Home Events Grievances and Complaints: Ensuring Hospitals Compliance

Grievances and Complaints: Ensuring Hospitals Compliance


Date: 8/8/23

9:00 – 11:00 A.M.  Central time


Registration fees:     $225 per facility   |   Non-Members Registration Fee:  $350 per facility


Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.


This program will cover the CMS requirements on grievance regulations.  The speaker will review a federal law that is 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, including discrimination. This webinar will also discuss the Joint Commission standards on complaints and the DNV Healthcare standards on grievances, indicating that their standards cross walk to the CMS grievance interpretive guidelines. Hospital staff should be aware of and follow the hospital grievance and complaint policy, which should be approved by the board. This is a must-attend session for all hospitals.


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

  • Discuss that any hospital that receives reimbursement for Medicare patients must follow the CMS Conditions of Participation on grievances.
  • Recall that the CMS regulations on grievances include the requirement to have a grievance committee.
  • Recite that the Joint Commission has complaint standards in the patient rights chapter and DNV has a grievance standard in the patient rights chapter.
  • Recall that patients must be provided with a written notice that includes what steps were taken to investigate the grievance, the results, and the date of completion.
  • Describe that the Office of Civil Rights requires hospitals to have a process to handle grievances related to discrimination under Section 1557.


Laura A. Dixon most recently served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities,  practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.




Aug 08 2023


9:00 am - 11:00 am

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