Patient Complaint & Grievance Policy

Policy Statement

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 indicating the findings of the investigation, if requested or if the complaint rises to the level of a grievance. 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 Acknowledgement will be sent 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.

Administration

The Patient Care Quality Assurance Operations Committee of the Board designates the Virtual Patient Safety Group as the committee to have oversight of the Complaint and Grievance process and the authority to review and resolve grievances. The Virtual Patient Safety Group is led by the Chief Medical Officer and members include the Chief Patient Experience Officer, Chief Nursing Officer, Chief Regulatory Officer, Chief Quality Officer and Director of Patient Safety and Risk Management. Meetings are held on a regular basis in order to identify risk management trends that translate into institutional learning and improvement within the Medical Center.

The Chief Patient Experience Officer has oversight responsibility for the flow of information to the Virtual Patient Safety Group. The Director of Patient Relations is responsible for the daily operations of the program and for making recommendations for subsequent revisions to this policy and procedure.

Purpose

The purpose of this policy is to describe appropriate handling of complaints, including grievances, received from patients or patients’ representatives (e.g., family members, significant others, visitors).

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

Definitions

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 (when the concern is 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.

Procedure

Telephone Communication Procedure

  1. Internal Hospital Communication

    Complaints received by phone 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. Referral of the caller's name, telephone number and recorded information shall be provided to Patient Relations via telephone at (212) 263-6906 or PatientRelations@nyumc.org within one day.

  2. Acknowledgement

    The complainant will receive a return phone call from Patient Relations within one day of the referral. 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

  1. Internal Hospital Communication

    Hospital personnel will collaborate as necessary to resolve inpatient concerns prior to patient discharge and outpatient concerns prior to the patient’s departure from the site of care.

    A patient or patient’s representative who expresses concern to hospital Administration will be referred to Patient Relations.

  2. Acknowledgement

    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

  1. 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 his or her designee, within one day for recording in the patient feedback system.

  2. Acknowledgement

    Within seven days of receipt of a grievance, the hospital will attempt to review, investigate and reconcile the issue raised or provide an acknowledgement letter to the patient or patient’s representative. This letter will be sent from Patient Relations and the acknowledgement letter will include:  

    • Confirmation of receipt
    • Expected reasonable timeframe for the hospital’s response to the concern identified
    • Name and contact information for the Patient Relations Specialist managing the case

    The acknowledgment will be documented in the patient feedback system.

    Written communication addressed to a senior leader (the Dean or a Vice Dean) will be acknowledged by the Chief Patient Experience Officer. The acknowledgment will name Patient Relations as the point of contact for the patient or the patient’s representative.

  3. 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 (e.g., nurse manager, department manager, unit medical director) assigned to provide feedback will investigate, address and return a response to the assigned Patient Relations Specialist within seven days of referral.

    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 within seven days of the claim.

    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. Investigation and written response to each grievance will not exceed 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 patient’s 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 reduction of fees equals $100.00 or less, the Director of Patient Relations, with discretion, is empowered to consider/honor the request without senior leadership approval.

    When reimbursement, waiver or a reduction of fees over $100.00 is requested by a patient or patient’s representative, Patient Relations will make the recommendation with all supporting facts. The decision will be made by the Chief Patient Experience Officer in conjunction with the SVP Vice Dean and Chief of Hospital Operations.

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.

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.

Documentation

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 required fields
    • Patient name, DOB, demographics
    • Medical record number
    • Submission date
    • File Owner
    • Classification
    • Location
    • Description of concerns
    • Parties involved in review
    • Referral to Patient Safety and Risk Management
  • Documentation of steps taken to investigate and feedback
  • Pdf of the original complaint, acknowledgement letter, Pdf of interim communications, Pdf of final response

Communication of Patient Complaints and Grievances

Patient Relations will email a weekly report on the status of open patient grievances 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.

NOTES:

  • A staff member of Patient Relations is available seven days a week. Missed calls will be returned within one day.
  • Patients or their representative who have worked with Patient Relations staff to resolve an issue, but remain unsatisfied, will 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.

Legal Authority/References

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

Policy Enforcement

The policy will be enforced by the SVP and Vice Dean, Chief of Hospital Operations and the Chief Patient Experience Officer.