Target Audience:

Consumer Advocates or Patient Advocates, COO, All nurses with direct patient care, Nurse Managers, JC Coordinators, all Department Directors, CEO, CNO, CMO, CFO, Board Members, Quality Improvement Coordinators, Risk Managers, Legal Counsel, Nurse Educator, Patient Safety Officer, ED Manager, Compliance Officer, Staff Nurses, Clinic Managers, OR Nurse Director, ICU Nurse Director, CCU Nurse Director, Outpatient Director, HIPAA Privacy and Security Officer, Lab Director, Policy and Procedure Committee, Ethicist and anyone involved in the implementation of the CMS Grievance or JC Compliant Standards

A few of the topics to be discussed:

• Background on CMS CoPs
• How to find current copy
• CMS deficiency memo
• How to find changes in the hospital CoPs
• Issuance of final interpretive guidelines
• TJC standards
• Recent standing order memo
• Preprinted order sheet changes
• Federal Register, interpretive guidelines, survey procedure
• P&P requires to ensure patients have information on rights
• Prompt resolution of grievances
• CMS definition of grievance
• Definition of staff present
• TJC definition and six elements of performance on complaints
• P&P with all the required elements
• Form to collect information
• HIPAA requirements if request not from patient
• Need to determine person is authorized representative
• Billing issues and information on patient satisfaction
• Telephone complaints after discharge
• Customer service and complaints
• Audits and PI required
• Policy to encourage staff
• Process for prompt resolution
• Requirement to inform each patient on how to file grievances
• Board's responsibility in grievance process
• Grievance committee required
• Referral to QIO and State Department of Health
• 2014 changes to QIOs process
• P&P on grievances
• Written notice to patient requirements
• Time frame for responding to grievances
• 7 day rule
• System analysis approach
• What should critical access hospitals do?

Consumer Reporting System for Patient Safety Event

• Proposal by AHRQ
• Background
• Voluntary collection of information from patients
• Federal register proposal