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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. Framework for Resolution. Backdrop Past Processes Current Processes Case Examples.

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“Informal Complaint Resolution”

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  1. 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

  2. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  3. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  4. Framework for Resolution • Backdrop • Past Processes • Current Processes • Case Examples Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  5. Issues Involved in Public Complaint Investigations Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  6. Backdrop: Committee Decisions Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  7. 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

  8. Past Resolution Processes • 1990-1998 Committee Resolution • 1997-2001 Informal Staff Resolution Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  9. 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

  10. 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

  11. 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

  12. 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

  13. Complaints Process Survey2001 • Telephone Interviews • Satisfaction Indicators • process • quality • outcome Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  14. 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

  15. Current Process 2001 – present Proactive Staff Resolution Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  16. Complaints Per Area of Practice Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  17. 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

  18. Investigator on Call • Calls from our general inquiries area • letters Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. Myth: Apology = Admitting Guilt Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  36. 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

  37. 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

  38. Apology Busters Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  39. 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

  40. 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

  41. 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

  42. 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

  43. Is “I’m sorry”, an apology? Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  44. Is “I’m sorry”, an apology? Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  45. QUESTIONS ??? Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

  46. 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

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