Health Care Quality Is Everyone’s Responsibility

Health Letter, February 2015

By Alan Levine

The following is reprinted with permission from the November 2014 issue of the Capitol Hill Village (CHV) newsletter.

Most of us will speak up if we go to a restaurant and the food arrives cold or we get the wrong order. We will tell our auto mechanic if the car still makes that funny noise after we paid to have it repaired. Somehow, however, many of us still feel differently about health care services. We are uncomfortable questioning or, worse yet, complaining. Part of this attitude may reflect a rapidly changing but still common view that places health care providers on a professional pedestal. For others, our reticence reflects our lack of comfort with the complexity of medical science and the increasingly confusing complexity of the health care provider and financing system.

The message here is: it really is okay to ask questions, demand explanations that you can understand, and, yes, even to complain. It is your body and health or that of someone you hold dear. Who has a greater right to express concern? Also, when you speak up, you are not just looking out for yourself. You are providing important information that can help providers, as well as outside accrediting and monitoring groups, identify potential problems and improve the system for future patients.

If You Have a Question or Concern, Start Inside the System

  • Hospitals and large physician practices have supervisory structures and formal systems for dealing with concerns, so, in escalating order of seriousness:
  • First, talk directly with the provider involved. Sometimes the only thing wrong is poor communication.
  • If you are still uncomfortable, talk to the supervisor of the doctors, nurses, or other provider.
  • For a physician, this may be the senior attending physician, the division director or section chief, the department chair, the chief medical officer, chief quality and safety officer, or chief of staff.
  • For nursing care, the charge nurse is the first step up, followed by the unit’s nurse manager. At the top of the hierarchy is the chief nursing officer.
  • For general concerns about care at a hospital, physician group, skilled nursing facility, or other provider, especially if your concern relates to more than one provider (e.g., several nurses), spans various types of providers (physicians and nurses, nurses and transport staff, etc.) or concerns more than one event or episode, ask to speak with the patient advocate or ombudsman, the chief administrative officer, the chief quality and safety officer or even, if there is concern about true medical risk/harm, the clinical risk manager.

Sometimes You Need to Go Outside for Help

A variety of private and public entities are involved in monitoring and investigating health care quality. These organizations can provide information to help you choose a provider and to resolve concerns and issues that you may have. Among these are:

  • The Joint Commission, an organization that accredits and certifies hospitals, clinics, and some other health care organizations and invites complaints about hospitals on its website http://www.jointcommission.org/report_a_complaint.aspx. But, the Joint Commission does not always inform consumers about what its inspectors found and how the hospital has corrected the problem.
  • State Departments of Health and Health Care Facility Licensing Agencies. Each state has an agency that licenses and inspects hospitals and other health care providers on behalf of the state, the federal government, or both. These agencies can respond to complaints against any hospital or certain other licensed provider. A national directory of contact information for these agencies and departments can be found at: http://go.cms.gov/1rH8MPD.Talking to these state agencies will generally get you more information as they are more transparent than the Joint Commission. State survey agencies are required to complete a Statement of Deficiencies and Plan of Correction, known as a CMS Form 2567. If inspectors do not find problems after reviewing a complaint, the complaint is called “unsubstantiated,” and the details of the inspection are not made public on the 2567 form. If, however, inspectors find that hospitals have violated Medicare standards or rules, they provide details on the Form 2567, and hospitals are given the opportunity to detail how they plan to fix the problems. This form, once the complaint investigation is completed, is publicly available. Sometimes inspectors go to a hospital solely to investigate possible violations of state rules and sometimes they are looking into violations of federal rules. You can visit www.hospitalinspections.org, a website run by the Association of Health Care Journalists, to see substantiated complaints that involve federal rules.
  • Complaints Against Physicians. If you have a complaint about a physician involving quality of care and you haven’t been able to resolve the issue with the physician, it may help to first look to your state’s medical board, which licenses and regulates physicians in the state, to see if the doctor has had disciplinary action(s) taken against him/her. Some states also list medical malpractice information and hospital disciplinary sanctions. A directory of state medical boards can be found at www.aimmembers.org/boarddirectory/. The medical board website for your state should provide a process for filing a complaint.
  • Other Accreditation Entities. Hospices, homecare agencies, and other specialized providers may be accredited by specialized accrediting organizations. Ask the provider if they are accredited and by what entity. Then contact that accrediting entity for more information. Also, the Village has a list of these other entities and can assist members in identifying the appropriate organization.
  • Medicare Quality Improvement Organizations. If you are a Medicare patient, you also can complain to the Quality Improvement Organization (QIO) for your state regarding physicians, hospitals, hospices, homecare agencies, or other health care providers. A directory of state QIOs can be found at: www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793. While the results of those investigations are shared with patients, QIOs will only tell patients whether the standard of care was met or not met. QIOs will not provide any further details.
  • Contact your insurer if you have private insurance, and send a complaint to the insurance company that paid the bills for your treatment. In cases of true harm or financial loss, you may want to check with an attorney who specializes in medical care issues.

Most health care providers want to do their best and serve their patients well. Feedback—good and sometimes not so good—is important and generally welcome information that they can use to continuously improve the quality of care. So, don’t be afraid. Ask questions! Speak up!

Alan Levine is a CHV member, a former member of the Inspector General’s staff at the U.S. Department of Health and Human Services, and a volunteer at Public Citizen.