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Expect the Unexpected: Are We Clearly Prepared?. “Informal Complaint Resolution”. Irene Clarke, Katja Lutte, Cheryl McDougall College of Physicians & Surgeons of Ontario. Framework for Resolution. Backdrop Past Processes Current Processes Case Examples.

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informal complaint resolution

Expect the Unexpected: Are We Clearly Prepared?

“Informal Complaint Resolution”

Irene Clarke, Katja Lutte,

Cheryl McDougall

College of Physicians & Surgeons of Ontario

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

slide2
Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

slide3
Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

framework for resolution
Framework for Resolution
  • Backdrop
  • Past Processes
  • Current Processes
  • Case Examples

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

issues involved in public complaint investigations
Issues Involved in Public Complaint Investigations

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

backdrop committee decisions
Backdrop: Committee Decisions

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

outcomes
Outcomes
  • Complainant
    • frustration and disbelief
  • Doctor
    • stress and annoyance
  • Complaints Committee
    • $600,000 per year

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

past resolution processes
Past Resolution Processes
  • 1990-1998

Committee Resolution

  • 1997-2001

Informal Staff Resolution

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

committee resolution 1990 1998
Committee Resolution(1990 – 1998)
  • Complaints Committee Directed
  • Resolution by:
    • Staff facilitators
    • External mediators

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

committee resolutions 100 cases
Committee Resolutions 100 cases
  • Outcome

Agreement –20%No Agreement –80%

  • Why

Complainants

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

Physicians

        • Process too slow
        • Mediator: no clinical knowledge

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

informal staff resolution 1997 2001
Informal Staff Resolution1997-2001
  • Complainants consented to resolution

Via phone or letter

  • Patient Records
  • Written Physician Response
  • Written information
  • Committee Chair Approval

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

informal staff resolutions results 2001
Informal Staff Resolutions Results -2001

40%vs.20%resolve

157days vs.547 +days

$500,000 vs $600,000

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

complaints process survey 2001
Complaints Process Survey2001
  • Telephone Interviews
  • Satisfaction Indicators
    • process
    • quality
    • outcome

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

complaints process survey 20011
Complaints Process Survey 2001
  • Satisfaction Level
      • Desired Outcome
      • Time
      • Continual Communication
      • Investigator with clinical knowledge
      • Resolution vs. Decision

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

current process
Current Process

2001 – present

Proactive Staff Resolution

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

complaints per area of practice
Complaints Per Area of Practice

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

proactive staff resolution
Proactive Staff Resolution
  • Designated Staff
    • nurses, physiotherapists, social workers
  • With
    • significant clinical practice background
    • management or teaching experience
    • know health care system
  • Can communicate

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

investigator on call
Investigator on Call
  • Calls from our general inquiries area
  • letters

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

investigator on call 2005
Investigator on Call2005
  • 366 telephone inquiries forwarded to on-call investigators;
  • 26 converted to complaints.

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

investigator on call 20051
Investigator on Call2005
  • 145 letters earmarked for on call resolution
  • 9 converted to formal complaint

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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

resolution criteria
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;

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

resolution criteria1
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;

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

no resolution when
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;

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

what investigators do
What Investigators Do
  • Telephone/Meet
    • Complaint as a “whole”
    • Records
    • Provide Context
    • Physician Verbal Response
    • Joint meeting
  • Medical Director Approval

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

what they do
What They Do
  • Joint Resolution with Hospitals
  • Meet
    • Complainant
    • Physician/s
    • Chief of Staff
    • Patient Rep
  • Records available at meeting

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

what are key actions
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

how did we do 2004
How Did We Do?2004

58%resolved (up from40%)

62%resolved

65days(down from157 days)

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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

benefits1
Benefits
  • Educational Value
  • System Improvements
  • Increase in satisfaction for all parties, including investigators
  • Positive College Image

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

benefits2
Benefits

Patient Safety (Lucian Leape, MD)

Responding to the patient

What do patients want?

  • Know what happened (98%)
  • Receive an apology
  • Be assured the hospital/doctor is doing all that can be done to prevent a recurrence

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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

benefits3
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

fools rush in where angels fear to thread
Fools rush in where angels fear to thread
  • Cannot compel physicians to apologize
  • Can ask or convey the complainant’s wish for an apology

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

negotiating 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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

myth apology admitting guilt
Myth: Apology = Admitting Guilt

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

apology without implied 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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

components of suitable apology letter
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

apology busters
Apology Busters

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

wrapping it up
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

example 1
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

example 1 cont d
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

example 2
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

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

is i m sorry an apology
Is “I’m sorry”, an apology?

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

is i m sorry an apology1
Is “I’m sorry”, an apology?

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

slide45

QUESTIONS ???

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia

speaker contact information
Speaker Contact Information

Irene Clarke, Katja Lutte, Cheryl McDougall

College of Physicians & Surgeons of Ontario

80 College St., Toronto, ON, M5G 2E2

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

iclarke@cpso.on.ca

klutte@cpso.on.ca

cmcdougall@cpso.on.ca

www.cpso.on.ca

Presented at the 2006 CLEAR Annual Conference

September 14-16 Alexandria, Virginia