A 2013 study on the ESRD beneficiary grievance process, The ESRD Beneficiary Grievance Process (OEI-01-11-00550) conducted by the U.S. Health and Human Services, identified deficiencies at facilities across the country. Because of this study, the following five recommendations for improvement were made to CMS: 1) define “grievance” for facilities, 2) require that facilities report grievances regularly to their respective networks, 3) provide guidance to facilities on what constitutes a robust process for anonymous grievances, 4) work with the Agency for Healthcare Research and Quality to add a question to the standardized satisfaction survey to assess ESRD beneficiaries’ fear of reprisal, and 5) provide networks with better technical support for their grievance database. Of these recommendations CMS is working to address barriers related to the definition of a grievance, what constitutes a robust process for anonymous grievances, and proving better technical support for the grievance database. It is important for patients to be able to file a grievance without fear of reprisal. In order to reduce the fear of reprisal, all facilities must develop an anonymous internal grievance process that allows patients, family members, or caregivers to voice their concerns. According to CMS guidelines, in an anonymous grievance, the identity of the person(s) will remain unknown to the facility. Patients should be educated that the facility is unable to contact an anonymous grievant to inform them of the steps taken to investigate the grievance or the outcome of the investigation. In these cases, the grievant should be advised of the following:
- The grievance will be investigated, but the facility will be unable to report back to them, unless a name and address is provided.
- Because of the small population in dialysis facilities, the provider involved may be able to identify the grievant, even when anonymity is maintained.
- The investigation may be limited due to minimal amount of information available to the facility.
Dialysis facilities are required to ensure a process has been implemented for patients to express concerns about their care without reprisal or denial of services.
According to CMS, a grievance is defined as “a written or oral communication from an ESRD patient, and/or an individual representing an ESRD patient, and/or another party, alleging that an ESRD service received from a Medicare-certified provider did not meet the grievant’s expectations with respect to safety, civility, patient rights, and/or clinical standards of care.” The grievant is not required to explicitly state that the care did not meet professionally recognized standards.
Federal regulations at 42 CFR §405.2112(g) specify “evaluating and resolving patient grievances” as one of the Network’s functions. The Network’s case review responsibilities include investigating grievances filed with the Network and addressing non-grievance access to care cases. However, some concerns do not fall under the jurisdiction of the Network; in these cases patients would be referred to a more appropriate agency, such as the state health department.
The following resources provided by the Network can help educate staff and patients about grievances:
For more information, or assistance with patient grievances, please contact the Patient Services Director in your Network.
When challenged with the task and responsibility of delivering high quality health care, it is also necessary to take an in depth view and analyze causation of grievances, behaviors and issues that result in patients becoming at risk to having no access to dialysis care. This can include involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. Managing Disruptive Behavior by Patients and Physicians: A Responsibility of the Dialysis Facility Medical Director, published by the Clinical Journal of the American Society of Nephrology, directly speaks to the challenges and opportunities available that require collaborative efforts to uncover root causes, as well as the effectiveness of leadership at the facility level.
ESRD Networks serve as a resource to both patients and providers for grievance mitigation and conflict resolution. For assistance, please contact your local Network.