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.
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.
Part 4: Creative Complaining: Going Rogue
Thanks for this post! I like how you provided some insight into the goal of the critical review process and why patients might be disappointed in outcome. More knowledge and awareness of the review purpose and process might alleviate some of that disappointment so I'm glad you have highlighted it here.
ReplyDeleteAs I was reading, I couldn't help but think of parallels in other systems of care, and how there too, it is often some kind of communication breakdown at the core of a problem or concern.
It takes a whole lot of courage to bring a concern or complaint forward for all the reasons you listed in your post. I appreciate you highlighting this process.
Thanks for your comment. It's tough to address all of the issues in a short blog post. It's a complex process and a complex issue. In my thought process...I keep coming back to the issue of communication again and again.
ReplyDeleteIt is a very difficult read but the Judicial Inquest into the death of Brian Sinclair shows (repeatedly) how lines of communication, silo thinking, and lack of a caregiver or patient advocate could have saved his life. I know that isn't one of the key recommendations of the inquest but it is glaringly obvious as you read the inquest.
Here is the link:
http://www.manitobacourts.mb.ca/site/assets/files/1051/brian_sinclair_inquest_-_dec_14.pdf
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