listening and responding to patient complaints: a health system approach
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Dr Anne Duggan
Acting Director Clinical Governance
Hunter New England Health Local Health District
Listening and Responding to Patient Complaints: a Health System Approach
Clinical Governance – Pursuing, Quality, Safety and Excellence
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SMH 22/9/12
Patients complain of spending
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SMH 22/9/12
Abuse of doctors
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Sir Luke Fildes, The Doctor, 1887, Tate Gallery
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“If I had an hour to save the world I would spend 59
minutes defining the problem and 1 minute finding a
solution”
Einstein
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19th century Medicine - Snow‟s Broad Street Pump 1854
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20th century Medicine Age of Discovery
• Aspirin -1900s
• Blood transfusion – 1910s
• Insulin - 1920s
• Penicillin - 1940s
• Dialysis- 1940s
• Steroids – 1950s
• Ulcer healing drugs -1970s
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“Not for the good it will do but that nothing will be
left on the margin of the impossible”
- T.S. Eliot
Clinical Governance – Pursuing, Quality, Safety and Excellence
`I don't much care where--' said Alice.`Then it doesn't matter which way you go,' said the Cat.
`--so long as I get SOMEWHERE,' Alice added as an explanation.`Oh, you're sure to do that,' said the Cat, `if you only walk long
enough.'"
“Would you tell me, please, which way I ought to go from here?'
`That depends a good deal on where you want to get to,' said the Cat.
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Healthcare Health
What is the matter with you? What matters to you?
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“These medical advances often mean longer and more
fulfilling lives. There are, however, broader implications.
Greater clinical uncertainty requires both greater
professional judgement as to what is the right course of
action for an individual patient and a more open and
honest discussion of risks to enable patients to make
informed decisions.”
- Lord Darzi
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Benefits and Harm
Harm Benefits
Units of
benefit
No. of Affected Population treated
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Patient Centred Care
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James Gillray illustrates the common practice of bloodletting (“breathing a
vein”) to help cure disease. 1804
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The NSW Health Framework for managing the quality
of heath care provided in NSW is based on the Six
Dimension of Quality. The six dimensions of quality
health care are:
- Safety
- Effectiveness
- Appropriateness
- Consumer participation
- Access
- Efficiency
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Listening and responding effectively to patient
complaints and feedback is one of the most
important investment we can make to ensure a
viable public health sector for the future.
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• Building a systems based approach
• Capturing and responding to patient feedback
• Dealing with difficult complainants
• Measuring for quality improvement
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Hunter New England Health
840,000 population (12%)
130,000 sq kms
49 inpatient facilities
68 locations
3225 beds
55,600 operations annually
14,000 staff
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Building a systems based approach
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Definition and framework
NSW Ministry of Health Complaint Management
Policy PD2006_073
Definition
A complaint is:
1. An expression of dissatisfaction with a service
offered or provided, or
2. A concern that provides feedback regarding any
aspect of service that identifies issues requiring a
response
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Principles
• Compliance with policy
• Consumer engagement
• Open while protecting confidentiality
• Sensitivity and timeliness *
• Fair to all parties, just outcomes
• Quality improvement and risk management
- record, review, aggregate to improve services
• Health Service and staff accountability
*NSW Ministry of Health benchmarks are:
Acknowledgement within 5 calendar days 100%
Resolution within 35 calendar days 80%
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System for complaints management
• Register in IIMS via the Complaint Notification Form.
• If clinical incident link to the Clinical Incident Form.
• Acknowledge within five calendar days (100%):
• Explain the process
• Identify contact person for the complainant
• Explain expected timeframes
• Assess and assign to the relevant person to co-
ordinate management
• Resolve within 35 days (benchmark 80%)
Clinical Governance – Pursuing, Quality, Safety and Excellence
Executive Support Service
• Access for complainants 1800 line
• Clarity of process and responsibilities
• Support for the process
• Monitoring and accountability
• Reporting framework
• Improvement pathway
• Senior Complaints Officer
28
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Framework
• At point of service acknowledgement
explanation
validation
• Through a staged process
(Unresolved or beyond delegation)
• Through referral to an external body/agency
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WEEKLY ACKNOWLEDGEMENT REPORT AS AT 18 SEPTEMBER 2012
Incident Location Incident Id
Date complaint received
How was the complaint received
Days Since Received
Complainant first name
Complainant last name Manager
**URGENT** OVERDUE FOR ACKNOWLEDGEMENT > 5 DAYS < 14 DAYS
LMSR 1321848-20 12-Sep-12Direct from complainant -letter 6 Crystal F Jude Cons
FOR ACKNOWLEDGEMENT - MATTERS NEARING 5 DAY BENCHMARK
Mental Health Banksia ( Northern Region: Tamworth) 1322604-20 14-Sep-12 NSW Minister of Health 4 Rosemary L Jude Cons
Tenterfield 1322601-20 14-Sep-12 NSW Minister of Health 4 Rosemary L Michael Mo
Tamworth BH Ward 4 Surgical 1322445-20 14-Sep-12
Direct from complainant -letter 4 Ken M Brad Hans
REMINDER - BENCHMARK FOR ACKNOWLEDGEMENT WITHIN 5 DAYS OF RECEIPT OF COMPLAINT
Medirest Catering 1323406-20 16-Sep-12 2 Bob Epp
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Capturing and responding to patient feedback
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What do People Complain About?
Complaint Issues 2007-08
0
50
100
150
200
250
300
350
400
Access Communication Corporate
Services
Cost Grievances Professional
Conduct
Privacy
Discrimination
Treatment Consent
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Clinical Communication -
Leads from Incidents and Complaints
Data from calendar year 2006
• 403 incidents reported to involve clinical communication
• 171 complaints involved clinical communication
• 127 Root Cause Analysis (RCA) involved communication
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Complaints associated with Communication
reported through IIMS in 2006
communicating at handover
3% policies communicated
adequately
3%timely transfer of investigations
to those in charge
1%communication on transfer
between facilities
4%
communication with patients
and carers regarding clinical
information
17%
communication with patients
and carers regarding
processess
11%
speaking up for safety
regardless of status.
1%
Relaying concerns about a
deteriorating condition to a
senior clinician
3%formal documentation systems
of communication
4%
interpersonal communication
principles and processes
53%
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Incidents associated with Communication
reported via IIMS in 2006
policies communicated
adequately
8%
timely transfer of investigations
to those in charge
3%
communication on transfer
between facilities
34%
Relaying concerns about a
deteriorating condition to a
senior clinician
6%
communicating at handover
32%communication with patients
and carers regarding processes
2%
communication with patients
and carers regarding clinical
information
5%
interpersonal communciation
principles and processes
2%
formal documentation systems
of communication
1%
speaking up for safety
regardless of status.
7%
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Comparison of RCA findings relating to Communication
with Initial Incident Report – 2006
76%
24%
RCAs with
Communication
Identified as an ISSUE,
but not by notifier
Incidents with
communication issues
identified in RCA, and by
Notifier
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Values
NSW Ministry of Health CORE values
• Collaboration
• Openness
• Respect
• Empowerment
Hunter New England Local Health District (HNELHD)
• CORE Values
• Excellence Program
“Every Patient Every Time”
Clinical Governance – Pursuing, Quality, Safety and Excellence
Standardisat
ion
AcceleratorsMust
Haves SM
Performan
ce Gap
Objective
Evaluation
System
Leader
Developme
nt
Foundation
Agreed upon
tactics and
behaviors to achieve
goals
Re-recruit high and middle
performers
Move low performers up or out
Processes that are
consistent & standardised throughout
the organisation
Leader Evaluation
Staff Evaluation
Discharge Call
Rounding
Idea Express
Aligned Goals Aligned Behavior Aligned Process
Create process to
assist leaders in developing skills and leadership competen
cies necessary to attain desired results
Implement an organisation-wide staff & leadership evaluation system to hardwire objective
accountability
Evidence-based leadership practices
AIDET ~ Five Fundamentals of Consistent Communication to Patients &
Carers
A Acknowledge Safety and respect
I Introduce Decrease anxiety
D Duration Increase
cooperation
E Explanation Quality
T Thank You Value & respect
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QSP
Knowledge industry and we provide
healthcare
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Ongoing Challenges
• Open Disclosure
• Fear of litigation
• “Second victim”
• Problem practitioners
• Communication training
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Prerequisites for successful open disclosure
Clinicians need to:
1. be aware that they will be legally protected from liability
2. know that they are authorised by their employer and
government to make an apology
3. be prepared to admit they have made a mistake
4. accept that making an apology is the right thing to do
5. believe that an apology may serve a good purpose
6. know when and how to make an appropriate apology
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The evidence for good communication
Up to 80% of malpractice claims are attributed to failures
in communication and/or a lack of interpersonal skills.
- Chris Wheeler Deputy NSW Ombudsman
-
Physicians with the highest risk for lawsuits were poor
listeners, often failed to return phone calls, and were
rude and disrespectful to patients. Hickson et al. (2002)
"Physicians are most often sued, not for bad care, but
inept communication. JCAHO (2005)"
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The evidence for good communication
These same "inept communication practices" result in
the majority of patient safety issues.
In 1996, JCAHO identified communication as one of
the top five issues contributing to the generation of
medical errors.
A 2003 JCAHO study documented communications
breakdowns as the root cause of over 60% of 2,034
medical errors, of which 75% resulted in the patient's
death (COPIC, 2005). In other words, 915 people
died as a result of a communication error.
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Open disclosure plicy NSW and National
An apology is an expression of feelings – an expression of
sorrow, remorse or regret and an acknowledgement of fault, a
shortcoming or a failing.
An apology is a communication of information – a message. It
consists of words that are exchanged that pave the way for a
reconciliation.
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The six „R‟s of an apology:
• Recognition
• Responsibility
• Reasons
• Regret
• Redress
• Release
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National Standards for Open Disclosure
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Dealing with difficult complainants
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Four complaints:
Ms A Her sibling‟s undiagnosed mental illness and treatment
within a mental health model.
Mr BHis osteomyelitis post hip replacement.
Mr and Mrs C
Their baby‟s birth injuries
Mrs DHer husband‟s chronic illness and suicide.
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Measuring for quality improvement
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Complaint Performance Indicators
Two Performance Indicators for Complaint Handling are
measured monthly:
Acknowledgement within 5 days (benchmark = 100%)
Resolution within 35 days (benchmark = 80%)
Reports on Complaint Performance Indicators are provided
to the Executive Leadership Team and the HNE LHD
Clinical Quality and Patient Care Committee to monitor
progress
Quarterly and annual reports are disseminated to the
Organization via the Clinical Governance Intranet
Clinical Governance – Pursuing, Quality, Safety and Excellence
Number of complaints received by month - Comparitive
0
50
100
150
200
250
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2007/2008
2008/2009
2009/2010
2010/2011
2011/2012
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Complaints about Communication by issue for HNE for 2011/2012
0
20
40
60
80
100
120
140
160
Attitude Inadequate information Wrong/Misleading information Interpreter/special needs
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Complaints Management
Summary
• Learning Opportunity – define the problem
• Early apology – bad news never gets better with time
• Communication for understanding – a learned behaviour
• Work together e.g. HCCC - Not every complaint can be resolved
• Create the culture – measure to improve
• Create the space
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“If I had an hour to save the world I would spend 59
minutes defining the problem and 1 minute finding a
solution”
Einstein
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