When Things Go Wrong
Things can and do go wrong in every organisation. There is nobody, including the Ombudsman, who can say that nothing ever went wrong in their office, surgery, clinic, ward or operating theatre. Everybody makes mistakes. However, few people can easily accept their own mistakes. This is probably more the case in medicine than in most other occupations, because errors can have such serious consequences. The critical question for individuals is how they react when such mistakes are made and things go wrong. Conversely, the critical question for the new Executive is how it views the culture surrounding the resolution of such errors. The crucial element in this equation is the concept of culture.
Culture manifests what is important, valued and accepted in an organisation. It is not easily changed nor is it susceptible to change merely by a pronouncement, command or the declaration of a new vision. At its most basic it can be reduced to the observation the ways things are done around here. Complaints are an inevitable consequence of errors, consequently, an understanding of the way things are done around here is a fundamental first step to developing proper and effective complaint handling procedures.
Most people instinctively regard complaints as unpleasant because they can be a very personal comment on performance. In the hospital context once the word complaint is used there is always the danger of a personal and usually negative reaction. Doctors articulate their sense of fear and hurt, concern about their reputation, distress at the lack of understanding of their action and motives, and their vulnerability. Worry, surprise, annoyance, anger, disappointment, anxiety and distress are among the most common emotions experienced. Clearly, there may be a fear that complaints will have a significant and lasting impact on those to whom blame is attributed. The challenge to the practitioner's expertise is likely to be construed as greater than the content of the particular complaint, resulting in an almost symbolic resistance to such challenge. Indeed, the intensity and duration of the emotional aftermath does not seem to relate to the size of the error or the seriousness of the complaint, but rather to the ability of the individual doctor to put it into perspective. Responses can, and do, exacerbate a complainant's sense of grievance by appearing defensive, using technical language, commenting on the failure of complainants' attempts to manage illness, casting doubt on the complainants' account by labeling them a 'bad patient' and arguing that dissatisfaction is a symptom of the illness being treated.
The experience of the Ombudsman has been, in general, that complaint handling in hospitals has been very much dependent on the goodwill and co-operation of medical staff. With certain exceptions, the Ombudsman has rarely found that health professionals, particularly doctors and consultants, engage wholeheartedly with patients' complaints. This, when allied to a reluctance by patients to complain, usually because they are very dependent on the system, makes for a very unsatisfactory situation. Complaint handling is invariably seen by medical staff as very much a matter for the administrators, even though the kernel of the complaint might well involve particular doctors or consultants.
This may be because it is felt that the examination of complaints; interferes with other (more important) work, causes delay, can reflect badly on the individual performance of colleagues, arise because of the actions of "cranks", is made solely for the purpose of seeking compensation.
However, it is essential that they view the handling of complaints and patient safety as an integral part of clinical governance and risk management. Clinical governance is about using information so as to manage processes in a way which will ensure the effectiveness and safety of clinical outcomes. Information may come from clinical audit, adverse incident reporting, risk management and complaints procedures. This can lead to the systemic identification, treatment and evaluation of risks, incidents and near misses with consequent learning from the lessons observed.
Complaints as an aspect of Quality in Healthcare
A key indicator in any assessment of the quality of our health service is the way it reacts to the needs of its clients, patients and service recipients. The Executive needs to be aware, and open, to the views of these clients. One of the more important avenues through which these views can be brought into focus is through effective complaints handling mechanisms which are accessible, consistent and provide remedies which are fair. Yet in the survey of patients in acute hospitals referred to in the chapter on Communications, the Irish Society for Quality and Safety in Healthcare found that almost 75% of those surveyed were unaware of a complaints procedure, whilst almost 20% considered that they had grounds to express dissatisfaction with some element of their stay in hospital. Of those who did complain over 40% were dissatisfied with the outcome, whilst a further 31% were only somewhat satisfied. There is much for the Executive to consider in these responses.
Why is a Good Complaint Examination Important?
Complaints procedures provide an opportunity to put things right for the patients, clients and their families. But they have an equally important role to play in improving services. Complaints from patients, clients and their families can provide a useful additional means of monitoring the quality of health services. Constructive comments and suggestions also provide a helpful insight into existing problems and offer new ideas which can be used to improve these services and provide an opportunity to establish a positive relationship with the complainant and to develop an understanding of their needs.
If a dismissive or defensive approach is adopted in examining a complaint an opportunity for a constructive outcome can be lost, and an issue can escalate from what might have been a minor situation into something more serious and intractable. It is the experience of the Ombudsman that people who make complaints are usually not motivated by prejudice or malice and are not generally seeking financial compensation. What they do tend to look for is a sincere apology or explanation and an assurance that the matter giving rise to the complaint will not re-occur. When a complaint is seen to be ignored, or is handled inadequately, the situation can rapidly deteriorate and lessen the prospects of a resolution.
Statutory Complaints Procedure
The Health Act 2004, provides for the establishment of a statutory framework for these complaints procedures. Under this statutory framework, the Health Service Executive will be required to establish procedures for dealing with complaints about the services it provides or about those of other agencies that provide services on behalf of the HSE. During 2005 consultation on the development of a National Complaints Handling Framework took place. In the course of the year the Department of Tánaiste Health and Children began drafting regulations which will give a statutory basis for the handling of complaints. The Regulations have not been published to date. However, I understand that the initial emphasis will be to seek a resolution of the complaint at local level, but with access to independent review if the complainant is dissatisfied with the outcome of the local examination of the complaint. Following this review, if the complainant is still dissatisfied, he/she will have access to the Office of the Ombudsman or the Office of the Ombudsman for Children where appropriate.
The Characteristics of Good Complaint Handling
It is the Ombudsman's experience that complaints are best dealt with through local resolution where the emphasis should be on achieving quick effective resolutions to the satisfaction of all concerned. In trying to reach local resolutions the Ombudsman has always considered that it is important for service providers to try to view complaints from the point of view of the service recipient. The concerns of the complainant should be understood and possible options for the resolution of the complaint should be considered as soon as possible, even if all that can be done is to give an explanation or apology for any misunderstanding. It is important, therefore, to adopt a constructive attitude towards complaints. They should be dealt with in a positive manner, lessons should be learned and changes made to systems or procedures where this is considered necessary. Complaint handling systems should be strongly supported by management and reviewed and adjusted, where necessary, on a regular basis. They should be well resourced, staffed by competent and well-trained and experienced personnel.
In essence good complaints handling procedures should be; well publicised, easy to access, simple to understand, quick, confidential, sensitive to the needs of the complainant and those complained against, effective, providing suitable remedies and properly resourced
A Particular Example
The following example of an investigation completed by the Ombudsman illustrates the various issues outlined above. A family complained to the Ombudsman about the response of a general hospital to the following matter.
Their father had been admitted to hospital complaining of severe pain in his lower back and legs. During the following days he was examined by various doctors but he remained in severe pain and discomfort and became increasingly agitated. His family became concerned and distressed and continually sought explanations from both nursing and medical staff as to the cause of their father's pain and discomfort. The family considered that the attitude and response by a particular doctor was very unsatisfactory. They described his attitude and demeanour as dismissive and stated that he refused to give them information on their father's condition and proposed treatment. Eventually, they became so concerned about their father's condition that family members remained with him in the hospital. Their father was subsequently the subject of an emergency transfer to another hospital where he died shortly after his admission as a result of a ruptured aneurysm.
The family were at a loss to understand the standard of medical care he received after having these concerns raised. They were particularly aggrieved that they were not informed of the nature and severity of their father's condition and of the proposed treatment to alleviate it. Despite raising concerns with the nursing and medical staff on a number of occasions, the family continued to be aggrieved that his condition remained untreated until his emergency admission to another hospital.
The investigation by the Ombudsman revealed the following deficiencies in the manner in which the complaint was handled by the hospital;
i) the family were not viewed as human beings but as possible adversaries in future legal proceedings,
ii) the hospital's Complaints Officer referred the family's concerns to the relevant Consultant. He (the Consultant) had earlier referred the family to the Hospital's Complaints Officer, thus initiating a circular approach rather than undertaking to have the family's complaint examined by himself in conjunction with the senior hospital administrators,
iii) a response by the Hospital which left the family somewhat confused as to what precisely had happened to their father, what treatment he received and why his vascular condition was not diagnosed earlier, given the observations the family had made to the nursing and medical staff. The family also had genuine concerns about the way in which their father was transferred to the other hospital, although the Ombudsman was able to reassure them, on the basis of the investigation, that this aspect appeared to have been dealt with properly,
iv) a paucity of records covering critical treatment junctures,
v) a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with patients,
vi) an absence of relevant entries on the nursing notes during a period of significant nursing intervention.
Overall it was clear from the investigation that the family's concerns had not been adequately addressed and the Ombudsman upheld their complaint.
The investigation provided answers to most of the questions raised by the family. Other recommendations centred on procedures in relation to nursing records, medical notes, complaint handling with particular reference to the role of the Consultant in dealing with complaints and the importance of good communications procedures in responding to the concerns of complainants, and most importantly the delivery of a personal apology to the family.
The case identified a particular issue for joint consideration by the management of the Health Board, the Hospital and the medical staff viz. the need for greater clarification in the respective roles and relationships of junior and senior medical staff. In particular, the Ombudsman recommended that consideration should be given to an administrative protocol outlining the circumstances in which a junior member of a medical team should consult with his or her Consultant when a patient's condition gives cause for concern, and the corresponding obligation on Consultants to be accessible for such consultation. The outcome of these recommendations included;
i) the delivery of the personal apology,
ii) the establishment of a new management structure that would include Consultant medical staff and so incorporate the role of the Consultant medical staff into the complaints procedure,
iii) the establishment of a new programme of nurse education in relation to best practice in the maintenance of nursing notes,
iv) the establishment of a chart review and audit of nursing documentation to determine effectiveness of the programme and generally to monitor documentation,
v) the inclusion of a new module in the NCHD induction programme to address the protocol for medical notes (other acute hospitals within the Board were requested to develop similar best practice in relation to these initiatives),
vi) the development of a new complaints procedure and an administrative protocol relating to the respective roles and relationship of junior and senior medical staff.
It is very important to note that the family in this case did not pursue their complaint in a vindictive way or with a view to litigation. In essence, all they were seeking were clear answers to their questions about their late father's treatment, appropriate apologies for the shortcomings they perceived and assurances that lessons would be learned for the benefit of future patients and their relatives. The Ombudsman tried to provide this for them, and the outcome of the case is a very good example of how an effective complaints process, embedded in the proper culture, could have enabled the particular Hospital to provide appropriate redress for the family in a non adversarial manner, whilst at the same time effecting quality improvements in the service which would benefit other users and help to prevent similar problems occurring in the future.
The Future
The Ombudsman's hope for the new HSE framework for handling complaints is that it will meet these essential requirements, and that it will become an established feature in the landscape of quality customer service and complaint handling. The Ombudsman looks forward to the completion of the framework for the handling of complaints and its application on a national basis throughout the health service. The Ombudsman acknowledges that the perfect system will not be easily achieved and that the system will be the subject of on-going review and change over the next few years as the system evolves. The experience of the UK, where a single complaints system was introduced in 1996, is interesting and relevant. In the years since 1996 the National Health Service (NHS) complaints procedure has been evaluated and revised. However, in an in-depth review of the system, published in 2005, by Ms Ann Abraham Parliamentary Commissioner and Health Service Ombudsman, she identified key weaknesses which may have resonance for the proposals being considered for the HSE and are therefore of relevance.
In her report she commented that:
"NHS bodies need to be responsive to complaints and value the feedback they provide. To do so they need competent, trained and motivated staff using robust local procedures."
She went on to say that:
"dealing with complaints should not be a stand alone activity. The lessons from them must feed into improvements in the service delivered to patients."
The above comments echo the sentiments of the Ombudsman on the HSE complaint handling proposals. The Office has always been very keen to heighten the awareness of the public of the value of having accessible and effective complaint handling procedures in operation. The Ombudsman's Guide to Internal Complaints Systems - Settling Complaints - and the Ombudsman's guide to the provision of redress, an essential ingredient in effective complaint handling - Getting it Wrong and Putting it Right - will both be included in the consolidated Code of Good Administrative Practice which, as referred to in her introduction to this Report, the Ombudsman intends to publish in the near future.