What to Do if You Have a Concern about Quality
in a California Hospital

Introduction

Thousands of people become patients in California hospitals every year.  Whether they come into the hospital through the emergency room or check in for a scheduled surgery or to have a baby, they expect—and mostly receive—high quality care from the staff that cares for them.  However, there are times when patients or family members have concerns about the quality of care received in a hospital.

• What should a patient or family member do if they have a concern about quality?
• Who should they talk to?

This brief provides answers to these questions and links to resources that can help. It addresses steps you can take within a hospital or with organizations that regulate or oversee hospitals.  You can also consider a malpractice lawsuit, but that is not the focus of this brief.

For many of us, it's not easy to act on a concern about the quality of care we or a loved one are receiving in a hospital.  The process can be stressful, frustrating and take a long time.  And ultimately others may not agree with the way we see the situation.

• Is it worth it to pursue a concern about quality?

Only you or your loved one can decide.  However, consider the continued harm that might take place if you don't take action – for yourself, your loved one, and/or other patients and their families.

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What is quality of care?

Quality health care is characterized by doing the right thing, at the right time, in the right way, for the right person – and having the best possible results.

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In a California hospital, what are your rights when it comes to quality of care?

California and federal laws give hospital patients many rights.  Hospitals must notify patients of these rights by giving them a handout and/or posting these rights throughout the hospital. Some of the rights related to quality include:

• The right to receive care in a safe setting
• The right to considerate and respectful care
• The right to receive information about your care – including unanticipated outcomes
• The right to file a complaint or grievance

For a full list of all of your rights, see the California Hospital Association's List of Patient Rights:

http://www.calhospital.org/sites/chadocuments.org/files/file-attachments/2008PatientRights_English.pdf
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What types of quality concerns might you experience?

Health care quality concerns could arise for a variety of reasons in a hospital:

• How well the staff work together to care for you and make the hospital safe—for example, making sure the right medical chart accompanies the right patient or that information about a patient is handed off between departments in a timely and accurate way.
• A specific action a hospital staff member takes (or doesn't take) as they treat you or a family member, for example, washing their hands to prevent an infection or making sure they don't give you a drug that causes a known allergic reaction.

Because hospitals are treating sick and vulnerable patients, they’ve established systems of checks and balances to minimize the possibility that they'll make a mistake. Sometimes those systems aren't followed, or other actions lead to mistakes. Such mistakes may have no effect on your health, may cause some inconvenience or pain, or may have serious health consequences. What should concern patients the most—and what concerns organizations that oversee hospitals—is when there is a pattern of problems in a hospital. If something happens again and again, it probably indicates a larger problem with quality of care that could put any hospital patient at risk.

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What steps should you take if you have a concern about quality?

For many concerns, it’s usually best to try first to resolve your concern with the people caring for you, such as your nurse or a hospital social worker.  If, however, you don't feel that they are helping, you can call the hospital department devoted to addressing patient concerns, particularly while you’re still in the hospital.  These departments have a variety of names such as Patient Relations, Patient Advocate, Guest Relations, Ombudsman or Customer Service. The hospital switchboard can connect you with the department, or look for its contact information on the papers you received when you entered the hospital.  A Patient Relations staff person should quickly talk with you about your concern and then talk with others who can help get it resolved, for example, the head nurse, physicians or other staff who are caring for you.

What if it's an emergency? Hospitals have regular procedures to deal with patients who get sicker in the hospital.  However, sometimes patients or families notice something about a patient’s medical condition that the health care team doesn’t recognize or address, and they feel it’s an emergency.   For example, it might be a subtle change in the patient's mental state.  Most hospitals have a special team, usually called the rapid response team or medical emergency team, that can be called to assess a patient who’s showing signs of decline. Your first step should be to ask a nurse or physician to call the rapid response team.  If you can't get the hospital staff’s attention, don’t  hesitate to call the hospital operator yourself and ask for the rapid response team. Some hospitals also have a specific helpline (sometimes called “Condition H”) that patients can call for emergency assistance. That number should be posted on the wall or on the room telephone.  If you can’t find these numbers or the hospital doesn't have a rapid response team or patient helpline, call the hospital operator and tell them you have an emergency. Ask for the charge nurse, the nurse supervisor or the administrator on call.

After dealing with the Patient Relations department, if your problem is still not resolved, under the law, you can file a grievance with the hospital. The hospital must inform you whom to contact to file a grievance and it must review, investigate and resolve the grievance in a reasonable amount of time—generally 7 days.  The hospital should respond in writing, in non-technical language you can understand.  The letter should indicate the steps taken on your behalf to investigate the grievance, the results of the review and a contact person.  You or the hospital may also want to meet in person to talk about the incident.  A grievance is considered resolved when you are satisfied with the actions taken by the hospital on your behalf.  There may be times, however, when the hospital feels it has taken reasonable and appropriate action and considers the grievance closed, but you are still unsatisfied.  That’s when you may consider filing your concern with a hospital oversight organization—the next step below.

If your concern about quality is still not resolved to your satisfaction and/or you want to prevent a similar event from happening to another patient, there are several places outside a hospital where you can file a complaint, including the California Department of Public Health and the Joint Commission.

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The California Department of Public Health

California hospitals are licensed by the California Department of Public Health (DPH).  In exchange for continuing to meet certain rules and regulations, they are allowed to care for patients.  One of the functions of the DPH is to receive and investigate complaints for any facility they license.  

You can file a complaint with DPH by:

• Contacting one of their District offices: http://www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx
• Completing and submitting their online complaint form: https://hfcis.cdph.ca.gov/LongTermCare/ConsumerComplaint.aspx
• Calling 800-236-8747

Submitting the complaint: You should be as specific as possible about your concern if you are writing your complaint.  Make sure you make a copy of what you send.  After DPH receives your complaint, you should receive information about the name of the DPH staff person who will investigate your complaint, a complaint number and how DPH intends to follow up. 

The investigation: What happens next depends on how serious your concerns are.  If the complaint involves a situation that could cause imminent danger, death or serious harm (“immediate jeopardy”), the investigators should be at the hospital investigating within 2 working days of the complaint.  Complaints that don't fall into this category should be investigated within 2-45 days of the time they are received.  All complaint investigations are unannounced—hospital administration and staff are not told in advance that the DPH investigator is coming. The DPH investigator will probably interview you, other patients, and family members, review your medical records, interview and observe staff members and inspect the facility.  You should be provided a copy of their report within 10 working days after its completion. 

What are the outcomes?  If the investigation finds your concern(s) to be true, DPH will issue a report outlining the problems and what the hospital must do to correct them.  Depending on the severity of the violation, DPH might issue an administrative penalty of up to $25,000 for the worst violations—those that caused or could cause serious injury or death to the patient.  You can find information on complaints and investigation outcomes for hospitals on the DPH website noted below.

How long will it take? There are no laws about how long an investigation can take, though DPH policy is to complete the complaint investigation within 45 days.

The Joint Commission

The Joint Commission is a non-profit organization that evaluates and accredits (that is, judges quality against a set of standards) health care organizations across the country.  The Joint Commission does its work by periodically going on site to review hospitals in action. The Joint Commission has accredited many California hospitals, which have to meet a wide range of standards and patient safety goals related to patient care, including quality of care.

You can file a complaint with the Joint Commission in several ways:

On-line: www.jointcommission.org/GeneralPublic/Complaint
E-mail: complaint@jointcommission.org
By Fax: Office of Quality Monitoring, (630) 792-5636
By Mail: Office of Quality Monitoring, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181

Writing the complaint: Be as specific as possible in no more than two pages and provide the name, address, city and state of the accredited hospital. For more information, call the Joint Commission's toll-free number: 800-994-6610, 8:30 AM to 5:00 PM CST.  The Joint Commission has an online complaint form that gives additional information about what they need in a complaint submission (http://jcwebnoc.jcaho.org/QMSInternet/IncidentEntry.aspx).

How the Joint Commission responds to complaints: The Joint Commission does an initial screen of the complaint to see, among other things, if it is relevant to their standards and therefore something they can act on.  Based on that finding, it is put into one of three categories.

• High Priority Quality Events – Such as an unexpected event that results in a patient death or serious injury.  This type of complaint is processed within 2 business days and may lead to an unannounced visit to the hospital  (the hospital does not know they are coming) or some other action where the hospital must explain their actions.
• Medium Priority Incidents – Such as delays in treatment, or a serious medication error. These are processed within 10 business days and also may require the hospital to explain their actions.
• Low Priority Incidents – All other complaints that don't fit into the above two categories. The Joint Commission acknowledges them and adds them to  the hospital’s record, but takes no further action.

After the Joint Commission receives your complaint, they send you an acknowledgment letter that includes a tracking number you can refer to if needed.  After the investigation, they should tell you by letter whether and which Joint Commission hospital standards were investigated and limited information about the outcome of their investigation.   If your complaint triggered an unannounced survey of the hospital, the findings from that survey can be shared with you. In every case, information from the complaint will become part of the Joint Commission's record about the hospital and may help focus their review the next time the hospital undergoes evaluation.

Another organization that accredits some hospitals in California is the American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP):

http://www.hfap.org/
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Where else can you go with a concern about quality?

Medicare: If Medicare (federal health insurance for people over age 65 or the disabled) pays for your or your loved one's care, you may have an additional place to express quality of care concerns.  Medicare pays organizations to oversee the quality of care provided to Medicare patients.  In California, that agency is called the Health Services Advisory Group (HSAG).  HSAG is primarily concerned with the quality of care that would be written down in the medical record.  After you file a complaint with them and authorize release of your medical records, a Board-certified physician reviews your records.  Then you get a letter indicating whether the standard of care was met in your case or not (that is, whether the hospital provided the expected level and type of care under the circumstances or not).  HSAG generally focuses on improving the performance of the hospital, not on punishment.

Timetables affect the handling of each step of HSAG review.  If you are no longer receiving the services in question, the review can take anywhere from 85 to 165 days to complete,  depending on whether a quality problem is found.  If you are still receiving the services in question, the review should take 38 to 83 days.

HSAG Medicare Beneficiary Complaint Hotline: 1-866-800-8749
TDD Hearing Impaired: 1-800-881-5980
Information about complaints and link to complaint form:

http://www.hsag.com/camedicare/complaints.aspx

Concerns about being discharged too early from the hospital: If you’re a Medicare patient and you feel a hospital is asking you to go home before you or your family think you're ready, you have the right to ask for an appeal from HSAG.  HSAG will quickly review your case and decide  whether Medicare should continue to pay for your hospital stay or not.

 Use the following HSAG number in this case:
1-800-841-1602
TDD: 1-800-881-5980

Medi-Cal: You can also call the Medi-Cal Fraud and Abuse Hotline if you have a concern about the quality of care in a hospital—for example, if a patient is abused or neglected by a staff member or they provide substandard care that results in a bedsore.    

Attorney General's Bureau of Medi-Cal Fraud & Elder Abuse: 800-722-0432
Website: http://ag.ca.gov/bmfea/index.php

Your health insurance plan or HMO: Hospitals are usually affiliated with a health insurance plan or HMO.  Call your health plan, explain the problem to them and ask whether you can file a complaint about the care provided in a hospital affiliated with their health plan.  A list of phone numbers and websites of health plans in California is available at the Department of Managed Care website:

http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_contact.aspx

or you can call the Department of Managed Care's Help Center:
1-888-466-2219
TDD: 1-877-688-9891

The Safe Patient Project is a project of Consumers Union (publisher of Consumer Reports magazine) that seeks to eliminate medical harm in the health system. The Project is collecting stories from patients about their experiences and concerns with care in hospitals and physicians' offices across the nation, including California.  While the Project can't help with your specific complaint, the collective power of stories from patients and families helps it pass laws and seek other changes to make health care safer.

www.safepatientproject.org
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Can you remain anonymous when you file a complaint?

You have the right to not give your name and remain anonymous when you file a complaint.  If you want that option, you should clearly state it when you file your concern.  You should know, however, that it may make your case more difficult to investigate and resolve as investigators won’t be able to review your records or interview staff about a specific incident or incidents.  You can talk with the agency where you file the complaint about the pros and cons of remaining anonymous in your specific situation. 

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What if the hospital retaliates against me or a loved one for filing a complaint?

Being concerned about retaliation is understandable given that you or a loved one depend on hospital staff to care for you.  However, it is absolutely against the law to retaliate against a patient for filing a concern.  If you feel you are being retaliated against, contact the state Department of Public Health. 

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What are patient surveys about my hospital care?

Some patients will receive a survey asking a series of questions about their recent hospital stay.  Use this as an opportunity to give feedback about the care you received.  Hospitals pay close attention to the results of these surveys as the overall results are published for the public to see.

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Where can you find out information about complaints and quality in California hospitals?

There are several online resources you can check for information about the quality of care provided by California hospitals, including complaints.

CalHospitalCompare:

This site provides information about the quality and timeliness of care for several types of conditions including heart care, pneumonia and maternity care.  It also provides information on patients' experiences with their hospital stay based on surveys. 

http://www.calhospitalcompare.org/?v=2

Cal HospitalCompare.org En Espanol (Spanish version):

http://espanol.calhospitalcompare.org/?v=2

Health Facilities Search, California Department of Health (DPH):

If you check “General Acute Care Hospital” in the list of facility types on this web page, you can get information on the number of complaints filed against hospitals and whether the state found that there was a problem (substantiated) or not (unsubstantiated).

http://hfcis.cdph.ca.gov/search.aspx?st=h|8

You can also check the following DPH site to see if a hospital has received an “administrative penalty,” which indicates a violation that caused or is likely to cause serious injury or death to a patient:

http://www.cdph.ca.gov/certlic/facilities/Pages/Counties.aspx

Hospital Compare:

A federal website that provides information on heart care, pneumonia, surgical care and children's asthma care.  It also includes information on hospital death measures, whether patients are hospitalized again within 30 days of leaving the hospital, and the results of patient surveys about their care.

http://www.hospitalcompare.hhs.gov/hospital-search.aspx

The Joint Commission:

The national accrediting organization provides a Quality Report about facilities it licenses, including information on whether the hospital met certain patient safety goals, their performance on heart care, pneumonia and pregnancy care and the results of patient surveys about their care.

http://www.qualitycheck.org

Upon request, the Joint Commission also provides the number of complaints a hospital has received.  Call 800-994-6610 to request that information.

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Other useful information:

If you’re concerned about the quality of care in a California hospital, managed care plan or HMO, or nursing home, or the care provided by registered nurses, here’s information about what to do:

What To Do If You Have Concern About Quality of Care from a California Physician:
http://www.informedpatientinstitute.org/PHYQuality-CA.php

What To Do If You Have Concern About Quality in a California Nursing Home:
http://www.informedpatientinstitute.org/NHQuality-CA.php

Managed Care: California Department of Managed Health Care, Problems and Complaints:
http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_default.aspx

Registered Nurses: California Department of Consumer Affairs:
http://www.dca.ca.gov/online_services/complaints/complain_rn.shtml

If you want to learn more about Malpractice, the National Health Law Program sponsors a consumer website called HealthCareCoach that includes information on malpractice and how to find an attorney. http://www.healthcarecoach.com/resources/index.php?view=detail&id=103&node=4