Skip to main content

Facilitating the achievement of optimal wellness for renal disease patients


EIDM/QARM Transition

Procedure for Evaluation of Complaints and Grievances Data
Collection, Analysis, Reporting and Quality Improvement

Data regarding complaints and grievances is routinely collected through contact reporting and is used to:

  • Document and report complaints and grievance  
  • Evaluate complaints and grievances through trends analysis of reported issues and concerns
  • Identify needs and opportunities to promote and support quality improvement actions and interventions

Data Collection

The Patient Services Department created the “Patient Services Contact Form” to ensure the consistent collection of data for reported patient and provider/facility staff concerns. Each contact generates quantifiable information regarding contact types, demographics as well as specific areas of concerns. This data is entered on an ongoing basis into a database which can then be retrieved, sorted, grouped, and analyzed across different categories of interest.

Data collected through contact reporting is used to trend according to selected categories on a monthly, quarterly, and/or annual basis. These categories include:

  • Complaints, grievances, facility concerns
  • Admission/placement concerns
  • Involuntary discharges
  • Concerns/outcomes of possible discharges
  • Facility-specific complaints
  • Demographics

Monitoring standards have been created in accordance with the Conditions for Coverage:

  • §416.50 Condition for coverage—Patient rights.
  • § 416.43 Conditions for coverage—Quality assessment and performance improvement.

Data Analyzes

Descriptive trend analysis is used to monitor changes in reported patient and provider/facility staff concerns.  Areas of focus include:

  • Reviewing the overall pattern of change over time
  • Comparing one time period to another time period.
  • Comparing one geographic area to another.
  • Comparing one population to another.
  • Assessing future impact/importance.

Aggregate data is trended quarterly to determine:

  • Number of grievances and complaints
  • Areas of grievances and complaints
  • Demographics of grievances and complaints
  • Number of complaints/grievances per facility and corporation
  • Network interventions used to address patient and provider/facility staff concerns

Data Reporting and Monitoring

The data are reported and monitored monthly in the Patient Services Department and trended quarterly. The Patient Services Department present graphs, tables, statistical results, and narrative that connect findings to Network interventions and quality improvement strategies including policy revisions and updates.  

The data are presented to the Patient Leadership Committee, Medical Review Board and Board of Trustees. Policy development impacting patient and provider/facility staff concerns is conducted under the leadership of the Medical Review Board with comments and review by all governance bodies.

The data are also presented during the annual meeting, patient meetings and posted to the TRN Web site to create awareness of patient and provider/facility staff concerns and to discuss potential solutions and ways to address these issues. Feedback is also requested through these venues to assist in the development of quality improvement or best practices strategies.

These data are incorporated in the Patient Services Department IQI quality metrics. The Network reviews the amount of time contacts are open to ensure that the Network complies with CMS guidelines.

Quality Improvement

Using root cause analysis to identify underlying factors (for example, communications) which impact patient and provider/facility staff concerns, the Patient Services Department undertakes the development (alone or in partnership) the development of:

  • Educational resources and materials for both patient and provider/facility staff
  • Training programs and workshops

Trends in reported patient and provider/facility staff concerns provide invaluable information for needs assessments, program planning, program evaluation, and policy development activities. Aggregate data is also used to assess:

  • Additional areas for Network interventions
  • Areas for technical assistance
  • Training and other educational opportunities
  • Resource development