Grievances and Complaints: Ensuring Hospital Compliance with CMS CoPs, TJC and DNV Standards, and OCR

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute
Health Institute

Date & Time

Thursday, April 4
9 - 11 a.m.

Register on or before Wednesday, March 27, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you!

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation.


C-suite officers, nurses with direct patient care, TJC coordinators, quality improvement coordinators, hospital legal counsel, and others involved with implementation of CMS CoPs, TJC or DNV standards

The following program content was provided by the speaker.


This webinar will discuss the federal law that is now in effect for hospitals and enforced by the Office of Civil Rights requirements under Section 1557 of the Affordable Care Act. Hospitals must have a grievance procedure and compliance coordinator to investigate any grievances alleging noncompliance with this law. There should be a process in place to resolve any grievance prohibited by Section 1557, and this information should be visibly posted in the hospital.

The Joint Commission standards on complaints, the Det Norske Veritas Healthcare procedures on grievances, and how these crosswalk to the Centers for Medicare & Medicaid Services grievance interpretive guidelines will be reviewed. Staff should be aware and follow the hospital grievance and complaint policy. There also will be a review of medical records documentation.


At the conclusion of this session, participants will be able to:

  • describe how a hospital must follow the CMS Conditions of Participation on grievances if they receive Medicare reimbursement
  • identify the CMS regulations under grievances, including the requirement to have a grievance committee
  • explain The Joint Commission complaint standards in the Patient Rights (Rights and Responsibilities of the Individual) chapter
  • explain the DNV grievance standard in the Patient Rights chapter
  • discuss how the hospital should provide the patient with a written notice that includes steps taken to investigate the grievance, the results and the date of completion


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians and other health care providers. Dill Calloway has authored more than 100 books and numerous articles.