D.11 MCP 217-01 PATIENT ADVOCACY PROGRAM 36C24423R0132.pdf

PATIENT ADVOCACY PROGRAM

MCP 217-01

Lebanon VA Medical Center Lebanon, PA 17042

Signatory Authority:

Lebanon VA Medical Center Director

Responsible Owner:

Patient Advocate

Rescinded Document:

MCM 217-01, Patient Advocacy

Program

Effective Date:

May 15, 2021

Recertification Date:

May 31, 2026

1. POLICY

a. It is the policy of this medical center to be responsive and sensitive to the needs of our Veterans and to resolve all concerns and complaints in a positive and timely manner. All patients will be informed that a Patient Advocate is available to receive any communication of dissatisfaction with care received that cannot be resolved by the treating staff.

b. The Patient Advocate will operate and maintain the facility’s grievance mechanism designed to receive, process, respond to, and resolve patient concerns and formal complaints. Each patient or family member making a complaint will receive a response that substantively addresses the complaint. If the facility has not resolved the complaint to the satisfaction of the patient or family, referral may be made to other sources of assistance, such as legal service and adult protective service programs.

c. Presentation of a complaint by a patient or family member does not compromise the patient’s future access to care.

2. JUSTIFICATION

a. To provide medical center policy and procedures regarding the mechanism for receiving and responding to patient concerns.

b. The Patient Advocacy Program is designed to:

(1) Provide a liaison between the patients and the facility staff.

(2) Provide a mechanism for timely resolution of patient concerns and complaints.

(3) Serve as a program of advocacy for the patients.

(4) Promote high quality health care through communication, consideration, and courtesy.

May 15, 2021 MCP 217-01

(5) Assist the patient in understanding eligibility, rights, and responsibilities as patients.

3. RESPONSIBILITIES

a. The Director has overall responsibility for development and implementation of a program to manage concerns and complaints of patients and families.

b. The Patient Advocate is responsible for responding expeditiously to any problem or concern, which cannot be resolved at the care line level. The Patient Advocate will:

(1) Interview complainant and/or concerned family members.

(2) Determine immediate action plan and discuss it with the complainant.

(3) Discuss possible solutions to the problem and potential resolution with complainant and take appropriate corrective action.

(4) Coordinate resolution with involved staff within timeframes indicated by the Patient Advocate. Timeframes will be established on a case-by-case basis, usually within 1 to 7 business days.

(5) Document the case accordingly in PATS-R, in a manner that will not compromise the Veteran’s future access to care, such as:

(a) All potential litigation complaints and recurring complaints involving individual staff members will be reported immediately to the Director for appropriate action.

(b) Concerns/complaints routine in nature will be documented and included in a quarterly report to the Director.

(c) All concerns will be tracked for resolution to identify quality of care problems. The trending developed from compilation of concerns and complaints will be addressed quarterly at the ELC and used to identify areas where improvements can be made in patient care and in overall functions of the medical center.

(6) Coordinate the Service Recovery Program which consists of employees identifying process breakdowns while having the ability to remedy the problem on the spot with minimal supervisory involvement. A customer service contact list consisting of one or two names from each area within the hospital was made and distributed to front line staff. A service recovery identification form was created to keep track of service breakdowns. These forms are sent to the Patient Advocate for tracking and trending purposes. “Comps” such as drink coupons, meal coupons, and gas cards are available as an offering of something extra to remedy the situation.

c. The Veteran Experience Officer is responsible for the design development and implementation of the Veteran Experience Programs at the medical center and its VA Community Clinics.

d. Each Care Line Manager/ACOS is responsible for responding expeditiously to any concern brought to his/her attention. He/she is responsible for educating employees in the care line to being sensitive and responsive to Veterans’ needs and concerns.

e. Patient Advocate Contact Persons are responsible for attempting to resolve issues at the service line level and for responding to concerns referred from the Patient Advocate’s Office.

f. Each Employee at the medical center and satellite clinics are responsible for responding expeditiously in resolving all patient problems and concerns, which can be addressed at his/her level. Each employee is also responsible for following supervisory channels to resolve those concerns that he/she cannot fully address.

4. OTHER PARAGRAPHS

Procedures:

a. Promote and evaluate patient satisfaction through reporting to various leadership groups, and the Executive Leadership Committee (ELC) quarterly.

b. Provide information to medical center personnel regarding the effectiveness of medical center programs in meeting the perceived needs from a customer perspective, for inclusion in the quality improvement activities at the facility. This will be accomplished at new employee orientation and Customer Service training.

c. Provides a copy of the “Health Care Guide for Veterans,” which is available upon enrollment and also on admission in each patient bedroom, contains information about Lebanon VA Medical Center. The “Health Care Guide for Veterans” books will be displayed prominently throughout the medical center and VA Clinics to inform patients, concerned visitors, and concerned others of the identification of the program offered at the medical center and VA Clinics.

d. Clinical Appeals Process – See attachment, VHA Directive 1041, Appeal of VHA Clinical Decisions, Appendix A, page A-1, dated October 24, 2016.

5. DEFINITIONS

a. The Patient Advocate is the title of a Veterans Affairs (VA) medical center staff member, and as such, has access to the medical and administrative records of patients who require assistance, or register on a “need to know” basis, with or without the patient’s permission.

(1) The Patient Advocate serves as a liaison between the consumer (the Veteran, the Veteran’s family, or the Veteran’s representative) and the facility in addressing and, if possible, resolving patient concerns.

(2) The Patient Advocate is required to understand and represent facility management. The primary function of the Patient Advocate, however, is to serve the needs of the patient and to serve as the patient’s advocate.

(3) The Patient Advocate assists in defining problems, concerns, and unmet needs, and works through the appropriate individuals and care lines to reach solutions within existing laws and regulations. To resolve patient concerns, the Patient Advocate activity crosses all organizational lines of authority and encompasses all services within the facility.

(4) Formal complaints against a provider will be answered within 7 days of the complaint. Email from the Patient Advocate to the provider must be followed up on within 72 hours. If no satisfactory response is given, then the complaint will be escalated to the Associate Chief of Staffs (ACOSs) for that specific Service Line. All others will be completed by the Patient Advocates with contact made by the Primary Care Management Module (PCMM) Coordinator to the Veteran. In an instance where a Veteran requests more than one change of provider within a year, then a request will be made to the Provider Change Committee (ACOS Medicine, Business Manager, Primary Care, Patient Advocate, PCMM Coordinator, and Supervisory Medical Services Assistant) to make a decision.

(5) The Patient Advocate serves as the Chairperson of the Customer Service Committee.

b. The Patient Advocacy Program:

(1) Ensures that patients receive the maximum benefits of their interaction with the VA health care system; and

(2) Provides a mechanism to partially comply with the standards promulgated by The Joint Commission (TJC), and included in VA Form 10-7991a, Information Booklet on Patient Rights and Responsibilities.

6. REFERENCES

a. Current The Joint Commission Manual for Hospitals: The Official Handbook

b. VHA Directive 1041, Appeal of VHA Clinical Decisions, Appendix A

7. RESCISSION

MCM 217-01, Patient Advocacy Program, dated Title, dated March 31, 2021.

8. REVIEW

This MCP will be reviewed 3 months prior to recertification or when notified of National policy mandates, Handbook/Directive/Notice updates/rescissions, or when any changes are necessary in the interim to ensure facility compliance. Necessary changes include local, VISN, and National changes.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of April 2026.

This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

X Robert W. Callahan, Jr.

Director

Date Approved: Month Day, Year

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: MCPs are available at:

https://vaww.lebanon.va.gov/LVAMC_Document_Directory.asp

Appendix https://vaww.lebanon.va.gov/LVAMC_Document_Directory.asp

May 15, 2021 217-01

A-1

APPENDIX A

GUIDANCE FOR DEVELOPING A FACILITY CLINICAL APPEAL PROCESS

Patient or patient’s representative does not agree with treatment decision at local medical facility.

Patient, or representative, works with treatment team and/or facility Patient Advocate to resolve dispute. Every effort is made to resolve dispute at point of care.

Clinical disputes not resolved at the clinical team level should be elevated to the medical facility’s Chief of Staff who will review, attempt to resolve the dispute, and make a determination on the issue within 5 days.

Chief of Staff provides written notification to the patient or the patient’s representative of the medical facility’s final determination as well as information on how the patient or patient’s representative can appeal the medical facility decision to the VISN.

Patient or patient’s representative decides whether to accept or decline determination.

YES NO

Decision entered into PATS by medical facility Patient

Advocate staff

Patient or patient’s representative can appeal to the VISN. The VISN has 30 days to complete review unless an external review is requested.

APPENDIX A