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

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Advice and resources for dealing with quality concerns

Thousands of people become patients in one of Pennsylvania's 219 hospitals every year. Some are treated in the emergency room. Others come to the hospital to have a baby, have surgery, or get treatment when they're sick. These hospital patients expect to receive quality care, and for the most part they do.

There are times, however, when people have concerns about the quality of hospital care that they or a loved one receive. If this happens to you, this tip sheet can help. It gives you:

  • Practical advice about what to do and who to talk with, including phone numbers and addresses
  • Links to resources that can help

This tip sheet explains steps you can take within the hospital to deal with your concerns about quality of care. It tells you how to contact the places that regulate or oversee hospitals.

Is it worth it to pursue a concern about quality?

For many of us, it's not easy to act on a concern about the quality of care we or our loved ones receive. The process can be stressful, frustrating and take a long time. In the end, it's possible that others may not agree with the way we see the situation.

Is it worth the time and energy to take action on concerns about the quality of hospital care? Only you or your loved one can decide. In making the decision, think about the continued harm that might take place if you do nothing—and think about how the actions you take might lead to better care for future patients.


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What is quality of care?

Quality health care is 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 Pennsylvania hospital, what are your rights when it comes to quality of care?

Under the law, you have rights in a Pennsylvania hospital. Some of these rights related to quality include:

  • The right to receive care in a safe setting
  • The right to make informed decisions regarding your care
  • The right to file a grievance or complaint

For additional information about patient rights and responsibilities, see this booklet from the American Hospital Association called The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities. It is available in several languages.


http://www.aha.org/aha/issues/Communicating-With-Patients/pt-care-partnership.html

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What are examples of quality concerns you might experience?

Health care quality concerns could arise for a variety of reasons in a hospital. Some might result from a specific action a hospital staff member takes (or doesn't take) as they treat patients. Examples include staff washing their hands to prevent an infection or giving you a drug that you shouldn't get. Other quality concerns could result from how well the staff work together to safely care for you. For example, making sure that the right medical chart goes with the right patient or that information about a patient gets to the right department.

Because hospitals are treating sick people, they've set up systems of checks and balances to lessen the chance that they'll make a mistake. Sometimes those systems aren't followed, or other actions lead to mistakes. Some mistakes may not affect your health at all; some may cause inconvenience or pain; others may cause serious harm.

What should concern patients the most—and what concerns organizations that oversee hospitals—is when there's a pattern of problems in a hospital. If something happens again and again, it could be a sign of a larger problem with quality of care that could hurt hospital patients.

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

Step 1 —Talk with hospital staff who can fix the problem.

For many concerns, it's usually best to try to fix your concern with the people caring for you first. This would probably be your nurse or a hospital social worker. If you don't feel that they are helping you, there is often a hospital department devoted to addressing patient concerns. These departments have names such as Patient Relations, Patient Advocate, Guest Relations, Ombudsman or Customer Service. The hospital operator can connect you with the department, or you can look for contact information on the papers you received when you came into the hospital.

Once you contact them, a Patient Relations staff person should quickly talk with you about your concern. They will then talk with others who can help address it. This might include the head nurse, physicians or other staff caring for you.

What if there's serious change in a patient's condition?

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 condition that the health-care team doesn't see or address—for example, a small change in a loved one's mental state that could indicate a serious health change.

Most hospitals have a special team for this situation called a rapid response team or medical emergency team. This team can be called to examine a patient who's quickly becoming sicker. If you cannot get the attention of the staff caring for your family member, don't hesitate to call the hospital operator yourself and tell them you have an emergency.


Step 2 — File a grievance with the hospital.

After dealing with the Patient Relations department, if your problem is still not resolved, under the law you can file a complaint or grievance with the hospital. The hospital must give you contact information for filing a grievance. It also must review, investigate and resolve the grievance in a reasonable amount of time—generally 7 days. The hospital should respond in writing, in a language you can understand. The letter should tell you the steps taken on your behalf to investigate the grievance, the results and a contact person. You or the hospital may also want to meet in person to talk about what happened.

A grievance is considered closed when you are satisfied with the actions taken by the hospital. There may be times, however, when the hospital feels it has taken reasonable steps to address your concern, but you are still unsatisfied. That's when you may consider filing your concern with a hospital oversight organization—the next step below.


Step 3 — File a complaint with organizations outside the hospital.

If your concern about quality is still not resolved 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. These include the Pennsylvania Department of Health and the Joint Commission.

The Pennsylvania Department of Health

The Pennsylvania Department of Health (DOH) licenses Pennsylvania hospitals. This means that the hospitals must meet certain rules and regulations in order to care for patients and receive payment. One function of DOH is to investigate complaints about any place they license. The department received 780 complaints about Pennsylvania hospitals in 2012-2013. After investigating them, DOH staff found that about 20 of the hospital complaints did have problems.

In addition, in 2012-2013, there were 6,441 "serious events" that were reported by hospitals to DOH. These are situations involving care that results in a patient's death or an injury that requires the patient to receive more health care services.

There are several ways that you can file a complaint with DOH:

Call the Hospital Complaint Hotline: 800-254-5164

Use an on-line complaint form:
http://www.portal.state.pa.us/portal/server.pt?open=514&objID=937981&mode=2

Mail your complaint to:
Division of Acute and Ambulatory Care
Room 532
Health and Welfare Building
625 Forster St.
Harrisburg, PA 17120


Submitting the complaint: Be as specific as possible about your concern when you are writing your complaint, and make sure you make a copy of what you send. Once DOH receives your complaint, they will send you a letter saying that they have received it. This generally takes a week after they receive it.

The investigation:  What happens next depends on how serious your concerns are and when they happened. With more serious complaints, DOH staff should be at the hospital investigating within days. Investigations of other complaints may take a little longer or wait until DOH staff are next scheduled to inspect the hospital. Some investigations may be completed over the phone or by e-mail or fax.

Complaint investigations that involve visits to the hospital are unannounced—the hospital staff are not told in advance that a DOH investigator is coming.

Depending on the type of complaint, the DOH investigator might talk to you or other patients and family members. They might look at your medical records, talk to and watch staff members and inspect the hospital. Once the investigation is done, you should get a letter from DOH telling you what they found. If you disagree with what they found, you can request that they review the information again; however, generally an investigation would only be re-opened if DOH staff receives new information.

What are the outcomes?  If the investigation finds that there is a problem with a hospital, DOH will issue a report outlining the problems they found. The hospital has 10 days to tell DOH what it plans to do to fix the problems. Some time after that, DOH staff will make another unannounced visit to make sure the hospital did fix the problem.

Sometimes, the hospital has to pay a fine of up to $500 a day for each problem that is found. Information on hospital complaints and investigation outcomes is available on the Pennsylvania Department of Health Quality Assurance Facility Directory website noted below.

How long will it take? Once the investigation begins, it generally takes about 60 days to complete it. The timeframe can vary, however, depending on the specific issues and what steps the hospital must complete to fix the problem.

Can you your complaint be treated confidentially? Yes, your complaint can be filed confidentially. You can request that the hospital not be told that you filed the complaint. The Pennsylvania Department of Health will contact you regarding the outcome of their investigation.


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The Joint Commission

The Joint Commission is a non-profit organization that evaluates and accredits (that is, judges quality against a set of rules or standards) health care organizations across the country. The Joint Commission does its work by periodically going on site to survey hospitals in action. It has accredited many Pennsylvania hospitals. Those hospitals have to meet many standards and patient safety goals related to patient care, including the quality of care they give to patients.

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

On-line: http://jcwebnoc.jcaho.org/QMSInternet/IncidentEntry.aspx
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 looks at each complaint to make sure that it's something they can act on. If so, it is then 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. It may lead to an unannounced visit to the hospital 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 adds them to the hospital's record, but takes no further action.

After the Joint Commission receives your complaint, they send you a letter telling you that they have your complaint. That letter will include a tracking number you can refer to if needed. After the investigation is done, you should receive another letter telling you whether and which Joint Commission hospital standards were investigated. You will also receive limited information about the outcome of the 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. It can help staff look for patterns of problems the next time the hospital is reviewed.

Other Hospital Accrediting Organizations

A few hospitals in Pennsylvania are accredited by the Healthcare Facilities Accreditation Program (HFAP). Here is a list of those hospitals:
http://www.hfap.org/AccreditedFacilities/index.aspx?FacilityType=HOSPN

To report a complaint against a HFAP hospital:
http://www.hfap.org/resources/complaintinformation.aspx


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Where else can you go with a concern about quality?

Government Agencies

Medicare: If Medicare (federal health insurance for people over age 65 or people under 65 who are disabled) pays for your or your loved one's care, you may have an additional place to go with a quality of care concern. Medicare pays a Quality Improvement Organization (QIO) in each state to oversee the quality of care provided to Medicare patients. In Pennsylvania, that organization is called Quality Insights of Pennsylvania.

You can call Quality Insights at the following number: 800-322-1914. Explain to the person who answers the phone what your concerns are. Depending on the type of problem you are having, they may be able to help right away. For example, with your permission, they may be able to call the hospital to see if they can help solve your problem. In other cases, they may ask you to send your complaint in writing using a complaint form.

After you file a complaint with Quality Insights and allow release of your medical records, a Board-certified physician reviews your records. Then you get a letter indicating whether the hospital did or didn't provide the expected level and type of care in your case. Quality Insights generally focuses on improving the performance of the hospital, not on punishing it.

If you are still in the hospital, the review should take 38 to 83 days. If you are no longer receiving services, the review can take up to 165 days to complete, depending on whether a quality problem is found.

For further information about how to file a complaint at Quality Insights:
http://www.qipa.org/Medicare-Consumers/Your-Medicare-Rights/Quality-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 can ask for an appeal from Quality Insights. They will quickly review your case and decide whether Medicare should continue to pay for your hospital stay or not.

Hospital Appeals Phone Number: 800-322-1914

Medicaid: You can also call the Medicaid Fraud Control Unit of the Pennsylvania Attorney General's Office if you have a concern about certain activities in a hospital. Examples include providing unnecessary services, billing for medical services that you didn't get, billing for more expensive services or billing more than once for the same medical service.

Pennsylvania Office of the Attorney General: 717-783-1481
For more information: http://www.attorneygeneral.gov/crime.aspx?id=177

Other Health Organizations

Your health insurance plan or HMO: Hospitals usually work with a health insurance plan or HMO. Call your health plan's customer service number, explain the problem and ask whether you can file a complaint about the care provided in a hospital affiliated with the health plan. Or look at the "complaints", "appeals", or "grievances" section of the HMO's website for information or forms to file.

Consumer Organizations

The Consumer Health Coalition is a non-profit Pittsburgh-based consumer health advocacy organization that provides information on health care quality and access. The Coalition provides educational workshops and trainings for consumers. As part of its Patient Safety Initiative, the Coalition is collecting stories about patients' experiences and concerns with their care in hospitals and from doctors.

http://consumerhealthcoalition.org/

The Safe Patient Project is a project of Consumers Union (the publisher of Consumer Reports magazine) that seeks to end 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 Pennsylvania. The Project can't help with your specific complaint. It can use the collective power of stories from patients and families to help pass laws and press for other changes to make health care safer.

http://safepatientproject.org/

ProPublica is a nonprofit investigative journalism organization. They have an online patient harm questionnaire that asks for details about your concern. They write articles about people's experience of patient harm to bring attention to these issues. The organization won't publish any information that would identify you without your permission. ProPublica also sponsors a Facebook group that can connect you with other patients who have been harmed.

Here is a link to the patient harm questionnaire:
http://www.propublica.org/article/patient-harm-questionnaire

On Facebook, search for: ProPublica Patient Harm Community

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

Being concerned about staff punishing you or a loved one is understandable given that you depend on them for care. 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 Health.

Hospital Complaint Hotline: 800-254-5164

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What are patient surveys about 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 because the results are published for the public to see.

Where can you find information about quality in Pennsylvania hospitals?

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

Pennsylvania Resources

Pennsylvania Department of Health Quality Assurance Facility Directory: Provides information on health inspection results for Pennsylvania facilities including hospitals.

http://app2.health.state.pa.us/commonpoc/dohqalocatorcommon.asp

Pennsylvania Health Care Cost Containment Council: A state agency that provides comparative information about the cost and quality of health organizations in the state. The hospital information includes a variety of topics including mortality (death) rates for procedures and information on hospital infections.

http://www.phc4.org/

Pennsylvania Health Care Quality Alliance:An organization that includes hospital, physician and health insurance companies in the state. The site provides information about hospitals' performance on cardiac surgery, hospital acquired infections and hip and knee replacements.

http://www.phcqa.org/

Pennsylvania Patient Safety Authority: Provides consumer-oriented tips about how to prevent medical errors, how to choose health facilities and a variety of other information about getting good care.

http://patientsafetyauthority.org/PATIENTSCONSUMERS/
PatientConsumerTips/Pages/PatientConsumerTips.aspx

National Resources

Hospital Compare: A federal website that provides information on heart care, pneumonia care, surgical care and children's asthma care. 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.medicare.gov/hospitalcompare/search.html

The Joint Commission: This national accrediting organization provides a Quality Report about the hospitals it licenses, including information on whether they met certain patient safety goals, their performance on heart care, pneumonia care 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 Pennsylvania managed care plan or HMO or a nursing home, or the care provided by a doctor or registered nurse, here's where to go for more information:

Doctors
What to Do if You Have a Concern About the Quality of a Pennsylvania Doctor
http://www.informedpatientinstitute.org/PHYQuality-PA.php


Managed Care/HMO
Bureau of Managed Care
Pennsylvania Department of Health
http://www.portal.state.pa.us/portal/server.pt/community/managed_care/14157

Health Care section of the Pennsylvania Office of the Attorney General
http://www.attorneygeneral.gov/seniors.aspx?id=395


Nursing Homes
What to Do if You Have a Concern About Quality in a Pennsylvania Nursing Home
http://www.informedpatientinstitute.org/NUHQuality-PA.php


Registered Nurses
Pennsylvania State Board of Nursing
http://www.portal.state.pa.us/portal/server.pt/community/
state_board_of_nursing/12515/consumer_information/572053