Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia “Informal Complaint Resolution” Irene Clarke, Katja Lutte, Cheryl McDougall.

Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia

“Informal Complaint Resolution”

Irene Clarke, Katja Lutte, Cheryl McDougall

College of Physicians & Surgeons of Ontario

Expect the Unexpected: Are We Clearly Prepared?




Framework for Resolution

• Backdrop

• Past Processes

• Current Processes

• Case Examples


Issues Involved in Public Complaint Investigations

5

5

6

16

36

63

65

0 10 20 30 40 50 60 70

Communication issues

Care issues

Conduct and behaviour issues

Records / Report issues

Financial issues

Consent issues

Sexual Abuse

% of time


Backdrop: Committee Backdrop: Committee DecisionsDecisions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2000 2001 2002 2003 2004 2005

No Further Action Caution in Person Referred to QA Referred to Discipline


Outcomes

Complainant frustration and disbelief

Doctor

stress and annoyance

Complaints Committee $600,000 per year


Past Resolution Processes

1990-1998Committee Resolution

1997-2001

Informal Staff Resolution


Committee Resolution(1990 – 1998)

Complaints Committee Directed

Resolution by:Staff facilitatorsExternal mediators


Committee Resolutions 100 cases

Outcome Agreement – 20% No Agreement – 80%

WhyComplainants

Process starts too late (after 1 year) Process too slow (6-12mo) Lawyer involvement

Physicians Process too slow Mediator: no clinical knowledge


Informal Staff Resolution1997-2001

Complainants consented to resolution

Via phone or letter Patient Records Written Physician Response Written information

Committee Chair Approval


Informal Staff Resolutions Results -2001

40% vs. 20% resolve

157 days vs. 547 + days

$500,000 vs $600,000


Complaints Process Survey2001

Telephone Interviews

Satisfaction Indicators process quality outcome


Complaints Process Survey 2001

Satisfaction Level Desired Outcome

TimeContinual CommunicationInvestigator with clinical knowledge

Resolution vs. Decision


Current Process

2001 – present

Proactive Staff Resolution


Complaints Per Area of Practice

Others(22% )

General Practice(49% )

Psychiatry(6% )

Obstetrics and Gynaecology

(6% )

InternalMedicine

(6% )

Orthopaedic Surgery(4% ) Paediatrics

(2% )

GeneralSurgery(5% )


Proactive Staff Resolution

Designated Staff

nurses, physiotherapists, social workers

Withsignificant clinical practice background management or teaching experience know health care system

Can communicate


Investigator on Call

Calls from our general inquiries area

letters


Investigator on Call2005

366 telephone inquiries forwarded to on-call investigators;

26 converted to complaints.


Investigator on Call2005

145 letters earmarked for on call resolution

9 converted to formal complaint

(of those 9, 6 were resolved pre-committee review)


Resolution Criteria

misunderstanding or miscommunication;

a known or common complication of a treatment/procedure;

an isolated incident of less serious conduct unbecoming a physician (i.e. not sexual abuse);

assistance to intervene beyond our jurisdiction;


Resolution Criteria

isolated incident of minor clinical mishap or oversight;

systems issue;

complainants indicate their wish to resolve;

complainant and respondent have agreed to the resolution process;


No Resolution When …

serious concern regarding clinical practice and/or conduct;

the complainant and/or subject physician are not receptive to resolution

the subject physician has a history of complaints pointing to a trend toward conduct or care that was inappropriate;


What Investigators Do

Telephone/MeetComplaint as a “whole” Records Provide Context Physician Verbal Response

Joint meeting

Medical Director Approval


What They Do

Joint Resolution with Hospitals

MeetComplainantPhysician/sChief of StaffPatient Rep

Records available at meeting


What are Key Actions?

Speedy assignment/ and contact Establish rapport with both parties Updates Language Paperless process ‘See’ care in records Collaborate with Chiefs of Staff Systems Approach Appreciation Letter


What Makes it Work? Complainant open to explanation Complainant wants ‘error’ fixed Physician open to explaining Physician willing to acknowledge No Lawyers Investigator Flexibility


How Did We Do?2004

58% resolved (up from 40%)

62% resolved

65 days (down from 157 days)

$315,000 (down from $500,000)


Benefits

Support for Process CMPA Chiefs of Staff Hospital Risk Managers/Patient Reps Individual Physicians


Benefits

Educational Value System Improvements

Increase in satisfaction for all parties, including investigators

Positive College Image


Benefits

Patient Safety (Lucian Leape, MD)Responding to the patientWhat do patients want? 1. Know what happened (98%)2. Receive an apology3. Be assured the hospital/doctor is doing

all that can be done to prevent a recurrence

**$ is way down the list of patient “wants”


Benefits

Patient Safety (Leape)The power of silence - destroys the patient’s trust - destroys the physician’s

integrity - “wall of silence” is

devastating for patients


Fools rush in where angels fear to thread

• Cannot compel physicians to apologize

• Can ask or convey the complainant’s wish for an apology


Negotiating an Apology

• The complainant request apology and the physician volunteers to apologize

• The complainant wants an apology and the physician needs encouragement

• No request for apology, but one would be the best way to resolve a complaint


Myth: Apology = Admitting Guilt


Apology without implied guilt

• I apologize if my behavior…• I apologize for causing you to

believe I was angry• Please forgive me if I offended you,

it was not my intention


Components of suitable apology letter

• Apologizes/regrets the behavior• Explains what happens• Conveys sincerity by expressing

remorse and displaying empathy• Reflects on the learning

experience• Reiterates regrets and apology


Apology Busters


Wrapping it up

• Ask the physician to cc me on letter• One to two weeks after letter sent, I

contact the complainant to discuss• Obtain agreement to close the file• Obtain authorization to close the file

from the medical director• Notify physician and complainant of

closure


Example # 1

• 28 years of age, TB, previously healthy

• Same Dr. for extended family• Pt so stigmatize, she can’t ever

utter “T.B.” – “ I have a disease”• In following up the contacts, the

secretary confirms the identity of the index case to a family member


Example # 1 (cont’d)

• The complainant wants the Dr. to be disciplined and to apologize (LOC)

• The Dr. was very stressed about the complaint, wanted to apologize, did not know how to begin

• A sample letter was provided


Example #2

• 16 year old in ER with back pain, swollen abdomen, urine positive for pregnancy, the nurse hears fetal heart beat, patient never had sexual relations

• Patient told she is pregnant, in denial• Mother not told anything because the

patient is 16• Patient is discharged


Is “I’m sorry”, an apology?


Is “I’m sorry”, an apology?


QUESTIONS ???


Speaker Contact Information

Irene Clarke, Katja Lutte, Cheryl McDougall

College of Physicians & Surgeons of Ontario80 College St., Toronto, ON, M5G 2E2

(416) 967-2600 ext: 408; 674; 494 (respectively)

[email protected]@[email protected]

www.cpso.on.ca

mailto:[email protected]









Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia “Informal Complaint Resolution” Irene Clarke, Katja Lutte, Cheryl McDougall.

Documents

virginia slide

clear annual conference

virginia backdrop

year slide

virginia framework

virginia issues

decision slide

virginia current process