2016 New CMS CoP Regulations for Managing Grievances and Complaints: What Hospitals Should Know about the CMS and Joint Commission and DNV Standards

Key Topics

• How to find current copy
• Background on CMS CoPs
• How to find changes in the hospital CoPs
• CMS deficiency memo
• TJC standards
• Issuance of final interpretive guidelines
• Preprinted order sheet changes
• Recent standing order memo
• P&P requires to ensure patients have information on rights
• Federal Register, interpretive guidelines, survey procedure
• CMS definition of grievance
• Prompt resolution of grievances
• TJC definition and six elements of performance on complaints
• Definition of staff present
• Form to collect information
• P&P with all the required elements
• Need to determine person is authorized representative
• HIPAA requirements if request not from patient
• Telephone complaints after discharge
• Billing issues and information on patient satisfaction
• Audits and PI required
• Customer service and complaints
• Process for prompt resolution
• Policy to encourage staff
• Board`s responsibility in grievance process
• Requirement to inform each patient on how to file grievances
• Referral to QIO and State Department of Health
• Grievance committee required
• P&P on grievances
• Changes to QIOs process
• Time frame for responding to grievances
• Written notice to patient requirements
• System analysis approach
• 7 day rule
• DNV Health NIAHO standards on grievances
• What should critical access hospitals do?

Who should Attend

Attendees from:

• Chief Operating Officer (COO)
• Consumer Advocates or Patient Advocate
• All nurse managers
• All nurses with direct patient care
• All department directors
• Joint Commission Coordinator
• Chief Nursing Officer (CNO)
• Chief Executive Officer (CEO)
• Chief Financial Officer (CFO)
• Chief Medical Officer (CMO)
• Quality Improvement Coordinator
• Board Members
• Legal Counsel
• Risk Managers
• Patient Safety Officer
• Nurse Educator
• Nurse Managers/Supervisors
• Emergency Department Manager
• Staff Nurses
• Compliance Officer
• Medical Department Nurse Manager
• Clinic Managers
• OR Nurse Director
• Surgery Department Nurse Manager
• CCU Nurse Director
• ICU Nurse Director
• HIPAA privacy and security officer
• Outpatient Director
• Lab director
• Director of Business Office
• Ethicist
• Policy and procedure committee
• Anyone involved in the implementation of the CMS grievance or Joint Commission complaint standards