Complaints

Question 1

The Joint Commission - TJC
Complaints

Answer 1

There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider.
For telemedicine services, the originating site has evidence of an internal review of the physician’s or other licensed practitioner’s performance of these privileges and sends to the distant site information that is useful to assess the physician’s or other licensed practitioner’s quality of care, treatment, and services for use in the privileging and performance improvement. At a minimum this information includes all adverse outcomes related to sentinel events considered reviewable by the The Joint Commission that result from the telemedicine services provided and complaints about the distant site physician or other licensed practitioner from patients, physicians, or other licensed practitioners or staff at the originating site.

Question 2

NCQA
Complaints

Answer 2

CR 1 Element A Factor 6 and CR 5 Element A Factor 3 & 5
The organization must conduct ongoing monitoring that includes the collection and review of complaints.
The organization must have mechanisms in place to investigate practitioner specific complaints from members upon receipt
Both the specific complaint and the practitioner’s history of issues must be evaluated. There must be evidence of an evaluation of the history of complaints for all practitioners at least every six months

Question 3

ACHC
Complaints

Answer 3

the medical staff bylaws define the unacceptable levels of performance that trigger the need for focused performance monitoring, which may include patient, family, or staff complaints.
Data collected regarding patient grievances and complaints that are not defined as grievances (as determined by the hospital) are reviewed through the Quality Assessment/Performance Improvement (QAPI) program.
At a minimum, the hospital must review and send information to the distant-site telemedicine entity on all adverse events that result from a physician or practitioner’s provision of telemedicine services, and on all complaints it has received about telemedicine physician or practitioner

Question 4

DNV
Complaints

Answer 4

PR.6 The hospital shall develop and implement a formal written grievance procedure, to identify the process that will be followed and the required correspondence, including grievance resolution, to be provided to the patient.
This includes among other items, a referral process for quality of care issues to the Utilization Review, Quality Management or Peer Review functions as appropriate.
In the resolution of the grievances, the organization shall provide the patient (and/or the patient’s representative, ad indicated) with written notice of its decision.
MS.15SR 1b(4) For telemedicine services complaints about the distant site physician or practitioner with clinical privileges at the hospital are included in performance information

Question 5

URAC
Complaints

Answer 5

As part of its recredentialing process, the organization considers any collected information regarding the participating provider’s performance within the organization, including any information collected through the organization’s quality management program. This may include information from sources such as complaints

Question 6

AAAHC
Complaints

Answer 6

Covered under the Quality Improvement and Management standards, risk management process includes an ongoing review of patient complaints and grievances that includes defined response times, as required by law and regulation
Application must include information about complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board

Question 7

Medicare Hospital COPS

Answer 7

482.13(a)(2)
The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance