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

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Advice and resources for dealing with quality concerns

Thousands of people become patients in California 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 mostly 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. You can also consider filing a lawsuit, but that is not the focus of this tip sheet.

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 loved ones receive. The process can be stressful, frustrating and take a long time. And 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 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 posting them throughout the hospital. Some of your 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/main/files/file-attachments/patientrights_english_1.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. 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 that could hurt any hospital patient.

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

Step 1 —Talking 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 another type of hospital staff person who can help you. They are called Patient or Guest Relations staff, Patient Advocates, Ombudsman or Customer Service staff. The hospital operator can connect you with them. Or 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 your concern. This might include the head nurse, physicians or other staff caring for you.


What if there’s a 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. Your hospital may 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.

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.


Step 2 — Filing a grievance with the hospital

After dealing with the Patient Relations staff, if your problem is still not solved, 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 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 — Filing a complaint with organizations outside the hospital

If your concern about quality is still not resolved to your satisfaction 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). This means that they must meet certain rules and regulations in order to care for patients and receive payment. One function of DPH is to investigate complaints about any place they license.

You can file a complaint with DPH by:

Sending the complaint: Be as specific as possible about your concern if you are writing your complaint. And make sure you make a copy of what you send. Once 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. Some complaints involve a situation that could cause imminent danger, death or serious harm (“immediate jeopardy”). In this case, investigators should be at the hospital 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.

Complaint investigations that involve visits to the hospital 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.

Can you remain anonymous when you file a complaint? You have the right to remain anonymous—that is, to not give your name or contact information. 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 as investigators won�t be able to review your records or interview staff about a specific incident or incidents. You can talk about the pros and cons of remaining anonymous in your specific situation.

How long will it take? There are no rules about how long an investigation can take, though DPH policy is to notify you within 30 days after the completion of their investigation.


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 going on site to survey hospitals in action. It has accredited many California 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://www.jointcommission.org/report_a_complaint.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 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 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 led to 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 at the hospital the next time it is reviewed.

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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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 one of the state Department of Public Health District offices: http://www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx

Or call: 1-800-236-9747


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Where else can you go with a concern about quality?

Government Agencies

Medicare: If Medicare (federal health insurance program for people over age 65 or people under 65 who are disabled) pays for your or your loved one's care, you have an additional place to go with a quality of care concern. Medicare pays a Quality Improvement Organization (QIO) to take complaints from Medicare patients. In California, that organization is called Livanta.

You can call Livanta at the following number: 877-588-1123. 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 Livanta and allow release of your medical records, a doctor 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. Livanta generally focuses on improving the performance of the hospital, not on punishing it.

For more information about the Livanta complaint system and to get an online complaint form:

http://www.bfccqioarea5.com/

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 Livanta. They will quickly review your case and decide whether Medicare should continue to pay for your hospital stay or not.

Hospital Appeals Phone Number: 877-588-1123

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: 1-800-722-0432
Website: http://oag.ca.gov/bmfea/


Other 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. 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.

http://safepatientproject.org/

In a joint effort with the Empowered Patient Coalition, the Safe Patient Project is conducting a survey about medical events from the perspective of the patient. For more information about the survey:

http://empoweredpatientcoalition.org/report-a-medical-event
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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.calqualitycare.org/

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.medicare.gov/hospitalcompare/search.html

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 1-800-994-6610 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 Doctor:
https://www.informedpatientinstitute.org/PHYQuality-CA.php

What To Do If You Have Concern About Quality in a California Nursing Home:
https://www.informedpatientinstitute.org/NUHQuality-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


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