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

Advice and resources for dealing with quality concerns

Thousands of people become patients in one of Maine's 41 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 received. If this happens to you or a loved one, 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 Maine hospital, what are your rights when it comes to quality of care?

Under the law, you have rights in a Maine 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/advocacy-issues/communicatingpts/pt-care-partnership.shtml

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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 hospital patients.

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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 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 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 your concern. 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.

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. 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.

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.

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 Maine Department of Health and Human Services and the Joint Commission.

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The Maine Department of Health and Human Services

Maine hospitals are licensed by the Maine Department of Health and Human Services (DHHS). This means that they must meet certain rules and regulations in order to care for patients and receive payment. One function of DHHS is to investigate complaints about any place they license. The department received 318 complaints about Maine hospitals in 2013. DHHS investigators found that 32 of those complaints did have a quality problem.

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

• Call this toll-free number: 800-383-2441 M-F 8:00-5:00. After 5:00 p.m., leave a voice message.
• Emergency Number: 800-624-8404  Available 24 hours/7 days a week
• Send an e-mail to: dlrs.complaint@maine.gov
• You can mail your complaint to:
  
  Division of Licensing and Regulatory Services
  Complaint Intake Unit
  41 Anthony Ave.
  11 State House Station
  Augusta, ME 04333-0011

Submitting the complaint: Be as specific as possible about your concern when you are writing your complaint. And make sure you keep a copy of what you send. Once DHHS receives your complaint, generally within a week you will receive a letter confirming that they have it.

The investigation:  What happens next depends on how serious your concerns are. Some complaints involve serious harm, or the possibility of serious harm, such as death or a very bad injury. If this happens it is called "immediate jeopardy." In this case, DHHS staff should be at the hospital investigating within 2 days of getting the complaint. Concerns that are "high priority" lead to investigations within 10 days. Medium and lower-level complaints may take anywhere from 45 to 100 days—or may wait until the next DHHS inspection of the hospital.

Complaint investigations that involve visits to the hospital are usually unannounced—the hospital administration and staff are not told in advance that a DHHS investigator is coming. Some investigations do not require a visit to the hospital.

Depending on the type of complaint, the DHHS 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 that tells you what was found. The investigation would only be reopened if DHHS received new information.

What are the outcomes?  If the investigation finds that there is a quality problem that hasn't already been fixed by the hospital, DHHS will issue a report listing the problems (called a Statement of Deficiencies). The hospital will then respond with a plan saying how they will correct those problems. If needed, DHHS staff can go back to the hospital to make sure that corrections were made.

Can you remain anonymous when you file a complaint?You have the right to remain anonymous when you file a complaint with the Maine Department of Health and Human Services (DHHS)—that is, to not give your name or contact information. If you do give your name and contact information, you can ask that DHHS staff treat it confidentially and not tell the hospital that you are the person complaining.

If you do want to remain completely anonymous, it may make your case more difficult because it may limit DHHS staff's ability to verify information. You also won't be able to follow up and learn about the case or receive information about what happened.

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 Maine hospitals. Those hospitals have to meet many standards and patient safety goals related to patient care, including quality of care.

Find out if your hospital is accredited by the Joint Commission by checking here: http://www.qualitycheck.org

Filing a complaint: 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:When writing the complaint, talk about what happened 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. The Joint Commission has an online complaint form that gives additional information about what they need when you send a complaint (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 includes 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 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.

Other Hospital Accrediting Organizations

A few hospitals in Maine are accredited by another organization called the Healthcare Facilities Accreditation Program (HFAP) (http://www.hfap.org/). For more information about how to file a complaint against an HFAP-accredited hospital: http://www.hfap.org/resources/complaintinformation.aspx

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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 and Human Services.

800-383-2441
M-F 8:00-5:00. After 5:00 p.m., leave a voice message.

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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 Maine, that organization is called Livanta.

You can call Livanta at the following number: 866-815-5440. 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://bfccqioarea1.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: 866-815-5440

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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 in the "complaints, appeals or grievances" section of the HMO's website for information or forms to file.

Consumer Organizations

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 Maine.  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/

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

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/getinvolved/item/have-you-been-harmed-in-a-medical-facility-share-your-story

On Facebook, search for: ProPublica Patient Harm Community

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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.

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Where can you find information about the quality of Maine hospitals?

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

Maine Hospital Ratings: A hospital rating site sponsored by the Maine Health Management Coalition that indicates how well Maine hospitals do on maternity care, patient safety and other areas. Also includes hospital satisfaction information.
http://www.getbettermaine.org/

Maine HealthCost: Gives information on the average costs of various types of surgeries (such as knee surgery or hip replacements), imaging services (such as CT scans or MRIs) and other procedures.
http://gateway.maine.gov/MHDO/healthcost/

Maine Hospital Quality Snapshots: Provides information about how well hospitals do in providing heart care, pneumonia and nursing care and in preventing infections and nursing care. The information is fairly technical, but still might be of interest.
http://www.mqf-online.com/summary/intro.aspx#MHQS

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 Maine managed care plan (HMO) or a nursing home, or the care provided by a physician or nurse, here's where to go for more information:

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

Managed Care/HMOs
Maine Bureau of Insurance
http://www.maine.gov/pfr/insurance/complaint.htm#a

Nursing Homes
What To Do if You Have a Concern About Quality in a Maine Nursing Home
http://www.informedpatientinstitute.org/NUHQuality-ME.php

Registered Nurses, Licensed Practical Nurses
Maine State Board of Nursing
http://www.maine.gov/boardofnursing/Discipline/complaint.htm