Patient Complaint & Grievance Policy
NYU Hospitals Center, as part of its total commitment to excellence, believes in the patient's and their representative's right to a courteous, prompt and complete response to their communications with the Hospital. Information and response provided by NYU Hospitals Center should be consistent in the presentation of facts and statement of policies. When appropriate or necessary, follow-up action and/or patient contacts are to be completed.
In accordance with New York State Hospital Operating Code Section 405.7, the Hospital will investigate complaints including grievances. The Hospital will provide the patient or patient's representative with a written response if requested, or if the complaint rises to the level of a grievance, indicating the findings of the investigation. The Hospital will also inform the patient or patient's representative of their right to complain to the New York State Department of Health and/or The Joint Commission if he or she is not satisfied with the Hospital's written response.
To ensure satisfactory, appropriate and consistent patient-sensitive communication, Patient Relations shall manage all complaints and grievances directed to NYU Hospitals Center, regardless of where first contact is made.
Patient Relations serves as a central resource for responding to all grievances with the exception of the following:
- Complaints, including grievances, citing only financial concerns will be managed by the Vice President for Medical Center Finance, Revenue Cycle Operations, for review and response to the patient. Patient Relations will document receipt of the grievance, acknowledgment, referral, and any supporting documents provided to the patient in the patient feedback system.
- Complaints, including grievances, regarding HIPAA privacy concerns shall be referred to the VP for Audit and Compliance/Privacy Officer who will determine their involvement in the investigation.
For these exceptions, an Acknowledgment will be communicated by Patient Relations to the patient or their representative within seven days of receipt. The Acknowledgment will inform the patient or their representative of the referral to Department/Point of Contact and that they will receive a written response within 30 days.
The Chief Patient Experience Officer has oversight responsibility. The Director of Patient Relations is responsible for the daily operation and subsequent revisions to this policy and procedure.
The purpose of this policy is to describe appropriate handling of complaints, including grievances, received from patients or patient's representatives (i.e. family members, significant others, visitors, etc.).
Policy Scope and Applicability
This policy applies to all patients receiving care provided by NYU Hospitals Center including its ambulatory sites (article 28 facilities). As part of the registration process, all patients are advised of their rights. Information on this process is available on the NYU Hospitals Center website: http://www.med.nyu.edu/patients-visitors/patient-visitor-information/patient-information/patient-services/patient-advocates
A "complaint" is defined as an expression of dissatisfaction brought to the attention of personnel. A complaint can be resolved by the appropriate department or with the assistance of Patient Relations. A complaint is not initially considered to be a grievance.
All complaints received by Patient Relations will be documented in the patient feedback system.
A formal "grievance" is defined as a written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (if not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to the rights and limitations provided by 42 CFR 489.
A complaint is considered a grievance when:
- It is received in writing (i.e., letter, email, fax, attachment to a patient survey)
- A patient or patient's representative requests that their complaint be handled as a formal complaint or grievance
- A patient or patient's representative requests a written response from the hospital
- A complaint is postponed for later resolution, referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution
All grievances will be received by/referred to Patient Relations for documentation in the patient feedback system, investigation and response to patient or the patient's representative.
Verbal Communication Procedure
Internal Hospital Communication
Verbal communications (i.e., telephone calls, discharge phone call referrals, etc.) are referred to Patient Relations when resolution is not possible by the individual receiving the call. The person receiving the call should record all pertinent information and tell the caller that their concerns will be referred to the Patient Relations Department to facilitate resolution. The phone number to Patient Relations should be provided to the patient or the patient's representative. The caller's name, telephone number and information shall be provided to Patient Relations via telephone at (212) 263-6906 at NYU Hospitals Center (North Campus) or (212) 598-6336 at NYU - Hospital for Joint Diseases (South Campus) or through hospital email addressed to PatientRelations@nyumc.org
The complainant will receive a return phone call from Patient Relations. If the issue cannot be resolved prior to a patient's discharge or end of visit, and meets the criteria for a grievance, the verbal communication will be escalated to a grievance and will follow the Written Communication/Grievance Procedure (Steps 2 & 3) detailed below.
In-Person Communication Procedure
Internal Hospital Communication
Hospital personnel will collaborate as necessary to resolve inpatient concerns prior to patient discharge.
A patient or patient's representative who expresses concern to hospital administration will be referred to Patient Relations.
If the issue cannot be resolved prior to patient discharge or end of visit, the verbal communication will be escalated to a grievance and the Written Communication/Grievance Procedure (Steps 2 & 3) will be followed.
Written Communication/Grievance Procedure
Internal Hospital Communication
Written communication is always considered a grievance and will be handled by Patient Relations. Written communication will be referred to the Manager of Patient Relations, or their designee, for recording in the patient feedback system.
Within seven days of receipt, a written or verbal acknowledgment to the patient or patient's representative, will be communicated by Patient Relations. The acknowledgment will include:
- Confirmation of receipt
- Expected timeframe for response
- Name and contact information for the Patient Relations Department member managing the case
The acknowledgment will be documented in the patient feedback system.
Written communication addressed to the Dean or a Vice Dean will be acknowledged by the Chief Patient Experience Officer, or designee. The acknowledgment will name Patient Relations as the point of contact for the patient or the patient's representative.
Investigation and Response
The Manager of Patient Relations, or designee, will assign each grievance to a Patient Relations Specialist. The Specialist will collaborate with the appropriate leaders of the disciplines/ departments involved to provide a formal response that complies with regulatory guidelines and this policy. The leader (i.e. nurse manager, department manager, unit medical director, etc.) assigned to provide feedback will investigate, address and return a response to the assigned Patient Relations Specialist. Feedback is requested within seven days of the referral for investigation.
Complaints, including grievances, regarding lost or stolen property will be managed by Patient Relations. Investigation for property will be conducted by Security Department and report will be provided to Patient Relations. Feedback is requested within seven days of the referral for investigation.
Patient Relations will complete a written response of the hospital's findings. The response will be provided to the patient or the patient's representative in a language and format they understand within 30 days.
Complaints, including grievances may be referred to the Department of Patient Safety and Risk Management, who will determine its involvement in the investigation. For grievances requiring involvement by Patient Safety and Risk Management, written response will be completed by, or in collaboration with, Patient Relations within 30 days.
If final response is not complete, interim contact will be made at day 15 and every 15 days thereafter with the patient or patient's representative to advise that the investigation is ongoing. Interim contact may be made in the form of a letter, e-mail or a telephone call.
Grievances filed by the patient or their representative, where the party requests financial consideration for a quality of care issue must be received in writing by Patient Relations. If received by telephone, Patient Relations will instruct caller to forward concerns in writing. The call will be documented in the patient feedback system and closed until receipt of letter.
When reimbursement, waiver or a reduction of fees is requested by a patient or patient's representative, Patient Relations will make the recommendation with all supporting facts to the appropriate members of senior leadership for approval.
Each written response will include the following information:
In the event that you are not satisfied with our response, you may contact:
- New York State Department of Health, Complaint Unit Hotline at 1-800-804-5447.
- If you prefer to write, please contact: New York State Department of Health Centralized Hospital Intake Program, Mailstop: CA/DCS Empire State Plaza Albany, NY 12237
- The Joint Commission at 1-800-994-6610 or email firstname.lastname@example.org.
- If you prefer to write, please contact: Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181
The hospital may use additional tools to investigate a grievance, such as a meeting with the patient and family. In its written response, the hospital is not required to include statements that could be used in a legal action against the hospital, or to provide an exhaustive explanation of every action taken to investigate or resolve the grievance, or any other actions taken by the hospital.
Patient Relations will ensure each patient complaint and grievance is appropriately documented in the patient feedback system. The electronic file will contain the following information as applicable:
- All relevant fields: o Patient name, DOB, demographics
- Medical record number
- Date of Receipt
- File Owner
- Description of concerns
- Parties involved in review
- Referral to Patient Safety and Risk Management
- Documentation of steps taken to investigate and feedback
- Copy of the original complaint (if written), copy of acknowledgment letter (if written), copy of interim communications (if written), copy of final response
Communication of Patient Complaints and Grievances
Patient Relations will provide a weekly report on the status of open patient grievances. This report will be emailed to senior leadership and anyone involved in a current investigation.
The trends and themes from patient complaints and grievances will be reported to the appropriate hospital and medical staff committees including the Quality Improvement Committee. Additional reports will be produced as requested. The hospital will work to identify and resolve any deeper, systemic problems indicated by themes, trends and/or individual grievances.
A physician specific report will be made available to clinical Department Chairs on a semi-annual basis, with copies to the Chief Medical Officer and the Medical Staff Services office.
- Patients or their representative who have worked with Patient Relations staff to resolve an issue, but remain unsatisfied, can be escalated up the chain of command to Patient Relations leadership or the Chief Patient Experience Officer, as appropriate.
- The statute of limitations for review and investigation of patient communications will be (2) two years from the date of service.
New York State Hospital Operating Code Section 405.7
CMS §482.13(a)(2) Condition of Participation: Patients' Rights
The Joint Commission Accreditation Requirements RI.01.07.01
42 CFR 489
The policy will be enforced by the SVP and Vice Dean, Chief of Hospital Operations and the Chief Patient Experience Officer.