Complaints and quality: myth and reality in New Zealand

1. Complaints and quality: myth and reality in New Zealand NZIHM Conference Wellington, 1 July Nicola Sladden, Chief Legal Advisor Health and Disability Commissioner

2. Overview • Setting the scene • Incidence of claims/complaints • Complainant motives • Complaints and quality of care

3. Injured/Unhappypatient Claim Complaint Accident Compensation Corporation Health care provider Health and Disability Commissioner Compensation Complaint resolution Professional discipline Competence review MALPRACTICE LITIGATION

4. New South Wales, Australia “[Doctors] now work in an increasingly hostile medico-legal environment. New South Wales is reputed to have one of the highest rates of medical negligence litigation in the world.” - Editorial, Critical Care and Resuscitation Image: www.worldcountries.info

5. United Kingdom The tidal wave of litigation crashing against the shores of the NHS threatens a crisis. … Dr Panting [of MPS] maintains that the situation is dire. "We are looking at a looming crisis of proportions that will make the flu epidemic seem like a drop in the ocean," he said. - BBC News, Litigation Next NHS Crisis, 2000 Image: ww.worldcountries.info

6. Florida, United States “[Florida’s medical malpractice legislation has] crippled the health care system and left patients, payers, and providers considerably worse off than before. These conditions have, undoubtedly, created the most hostile professional and clinical conditions observed in the US, while fomenting a major social and political crisis.” - Paul Barach, AHRQ Image: www.worldcountries.info

7. New Zealand “New Zealand continues to be one of the most hostile medico-legal environments in any of the places in which MPS operates ...” – Medical Protection Society

8. Overview • Setting the scene • Incidence of claims/complaints • Complainant motives • Complaints and quality of care

9. A “high incidence” of complaints? 1 in 3 doctors in NZ subject to complaint during career 1 in 17 doctors in NZ can expect to receive a complaint each year This has been described as a “high incidence” of complaints. Cunningham, 2003

10. “Complaint rates are low” Only 3 of 850 adverse events (found in Davis (PHCS review of 6579 1998 public hospital records) surface in complaints to HDC — 1 in 200 “Complaints are rare … the vast majority of preventable adverse events never trigger one” Bismark et al, 2006

11. Claims & complaints tip of iceberg in NZ • Fewer than 5% of eligible patients claimed ACC compensation • Among patients who suffered serious preventable injuries only1 in 25 complained to HDC Bismark et al, 2006

12. Disparities in complaints to HDC • The most socioeconomically deprived patients are 1/3 as likely to complain as most privileged • Elderly (65+) are 1/5 less likely to complain as those aged 18 to 44 • Pacific patients are 1/3 less likely to complain as non-Maori/non-Pacific patients (similar trend for Maori, but not statistically significant – ethnicity not recorded on many files) Bismark et al, 2006

13. Overview • Setting the scene • Incidence of claims/complaints • Complainant motives • Complaints and quality of care

14. It’s not just about the money Bismark et al, 2006; Hickson et al, JAMA 1992

15. “I want lessons to be learnt” “Surgeons should not be overworked to the point of mistakes. I hope those involved have been able to learn from this and can thus prevent a mistake which could result in loss of life.” (breast cancer survivor whose breast prosthesis was punctured by surgeon who mistook it for a fluid collection)

16. Illegitimate complaints HDC has power to take no action on a complaint considered to be trivial, frivolous, vexatious or not made in good faith s 38 HDC Act In practice, fewer than 1 in 100 complaints are vexatious — though often vexing for the provider.

17. Complaints are made for a reason • 64% of complaints to HDC (re public hospital admission in 1998) involved an adverse event • 51% of adverse events were judged preventable Bismark, 2006 • Yet only 6% of complaints to HDC result in breach finding. (HDC Annual Report 2005)

18. Overview • Setting the scene • Incidence of claims/complaints • Complainant motives • Complaints and quality of care

20. Harmful to patient care? “As a society, we believe that by making complaints we’re going to improve the delivery of health care. In fact, there is an increasing wealth of evidence to show doctors practise worse.” Cunningham, 2006

21. Distrustful doctors • 1 in 3 respondent doctors lost trust, goodwill and commitment to patients. Cunningham, 2004 • 38% of respondent surgical trainees felt complaint had negative effect on future doctor-patient relationships. Jarvis et al, 2006

22. Defensive medicine • 85% of respondent NZ surgical trainees reported that complaint made them practise more defensively Jarvis et al, 2006 • 93% of respondent US physicians reported that litigation made them practise more defensively. Studdert et al, 2005

23. Defending the patient • ‘Negative’ defensive medicine is harmful if high risk patients cannot get necessary care — but beneficial, if risky doctors restrict practice or retire. • ‘Positive’ defensive medicine is harmful if it results in unnecessary tests and procedures — but beneficial, if patients receive appropriate standard of care.

25. The purpose of investigating patient complaints • Individual resolution Resolution, not retribution • Improvement in health care safety and quality Learning, not lynching • Public protection Watchdog role

26. Case study – medication error • 91-year-old Eileen Anderson referred to PNH by GP with chest infection • Mrs A’s bradma label incorrectly placed on another patient’s drug chart • Mrs A’s own pack of medicines lost • Mrs A given wrong drugs (including morphine sulphate) for 4 days • No nurses or doctors detected the error even though Mrs A became more and more drowsy and confused.

27. Case study – medication error • Day 4 – error detected by house surgeon • Consultant not told • Family not told for another 3 days • Mrs A died 2 weeks later • Family not called to be with mother during last few hours, even though staff realised she was dying

28. Family’s response Mrs A’s daughter reported “a total loss of confidence in PNH. A distrust of becoming a patient there, sufficient to lead me to sell my home and relocate. Guilt – for taking my mother to PNH in the first place … guilt for all she suffered, and her death.”

29. Staff response “I was devastated.” ED registrar “Working conditions for medical registrars at PNH were exceptionally difficult.” Medical registrar “Continuity of care in NZ hospitals especially over weekends is often not possible, because of frequent changes of general staff, and these times call for overall vigilance. I will never forget Mrs Anderson.” Consultant

30. DHB response Recruitment and staff issue addressed Education programmes enhanced Handover processes improved Access to/review of drug charts standardised Swipe card system for ward dispensaries – all Drs have access Patient details in long hand on chart before label affixed

31. National response • HDC report sent to DHBNZ Safe and Quality Use of Medicines Group • HDC report prompted medication safety audits and improvements in hospitals nationwide eg, Auckland DHB

32. Conclusions • Need to remain mindful of the “rest of the iceberg” – most adverse events never come to the attention of ACC and HDC • ACC claims and HDC complaints offer a valuable “window” on serious threats to patient safety • NZ system offers potential to link dispute resolution with improvements in patient safety.

33. www.hdc.org.nz