1. 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

2. Advisors: John HornickDirector of Nursing Services Carey SmithManager of Regulatory Affairs Executive Sponsors: Les HallChief Medical Officer Dennis StambaughChief Quality Officer

3. 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.

4. UMHC Strategic Goals and Columns of Excellence 4 Service ~ Quality ~ Finance ~ People ~ Growth ~ Community 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 Acknowledging and answering patient’s questions and complaints contributes to each of the Columns of Excellence. Patient satisfaction includes:

5. 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.

6. 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

7. First at Complaints…

8. The Challenges

9. 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.

10. Stakeholders Guest Relations Regulatory Affairs Risk Management Patient Safety Administration Department Managers UH Physicians School of Medicine Frontline staff Patients Visitors Family Community

11. Going to the Key Players…

12. Survey Monkey Results N= 95

13. Survey Monkey Results

18. 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.

19. 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.

20. 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.

21. Interventions Considered 1.Education to all staff on role 2.Provide an executive report 3.Revise PSN System for ease of documentation 4.Revision of policy LowHigh 1, 3 Low 4 2 Impact Resources

22. 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

23. Establishing Ownership Executive Sponsors  Executive Committee Of Medical Staff  Department Chairs  Division Directors  Senior Leadership  Managers

24. Defining the Process

30. Anticipated Return

31. 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!!

32. 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

33. Team Function Discursive Discusser – Myra McCoig Wordsmith – Nancy Jones Organizer – Laura Hirshinger Badger – Kay Steward PI LDP Experience Guide - John Hornick Politician - Carey Smith