Complaints while you are a patient
Patient rights and responsibilities are not restricted to hospitals and large institutions; they apply to other aspects of the health care system as well. This includes your doctor’s office, your dentist, and your health care insurance provider. Relative to your health insurance, you will find specific reference to your rights and responsibilities included with descriptions of your health insurance coverage and policies and procedures or on their website. These rights are secured by a variety of state and federal laws related to regulation of the insurance and health care industry in the United States.
There is almost nothing more personal than our own and our family members’ health care. While it is good to know that your rights are well protected, everyone has questions and concerns about the many personal aspects of their health care and answers to your concerns should not have to wait or involve outside legal advice. That is why all health care providers and insurance carriers care about efficient and effective handling of questions and complaints. If you are experiencing problems or questions related to your own care or the care of a loved one, you should not delay – speak up! Remember, you have a right to know what is happening and who is providing your care, and what the plan is for your care. Delay in seeking answers to your questions can only increase your anxiety and confusion, and timely questions could help prevent a mistake in your care.
Most hospitals and larger health care facilities have separate independent departments dedicated to resolving patient complaints and questions that go by different names such as Patient Representative or Patient Advocacy. They are staffed by knowledgeable personnel who are there to intervene on your behalf if needed; or on occasion, on behalf of the staff caring for you when it is in your best interests. While you should always direct your concerns first to those directly responsible for your care, your next recourse is usually the institution’s Patient Representative or Patient Advocate. You always have a right to use any advocate, including a lawyer, your Health Care Agent as specified in a Health Care Power of Attorney, or other person you trust outside of the organization and you have a right to meet with them in a private setting. However, the necessity for this should be very rare. In most cases, the health care organization’s Patient Representative or Advocate will be able to resolve your questions.
Good Communication is the Key to Good Health Care
The key to good healthcare is open and honest communication between you and your healthcare provider. But, despite best efforts, communication can break down, particularly in times of stress. One of your fundamental rights as a patient is to understand the care that is being provided to you, including the medications and procedures that have been prescribed for you by your doctor. A growing trend across the United States has seen development of procedures to allow you or your family members to call a temporary “time-out” in your care and request immediate assistance from a team of health care providers who can be assembled similar to teams of providers who are assembled for health care emergencies, or “codes.” The team, who will include your immediate providers as well as other health care providers not directly involved in your care, will assess the situation and address any misunderstanding or questions you have about your or your family member’s care, assuring that you understand the treatment recommended for you. It can serve as an assurance that full and open communication is taking place, and as a double check on the appropriateness of your care, avoiding possible errors in your treatment. You should ask about whether such programs exist in any institution where you are admitted as an inpatient.
Medical Care Coordination
Patients with complex or chronic conditions such as diabetes often have conditions and symptoms that effect a variety of body systems, social and family situations, or even financial planning, and may require assistance from a variety of medical specialists, allied health professionals like therapists, home care specialists, and home medical equipment suppliers to support their treatment. Because it is often difficult for your primary care physician to keep track of the variety of treatments and processes taking place, a concept of Care Coordination has emerged. Put simply, Care Coordination is a discipline which involves “an interdisciplinary approach to integrating health care and social support services in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator following evidence-based standards of care. “While the effort is still led and supervised by your primary care physician, the effort may involve a nurse, social worker or other specially trained individual who assists the physician and patient with the complexity introduced when a variety of specialists and services are required and where conflicting priorities or instructions might be provided to the patient.
Use of formal Care Coordination processes is also becoming more common in complex pediatric cases. Some demonstration projects across the United States are resulting in reorganization of traditional medical practices into what has come to be known as a “Medical Home.” Larger health care providers have begun to experiment as well with “Care Coordinators” assigned to assist the primary admitting physician and patient with the complex task of coordinating the variety of specialists and allied professionals who might need to be involved in comprehensive care for the patient. It is a proactive effort at enhancing communication and guarding against conflicting courses of treatment that might cause harm rather than healing.
To learn more about Care Coordination, ask your Primary Care Physician or the Patient Representative, or you can learn more about Care Coordination at:
Reporting Complaints: State Regulators and Accrediting Bodies
While most complaints can be settled directly with those responsible for providing your care, you also have the right to seek help from the state Department of Health, or report incidents you feel need to be brought to the attention of accrediting bodies like the Joint Commission. The Joint Commission is a national accrediting body for hospitals and outpatient facilities used by most organizations in the United States.
You have a right to report serious incidents and complaints to your state’s Department of Health. The Pennsylvania Department of Health is responsible for licensing the operation of health care facilities in the Commonwealth of Pennsylvania. Complaints will be investigated and the results reported back to you. In Pennsylvania, you can find information regarding filing formal complaints at:
The Joint Commission’s website and complaint processes are described at:
1 Randall Brown, PhD., Mathematica Policy Research, Inc. THE PROMISE OF CARE COORDINATION: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses, Executive Summary: A report commissioned by the national coalition on care coordination (n3c) (March 2009 )