The Art of Complaining - Part 3: Formal Complaints

In my previous post I discussed informal ways you, as a patient or caregiver, you can raise issues or concerns without going through the formal complaint process.  When given an option this is always the fastest and least painful way to address a concern.  However, all too often the patient and the medical team come to a point where they don’t agree or an adverse event has occurred that requires going through the formal complaint process.

I am not a pessimistic supporter of the formal complaint process.  Too often the process is time consuming, bureaucratic, and marginalizes the patient point of view.  However, these processes are necessary to investigate complex situations and generate evidence based recommendations with the goal of improving the system.

The Formal Process of Health Care Complaints

To repeat, it is important to try to resolve concerns directly with your front line health care providers.  If there is an adverse event or other concern the front line staff have some tools available to document and rectify the concern.  That is always the place you start.  There is a way to escalate concerns but you have to start with your bedside nurse, charge nurse, attending physician, or unit manager.  If you cannot come to a satisfactory outcome it is reasonable to contact “Patient Relations” or whichever formal organization is tasked with addressing patient complaints/concerns.  

Photo Courtesy: www.notstandingstillsdisease.com

When a Patient Relations officer receives a complaint they have to assess the nature of the complaint.  The reason for this is that the types of complaint can span a wide variety of issues and severity.  Each type of complaint may have its own process to follow to rectify the situation.  In some severe cases their may be legislated processes to follow.  The types of complaints can vary greatly.  They can range from a complaint about the cafeteria food, parking concerns, and all the way to a medical error causing death.  All of this “triaging” of complaints can be time consuming.  If a complaint is medically related and of a serious nature the complaints can be categorized as “occurrences” or “critical incidents.”  These are very important legal terms that require specific response laid out in “Critical Incident Legislation” that most provinces now have.  The following is an excerpt from the Manitoba Health website that defines what a Critical Incident is:

Manitoba’s legislation defines a critical incident as 

“an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired.” This can include death, injury and disability, and “does not result from the individual’s underlying health condition or from a risk inherent in providing the health services.”  -source Manitoba Health

That being said just because you, as the patient, thinks a complaint meets the criteria of a critical incident, that doesn't mean it will be categorized as one.  There is a committee or investigative team that makes this determination (patients not included.)  The reason the system is very careful about what they define as a "critical incident" is because there are legislated requirements and a prescribed process to follow. The health system is required to follow these processes and perform them in a prescribed timeline.  That means it is time consuming and expensive.  Unfortunately, input from the patient or caregiver is limited as the focus of any investigation does not consider the motivation or purpose of the patient who may have raised the concern in the first place.  The only purpose of a critical incident investigation is for the purposes of learning and system improvement but NOT to address the concerns of the patient.  It is hoped that those goals would be mutually beneficial but that certainly is not always the case.

Here is another excerpt from the Manitoba Health website:  

(Critical Incident Reporting is a) mandatory no-blame critical incident reporting across the health system to support a culture of learning and openness. Critical incidents are not reported to lay blame on individuals. The purpose of reporting is to look at what can be done differently and what improvements can be made to the way health care providers work.   - source Manitoba Health

This is why the formal processes of filing a complaint can be so frustrating from a patient perspective.  These processes and investigations take a long time to complete.  The actual input or involvement by the patient is relatively limited and if the patient has specific questions that they want answered they may (or may not) get these concerns addressed depending on the way the investigation proceeds.  It is also worth noting that Critical Incidents can be initiated by anyone in the health care system.  Any investigation can be initiated without the patient even being aware it is going on.  I have first-hand experience with this.  The whole purpose of this process is to look at “system” issues NOT “patient” issues.  

Many patients enter into the process with the idea that “Finally, I will get some answers” but end up very disappointed when their specific concerns are not addressed.  The other issue that inevitably frustrates patients is the time consuming nature of these investigations.  To do a proper investigation and to engage all of the different stakeholders who may be involved is a time consuming proposition.  Health care is complicated, and trying to investigate an adverse event within health care is even more complicated.  From a patient point of view, the waiting is frustrating.  Not being aware of all of the inner workings of the investigation is even more frustrating.  This process was never setup with the patient in mind.

The Power Imbalance

A significant concern and a likely reason that many patients do not complain is that they may be in a situation where they need their health care team for ongoing care.  If they do all of the right things and talk to all of their providers and still cannot get their issue resolved, their next step may be to escalate their complaint and file a formal complaint.  I feel that for many patients this is one step further than many are willing to go.  This has been the case for me on a couple of occasions.  Patients worry that if they file a formal complaint that they will be treated negatively or be isolated by their health care team.  Patients live in fear of being labelled as “difficult” or “non-compliant.”  

For patients with complex health issues there may be only one specialist or clinic in their community that deals with "their" specific health condition.  If you alienate that team you risk losing any support you have.  You don’t have any option of going to another Doctor or clinic.  The potential of being isolated, trapped, and alone is a frightening prospect.  In addition to living with a complex medical condition you are now faced with the stress and anxiety of being forced to work with a medical team where there could be a palpable level of mistrust or animosity.  

Solutions

There are ways that the formal processes do help patients and I certainly want to stress the importance of these processes.  The formal processes are also necessary as they do provide helpful feedback that can result in system change.  

Patient Relations

If you go to patient relations and talk to a patient relations officer they can represent a conduit for you to address your concerns.  This can happen in a couple of different ways.  The officer can play an intermediary role between the patient and the health care provider.  Many times a skilled patient relations officer can identify where communication broke down and bring all the parties together and re-establish the lines of communication.  Patient relations can also help the patient better communicate their concerns in a way that may be non-threatening or frame their concern in a more effective way.  (Be able to translate from medical speak to patient speak and vice versa.)

Patient Relations can also present opportunities to the patient that they may not have thought of.  Many patient advocates, that I know, started out being advocates by going to the patient relations office and making a complaint.  Through this process the patient was asked to participate in a patient advisory group or similar organization.  This afforded the patient an opportunity where the patient can share their experiences and attempt to make changes through a patient committee.  In some cases this is all patients want...an opportunity to share their story and be heard.

Some health care organizations are also initiating “peer support" programs.  A patient may be put in contact with a patient “peer” who may have specific training in peer support and has the benefit of having their own health care experiences.  Patients have an inherent credibility among other patients.  It gives the patient a different perspective and resource to draw upon for support.  Many times peer support can provide a patient a peer who may have been in a similar situation or had a similar negative experience.  Shared experience can be a powerful tool.  I am a huge fan of peer support and continually advocate for health care organizations to expand these kinds of programs.  Patients can be a great support to other patients.  

The patient relations office can be a great resource for the patient but the inherent risk is that ultimately the patient relations office is a function of and accountable to the health care system.  The perception (and in some cases the reality) is that patient relations ultimately represent the hospital and this message can come through loud and clear to the patient.  This is something that all patients should be aware of when they make the decision to take a concern to patient relations.  When all is said and done, the patient relations office is working for hospital administration and not the patient. 

The Patient Ombudsman

Ontario has initiated a new avenue for patients to file a formal complaint.  In recent years they have established the office of the Patient Ombudsman.  I think many in health care are watching this development closely to see if this concept brings improvements to the complaint process.  This process is by all evidence is still a lengthy and bureaucratic process but the fundamental change is that the ombudsman’s focus is to address the concerns of patients.  The purpose is to address patient concerns and communicate with the patient on an ongoing basis to ensure the patient is apprised and involved in any of the steps in the process.  The big question is ...will recommendations by the Patient Ombudsman have any real effect?  Does the office of the Patient Ombudsman have any real "teeth."?

The Bottom Line

My perspective on this topic is rather unique.  I have experienced this process from the patient perspective, have talked to many patients about their experiences, and in an interesting turn of events I have reviewed patient complaints in my role as a hospital board member.  So I have seen both sides of the process.

My overall impression of the formal complaint process is that I recommend that patients and their families use the processes that are provided, but the reality is that many go through the process and are left disappointed by the experience.  We have to be realistic about our expectations, but that is not an excuse not to try.  Like everything in health care, you truly have to understand how the process works in order to maximize your benefit.

I believe there are many improvements that can be made in these processes and I have seen some isolated cases where some very encouraging improvements are happening.  From what I have seen, and I know I sound like a broken record here, most complaints have their root cause in some kind of communication breakdown.  Reading a critical incident review is an exercise in futility.  When reading these reports you can take a highlighter and identify dozens of opportunities where with some improved communication a serious incident could have been prevented if people were just talking to each other.  There needs to be a fundamental shift in how we communicate in health care to be more inclusive of patients and to break down the dreaded “silos” that exist within the system.  Communication is not just a  "patient-provider" issue it is also a "provider to provider" issue.  Aside from financial constraints, I believe, improved communication represents the largest opportunity for improvements in health care delivery.  The patient complaint process is just one component that would benefit significantly.

Next Post in my series on Complaining:
Part 4: Creative Complaining: Going Rogue