0

Dr Anne Duggan

Acting Director Clinical Governance

Hunter New England Health Local Health District

Listening and Responding to Patient Complaints: a Health System Approach

Clinical Governance – Pursuing, Quality, Safety and Excellence

1

SMH 22/9/12

Patients complain of spending

Clinical Governance – Pursuing, Quality, Safety and Excellence

2

SMH 22/9/12

Abuse of doctors

Clinical Governance – Pursuing, Quality, Safety and Excellence

3

Clinical Governance – Pursuing, Quality, Safety and Excellence

4

Clinical Governance – Pursuing, Quality, Safety and Excellence

5

Sir Luke Fildes, The Doctor, 1887, Tate Gallery

Clinical Governance – Pursuing, Quality, Safety and Excellence

6

Clinical Governance – Pursuing, Quality, Safety and Excellence

7

“If I had an hour to save the world I would spend 59

minutes defining the problem and 1 minute finding a

solution”

Einstein

Clinical Governance – Pursuing, Quality, Safety and Excellence

8

19th century Medicine - Snow‟s Broad Street Pump 1854

Clinical Governance – Pursuing, Quality, Safety and Excellence

9

20th century Medicine Age of Discovery

• Aspirin -1900s

• Blood transfusion – 1910s

• Insulin - 1920s

• Penicillin - 1940s

• Dialysis- 1940s

• Steroids – 1950s

• Ulcer healing drugs -1970s

Clinical Governance – Pursuing, Quality, Safety and Excellence

10

“Not for the good it will do but that nothing will be

left on the margin of the impossible”

- T.S. Eliot

Clinical Governance – Pursuing, Quality, Safety and Excellence

`I don't much care where--' said Alice.`Then it doesn't matter which way you go,' said the Cat.

`--so long as I get SOMEWHERE,' Alice added as an explanation.`Oh, you're sure to do that,' said the Cat, `if you only walk long

enough.'"

“Would you tell me, please, which way I ought to go from here?'

`That depends a good deal on where you want to get to,' said the Cat.

Clinical Governance – Pursuing, Quality, Safety and Excellence

12

Clinical Governance – Pursuing, Quality, Safety and Excellence

13

Healthcare Health

What is the matter with you? What matters to you?

Clinical Governance – Pursuing, Quality, Safety and Excellence

14

Clinical Governance – Pursuing, Quality, Safety and Excellence

15

“These medical advances often mean longer and more

fulfilling lives. There are, however, broader implications.

Greater clinical uncertainty requires both greater

professional judgement as to what is the right course of

action for an individual patient and a more open and

honest discussion of risks to enable patients to make

informed decisions.”

- Lord Darzi

Clinical Governance – Pursuing, Quality, Safety and Excellence

16

Benefits and Harm

Harm Benefits

Units of

benefit

No. of Affected Population treated

Clinical Governance – Pursuing, Quality, Safety and Excellence

17

Patient Centred Care

Clinical Governance – Pursuing, Quality, Safety and Excellence

18

James Gillray illustrates the common practice of bloodletting (“breathing a

vein”) to help cure disease. 1804

Clinical Governance – Pursuing, Quality, Safety and Excellence

19

The NSW Health Framework for managing the quality

of heath care provided in NSW is based on the Six

Dimension of Quality. The six dimensions of quality

health care are:

- Safety

- Effectiveness

- Appropriateness

- Consumer participation

- Access

- Efficiency

Clinical Governance – Pursuing, Quality, Safety and Excellence

20

Listening and responding effectively to patient

complaints and feedback is one of the most

important investment we can make to ensure a

viable public health sector for the future.

Clinical Governance – Pursuing, Quality, Safety and Excellence

21

• Building a systems based approach

• Capturing and responding to patient feedback

• Dealing with difficult complainants

• Measuring for quality improvement

Clinical Governance – Pursuing, Quality, Safety and Excellence

22

Hunter New England Health

840,000 population (12%)

130,000 sq kms

49 inpatient facilities

68 locations

3225 beds

55,600 operations annually

14,000 staff

Clinical Governance – Pursuing, Quality, Safety and Excellence

23

Building a systems based approach

Clinical Governance – Pursuing, Quality, Safety and Excellence

24

Definition and framework

NSW Ministry of Health Complaint Management

Policy PD2006_073

Definition

A complaint is:

1. An expression of dissatisfaction with a service

offered or provided, or

2. A concern that provides feedback regarding any

aspect of service that identifies issues requiring a

response

Clinical Governance – Pursuing, Quality, Safety and Excellence

25

Principles

• Compliance with policy

• Consumer engagement

• Open while protecting confidentiality

• Sensitivity and timeliness *

• Fair to all parties, just outcomes

• Quality improvement and risk management

- record, review, aggregate to improve services

• Health Service and staff accountability

*NSW Ministry of Health benchmarks are:

Acknowledgement within 5 calendar days 100%

Resolution within 35 calendar days 80%

Clinical Governance – Pursuing, Quality, Safety and Excellence

26

Clinical Governance – Pursuing, Quality, Safety and Excellence

27

System for complaints management

• Register in IIMS via the Complaint Notification Form.

• If clinical incident link to the Clinical Incident Form.

• Acknowledge within five calendar days (100%):

• Explain the process

• Identify contact person for the complainant

• Explain expected timeframes

• Assess and assign to the relevant person to co-

ordinate management

• Resolve within 35 days (benchmark 80%)

Clinical Governance – Pursuing, Quality, Safety and Excellence

Executive Support Service

• Access for complainants 1800 line

• Clarity of process and responsibilities

• Support for the process

• Monitoring and accountability

• Reporting framework

• Improvement pathway

• Senior Complaints Officer

28

Clinical Governance – Pursuing, Quality, Safety and Excellence

29

Clinical Governance – Pursuing, Quality, Safety and Excellence

30

Framework

• At point of service acknowledgement

explanation

validation

• Through a staged process

(Unresolved or beyond delegation)

• Through referral to an external body/agency

Clinical Governance – Pursuing, Quality, Safety and Excellence

31

WEEKLY ACKNOWLEDGEMENT REPORT AS AT 18 SEPTEMBER 2012

Incident Location Incident Id

Date complaint received

How was the complaint received

Days Since Received

Complainant first name

Complainant last name Manager

**URGENT** OVERDUE FOR ACKNOWLEDGEMENT > 5 DAYS < 14 DAYS

LMSR 1321848-20 12-Sep-12Direct from complainant -letter 6 Crystal F Jude Cons

FOR ACKNOWLEDGEMENT - MATTERS NEARING 5 DAY BENCHMARK

Mental Health Banksia ( Northern Region: Tamworth) 1322604-20 14-Sep-12 NSW Minister of Health 4 Rosemary L Jude Cons

Tenterfield 1322601-20 14-Sep-12 NSW Minister of Health 4 Rosemary L Michael Mo

Tamworth BH Ward 4 Surgical 1322445-20 14-Sep-12

Direct from complainant -letter 4 Ken M Brad Hans

REMINDER - BENCHMARK FOR ACKNOWLEDGEMENT WITHIN 5 DAYS OF RECEIPT OF COMPLAINT

Medirest Catering 1323406-20 16-Sep-12 2 Bob Epp

Clinical Governance – Pursuing, Quality, Safety and Excellence

32

Clinical Governance – Pursuing, Quality, Safety and Excellence

33

Capturing and responding to patient feedback

Clinical Governance – Pursuing, Quality, Safety and Excellence

34

Clinical Governance – Pursuing, Quality, Safety and Excellence

35

What do People Complain About?

Complaint Issues 2007-08

0

50

100

150

200

250

300

350

400

Access Communication Corporate

Services

Cost Grievances Professional

Conduct

Privacy

Discrimination

Treatment Consent

Clinical Governance – Pursuing, Quality, Safety and Excellence

36

Clinical Governance – Pursuing, Quality, Safety and Excellence

37

Clinical Communication -

Leads from Incidents and Complaints

Data from calendar year 2006

• 403 incidents reported to involve clinical communication

• 171 complaints involved clinical communication

• 127 Root Cause Analysis (RCA) involved communication

Clinical Governance – Pursuing, Quality, Safety and Excellence

38

Complaints associated with Communication

reported through IIMS in 2006

communicating at handover

3% policies communicated

adequately

3%timely transfer of investigations

to those in charge

1%communication on transfer

between facilities

4%

communication with patients

and carers regarding clinical

information

17%

communication with patients

and carers regarding

processess

11%

speaking up for safety

regardless of status.

1%

Relaying concerns about a

deteriorating condition to a

senior clinician

3%formal documentation systems

of communication

4%

interpersonal communication

principles and processes

53%

Clinical Governance – Pursuing, Quality, Safety and Excellence

39

Incidents associated with Communication

reported via IIMS in 2006

policies communicated

adequately

8%

timely transfer of investigations

to those in charge

3%

communication on transfer

between facilities

34%

Relaying concerns about a

deteriorating condition to a

senior clinician

6%

communicating at handover

32%communication with patients

and carers regarding processes

2%

communication with patients

and carers regarding clinical

information

5%

interpersonal communciation

principles and processes

2%

formal documentation systems

of communication

1%

speaking up for safety

regardless of status.

7%

Clinical Governance – Pursuing, Quality, Safety and Excellence

40

Comparison of RCA findings relating to Communication

with Initial Incident Report – 2006

76%

24%

RCAs with

Communication

Identified as an ISSUE,

but not by notifier

Incidents with

communication issues

identified in RCA, and by

Notifier

Clinical Governance – Pursuing, Quality, Safety and Excellence

41

Clinical Governance – Pursuing, Quality, Safety and Excellence

42

Clinical Governance – Pursuing, Quality, Safety and Excellence

43

Clinical Governance – Pursuing, Quality, Safety and Excellence

44

Clinical Governance – Pursuing, Quality, Safety and Excellence

45

Values

NSW Ministry of Health CORE values

• Collaboration

• Openness

• Respect

• Empowerment

Hunter New England Local Health District (HNELHD)

• CORE Values

• Excellence Program

“Every Patient Every Time”

Clinical Governance – Pursuing, Quality, Safety and Excellence

Standardisat

ion

AcceleratorsMust

Haves SM

Performan

ce Gap

Objective

Evaluation

System

Leader

Developme

nt

Foundation

Agreed upon

tactics and

behaviors to achieve

goals

Re-recruit high and middle

performers

Move low performers up or out

Processes that are

consistent & standardised throughout

the organisation

Leader Evaluation

Staff Evaluation

Discharge Call

Rounding

Idea Express

Aligned Goals Aligned Behavior Aligned Process

Create process to

assist leaders in developing skills and leadership competen

cies necessary to attain desired results

Implement an organisation-wide staff & leadership evaluation system to hardwire objective

accountability

Evidence-based leadership practices

AIDET ~ Five Fundamentals of Consistent Communication to Patients &

Carers

A Acknowledge Safety and respect

I Introduce Decrease anxiety

D Duration Increase

cooperation

E Explanation Quality

T Thank You Value & respect

Clinical Governance – Pursuing, Quality, Safety and Excellence

48

QSP

Knowledge industry and we provide

healthcare

Clinical Governance – Pursuing, Quality, Safety and Excellence

49

Ongoing Challenges

• Open Disclosure

• Fear of litigation

• “Second victim”

• Problem practitioners

• Communication training

Clinical Governance – Pursuing, Quality, Safety and Excellence

50

Prerequisites for successful open disclosure

Clinicians need to:

1. be aware that they will be legally protected from liability

2. know that they are authorised by their employer and

government to make an apology

3. be prepared to admit they have made a mistake

4. accept that making an apology is the right thing to do

5. believe that an apology may serve a good purpose

6. know when and how to make an appropriate apology

Clinical Governance – Pursuing, Quality, Safety and Excellence

51

The evidence for good communication

Up to 80% of malpractice claims are attributed to failures

in communication and/or a lack of interpersonal skills.

- Chris Wheeler Deputy NSW Ombudsman

-

Physicians with the highest risk for lawsuits were poor

listeners, often failed to return phone calls, and were

rude and disrespectful to patients. Hickson et al. (2002)

"Physicians are most often sued, not for bad care, but

inept communication. JCAHO (2005)"

Clinical Governance – Pursuing, Quality, Safety and Excellence

52

The evidence for good communication

These same "inept communication practices" result in

the majority of patient safety issues.

In 1996, JCAHO identified communication as one of

the top five issues contributing to the generation of

medical errors.

A 2003 JCAHO study documented communications

breakdowns as the root cause of over 60% of 2,034

medical errors, of which 75% resulted in the patient's

death (COPIC, 2005). In other words, 915 people

died as a result of a communication error.

Clinical Governance – Pursuing, Quality, Safety and Excellence

53

Open disclosure plicy NSW and National

An apology is an expression of feelings – an expression of

sorrow, remorse or regret and an acknowledgement of fault, a

shortcoming or a failing.

An apology is a communication of information – a message. It

consists of words that are exchanged that pave the way for a

reconciliation.

Clinical Governance – Pursuing, Quality, Safety and Excellence

54

The six „R‟s of an apology:

• Recognition

• Responsibility

• Reasons

• Regret

• Redress

• Release

Clinical Governance – Pursuing, Quality, Safety and Excellence

55

National Standards for Open Disclosure

Clinical Governance – Pursuing, Quality, Safety and Excellence

56

Dealing with difficult complainants

Clinical Governance – Pursuing, Quality, Safety and Excellence

57

Clinical Governance – Pursuing, Quality, Safety and Excellence

58

Four complaints:

Ms A Her sibling‟s undiagnosed mental illness and treatment

within a mental health model.

Mr BHis osteomyelitis post hip replacement.

Mr and Mrs C

Their baby‟s birth injuries

Mrs DHer husband‟s chronic illness and suicide.

Clinical Governance – Pursuing, Quality, Safety and Excellence

59

Measuring for quality improvement

Clinical Governance – Pursuing, Quality, Safety and Excellence

60

Complaint Performance Indicators

Two Performance Indicators for Complaint Handling are

measured monthly:

Acknowledgement within 5 days (benchmark = 100%)

Resolution within 35 days (benchmark = 80%)

Reports on Complaint Performance Indicators are provided

to the Executive Leadership Team and the HNE LHD

Clinical Quality and Patient Care Committee to monitor

progress

Quarterly and annual reports are disseminated to the

Organization via the Clinical Governance Intranet

Clinical Governance – Pursuing, Quality, Safety and Excellence

Number of complaints received by month - Comparitive

0

50

100

150

200

250

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2007/2008

2008/2009

2009/2010

2010/2011

2011/2012

Clinical Governance – Pursuing, Quality, Safety and Excellence

62

Clinical Governance – Pursuing, Quality, Safety and Excellence

Complaints about Communication by issue for HNE for 2011/2012

0

20

40

60

80

100

120

140

160

Attitude Inadequate information Wrong/Misleading information Interpreter/special needs

Clinical Governance – Pursuing, Quality, Safety and Excellence

64

Clinical Governance – Pursuing, Quality, Safety and Excellence

65

Clinical Governance – Pursuing, Quality, Safety and Excellence

66

Complaints Management

Summary

• Learning Opportunity – define the problem

• Early apology – bad news never gets better with time

• Communication for understanding – a learned behaviour

• Work together e.g. HCCC - Not every complaint can be resolved

• Create the culture – measure to improve

• Create the space

Clinical Governance – Pursuing, Quality, Safety and Excellence

67

“If I had an hour to save the world I would spend 59

minutes defining the problem and 1 minute finding a

solution”

Einstein

Clinical Governance – Pursuing, Quality, Safety and Excellence

68