The Commission’s Early Resolution Project

Kieran PehmCommissioner

Travis BrownManager of Assessments

Overview of the Commission’s complaints handling functions

The Commission is an independent body dealing with complaints about health service providers in NSW.

The Commission is a co-regulator with the health professional councils.

The Commission receives, assesses, attempts to resolve, investigates and prosecutes health care complaints in NSW.

The Commission’s object is to protect public health and safety.

The Commission received 10,187 inquiries and 4,767 written complaints in the 2013-14 year.

2.6% referred to another body or person

4.3% referred for investigation by the Commission

5.5% resolved

8.1% referred for local resolution

9.3% referred to the Commission’s Resolution Service

17.8% referred to a health professional council for further action

52.4% discontinued

Breakdown of assessment of complaints 2013-14

Usual complaints assessment process

60 day timeframe

Written response required from provider

Providers are to respond to a complaint within 21 days

Usually medical records are requested when the complaint raises a clinical issue

Correspondence heavy

Minimal verbal contact with the parties

Reasons for establishing the Project

To reduce the discontinue rate from 52% to less than 40%.

To increase the resolved rate from 5.5% to 15% or higher.

To address feedback and perceptions that the Commission does not deal with less complex complaints in a serious manner.

To assist in reducing the caseloads of Assessment Officers in the face of an increasing caseload of 6-7% annually.

Identifying complaints suitable for early resolution

The Manager of Assessments receives and reviews all complaints prior to distribution to the Assessment Team Leaders.

Complaints where:

there is no identifiable risk to public health and safety

there is no significant clinical issues that will require a response and medical records

the complainant has clearly identified what they want as a result of lodging the complaint

are suitable for early resolution.

In other words, is a formal response required or is this something that can be resolved with a few phone calls?

Most common categories of complaints suitable for early resolution

Access to medical records

Billing issues

Arranging appointments

Apologies for disrespectful behaviour

Early Resolution Process The Early Resolution Officer (ERO) submits an assessment plan which

essentially sets out how he or she proposes to resolve the concerns raised in the complaint and this is approved by the team leader

21 day timeframe to resolve or otherwise assess the complaint

Intensive telephone contact with the parties

May assist parties eg. educate a party as to their rights and obligations on a particular issue or assist with drafting an apology

Voluntary process

If in attempting to resolve the complaint the ERO discovers significant clinical issues / issues that pose a risk to public health and safety, the ERO can remit the complaint back to the team leader to be assessed according to regular timeframes and processes

Consultation with the relevant health professional council

Case study 1

Complaint

A GP complained about a pharmacist who she says is rude and condescending to her over the telephone when he makes enquiries about her patients’ prescriptions. The pharmacist has accused the complainant of over-servicing her patients because she does not issue a maximum number of repeats.

The GP’s patients are mostly geriatric and from her experience they tend to lose or misplace scripts. The GP feels the pharmacist is unprofessional and should stop interfering in her practice. Both feel they are acting in the interests of the patients.

This complaint has been made to the Commission twice.

Case study 1Outcome of first complaint – usual assessment process

The complaint was assessed according to regular processes and timeframes.

A formal response was requested.

The pharmacist denied the tenor of the conversation with the GP. He claimed he was making an objective phone call to a doctor to confirm the number of repeats in the context where 2 repeats had been issued for a chronic condition where a maximum of 11 was allowed.

The Commission discontinued the matter because:

the complaint concerned a dispute between two practitioners as opposed to clinical issues or treatment of a patient

the complaint did not raise serious issues of public health and safety

Case study 1Outcome of second complaint – early resolution project

The GP’s colleague made a similar complaint to the Commission about the pharmacist. The complaint was identified as suitable for early resolution.

An ERO telephoned the parties.

The pharmacist was defensive. The ERO suggested to the pharmacist that perhaps both he and the GP were looking out for the best interests of the patients but that they disagreed about their management. He agreed to draft an apology.

The apology was never forthcoming however the complainant was grateful that the Commission had spoken with the pharmacist and hoped the message about his unprofessional behaviour got through, despite not achieving the outcome she had initially hoped (an apology).

The complaint was resolved.

Case study 2Complaint

An elderly lady had elective surgery postponed on two occasions, and by chance the hospital’s operating theatres were closed at the time whilst they transitioned to new theatres which resulted in further delays.

Admission staff communicated the situation poorly to the complainant and told her they were unable to provide her with a date for surgery in the future. After speaking with the administrative staff, the complainant was under the impression that the operating theatres had been closed permanently and that she would not be able to have elective surgery.

This was an unfortunate situation combined with a logistical event and poor communication by the hospital.

Case study 2Outcome

The ERO contacted the Director of Medical Services at the hospital, who in turn immediately phoned the complainant to apologise, explain what had happened in her case, reassured her that her surgery would be taking place, and arranged for her to be placed on the priority list given what had transpired.

The complainant had been on the waiting list for one year and after speaking with the Director she felt reassured her surgery would go ahead later in the year when the operating theatres re-opened.

The complaint was resolved.

Case study 3

Complaint

The complainant made several requests to obtain her medical records from her ophthalmologist. The requests were in writing and accorded with the requirements of the Health Records and Information Privacy Act 2002 (HRIPA). Her requests were ignored by the provider for 6 months.

Outcome

The ERO spoke with the doctor. The doctor said he hadn’t received a complaint or request for records in 22 years of practice. He was offended by the request and presumed it was motivated by concerns about his care and treatment. The ERO explained the various rights and obligations pursuant to HRIPA to the provider. After much discussion, the provider understood his obligations and a full copy of the records was provided to the complainant. The complainant was effusive in her praise and gratitude, and said she was so grateful the Commission could help her.

The complaint was resolved.

Key elements to resolving complaints early

Early contact with the parties

Clear expectations

Blocking out the background noise that often comes with complaints and identifying the key issues

Developing trust

Negotiation

Be clear and concise about the process and potential outcomes

Who is contacted ?

If the complaint involves a provider and/or facility in a Local Health District

Depending on the nature of the complaint, the ERO may contact the provider or facility directly.

In some cases, the LHD will be contacted in the first instance, for example, where a provider has not been identified in the complaint and the ERO requires assistance to identify a provider or key contact.

The LHD will be informed of the outcome at the close of the complaint by correspondence and provided with a copy of the complaint.

If the complaint identifies a health care provider not employed by an LHD

The ERO will contact the provider directly to extract what they may be willing to do to resolve the complaint.

Justice Health Complaints

Complaints that are made by inmates at correctional facilities

Generally these are referred for local resolution.

The ERO will make contact with the Justice Health client liaison officer.

Complaints suitable for early resolution are those where an inmate is complaining about a waiting list or where an inmate has requested to speak with the Nursing Unit Manager or a doctor.

Because the Commission is unable to contact inmates these complaints are often referred to the client liaison for further action and the inmate is informed by correspondence. A further complaint can be made if the further action is not taken.

Statistics

Resolved rate 2013-14 = 5.5%

With the commencement of the early resolution project in July 2014, the resolve rate has increased significantly:

1st Quarter 2014-15: assessments resolved rate = 14%

2nd Quarter 2014-15: assessments resolved rated = 13.9%

Percentage of complaints referred to project resolved

1st Quarter: ERO’s resolved 45.1% of complaints referred to the project*

2nd Quarter: ERO’s resolved 39.7% of complaints referred to the project*

* ERO’s are also given straight up referrals to Council matters to supplement the workload which accounts for another 20-25% of their outcomes.

Lessons learned so far

Quick and efficient

Excellent client feedback

Avoids bureaucratic delays

Important to carefully select appropriate complaints

Important to keep both parties’ expectations clear

Follow up result with documentation

Feedback“I cannot give enough thanks to HCCC for the help and courtesy I received. It was so much more than I expected. In no way did I expect to be treated so well and made to feel that my complaint was legitimate. I felt like I had someone on my side and to stand up for me. I felt empowered. Thank you once again. I’m very grateful. Dr X’s practice treated me unkindly and you guys were my island.”

“I wish to let you know that I visited the XYZ centre this afternoon for my dental appointment with Dr Z. He was a very kind man and was able to explain everything to me in a clear fashion, which I really appreciated.   He was also able to honestly answer some questions that I had been asking for some time.   I am glad to say that I was no longer just brushed off and was told the crown would be replaced at no further cost to me and a further date has been set in February 2015.  Nor did I have to pay for today's consultation. I am also aware that the above has taken place because you have assisted me greatly and for this I thank you very much.   Thank you.”