1. “Informal Complaint Resolution”
Expect the Unexpected: Are We Clearly Prepared?
“Informal Complaint Resolution”
Irene Clarke, Katja Lutte,
Cheryl McDougall
College of Physicians & Surgeons of Ontario
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

2. Presented at the 2006 CLEAR Annual Conference
Toronto is the biggest city in Canada, and is located on Lake Ontario across from Rochester, New York. We’re a short hour and a half drive from Buffalo. It is a multicultural city with a total population of over 2 ½ million. We’re currently enjoying some lovely fall weather after a very hot summer, and contrary to popular belief, we do not have snow all year round.
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

3. Presented at the 2006 CLEAR Annual Conference
The College is the self-regulating body for the province’s medical profession. We have over 26,000 members making us the largest medical regulatory authority in Canada.
The College regulates the practice of medicine, by licensing physicians, monitoring and maintaining standards of practice
through peer assessment and remediation, and investigating complaints against doctors.
All doctors in Ontario must be members of the College in order to practice medicine in the province.
The governing legislation guiding the practice of medicine is the Regulated Health Professions Act
The system of self-regulation is based on the premise that the College must act first and foremost in the public interest.
Investigations & Resolutions is the largest department at the College. To tell you more about the resolution process I
turn it over now to my colleague Katja Lutte
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

4. Framework for Resolution
Backdrop
Past Processes
Current Processes
Case Examples
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

5. Issues Involved in Public Complaint Investigations
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

6. Backdrop: Committee Decisions
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

7. Outcomes Complainant Doctor Complaints Committee
frustration and disbelief
Doctor
stress and annoyance
Complaints Committee
$600,000 per year
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

8. Past Resolution Processes
Committee Resolution
Informal Staff Resolution
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

9. Committee Resolution (1990 – 1998)
Complaints Committee Directed
Resolution by:
Staff facilitators
External mediators
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

10. Committee Resolutions 100 cases
Outcome
Agreement – 20% No Agreement – 80%
Why
Complainants
Process starts too late (after 1 year)
Process too slow (6-12mo)
Lawyer involvement
Physicians
Process too slow
Mediator: no clinical knowledge
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

11. Informal Staff Resolution 1997-2001
Complainants consented to resolution
Via phone or letter
Patient Records
Written Physician Response
Written information
Committee Chair Approval
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

12. Informal Staff Resolutions Results -2001
40% vs. 20% resolve
157 days vs days
$500,000 vs $600,000
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

13. Complaints Process Survey 2001
Telephone Interviews
Satisfaction Indicators
process
quality
outcome
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

14. Complaints Process Survey 2001
Satisfaction Level
Desired Outcome
Time
Continual Communication
Investigator with clinical knowledge
Resolution vs. Decision
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

15. Proactive Staff Resolution
Current Process
2001 – present
Proactive Staff Resolution
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

16. Complaints Per Area of Practice
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

17. Proactive Staff Resolution
Designated Staff
nurses, physiotherapists, social workers
With
significant clinical practice background
management or teaching experience
know health care system
Can communicate
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

18. Investigator on Call Calls from our general inquiries area letters
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

19. Investigator on Call 2005
366 telephone inquiries forwarded to on-call investigators;
26 converted to complaints.
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

20. Investigator on Call 2005 145 letters earmarked for on call resolution
9 converted to formal complaint
(of those 9, 6 were resolved pre-committee review)
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

21. Resolution Criteria misunderstanding or miscommunication;
a known or common complication of a treatment/procedure;
an isolated incident of less serious conduct unbecoming a physician (i.e. not sexual abuse);
assistance to intervene beyond our jurisdiction;
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

22. Resolution Criteria
isolated incident of minor clinical mishap or oversight;
systems issue;
complainants indicate their wish to resolve;
complainant and respondent have agreed to the resolution process;
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

23. No Resolution When …
serious concern regarding clinical practice and/or conduct;
the complainant and/or subject physician are not receptive to resolution
the subject physician has a history of complaints pointing to a trend toward conduct or care that was inappropriate;
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

24. What Investigators Do Telephone/Meet Complaint as a “whole” Records
Provide Context
Physician Verbal Response
Joint meeting
Medical Director Approval
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

25. What They Do Joint Resolution with Hospitals Meet
Complainant
Physician/s
Chief of Staff
Patient Rep
Records available at meeting
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

26. What are Key Actions? Speedy assignment/ and contact
Establish rapport with both parties
Updates
Language
Paperless process
‘See’ care in records
Collaborate with Chiefs of Staff
Systems Approach
Appreciation Letter
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

27. What Makes it Work? Complainant open to explanation
Complainant wants ‘error’ fixed
Physician open to explaining
Physician willing to acknowledge
No Lawyers
Investigator Flexibility
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

28. How Did We Do? 2004 58% resolved (up from 40%) 62% resolved
65 days (down from 157 days)
$315,000 (down from $500,000)
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

29. Benefits Support for Process CMPA Chiefs of Staff
Hospital Risk Managers/Patient Reps
Individual Physicians
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

30. Benefits Educational Value System Improvements
Increase in satisfaction for all parties, including investigators
Positive College Image
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

31. Benefits Patient Safety (Lucian Leape, MD) Responding to the patient
What do patients want?
Know what happened (98%)
Receive an apology
Be assured the hospital/doctor is doing all that can be done to prevent a recurrence
**$ is way down the list of patient “wants”
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

32. Benefits Patient Safety (Leape) The power of silence
- destroys the patient’s trust
- destroys the physician’s integrity
- “wall of silence” is devastating for patients
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

33. Fools rush in where angels fear to thread
Cannot compel physicians to apologize
Can ask or convey the complainant’s wish for an apology
Have been at CPSO for a couple of years, and I’m told one of the things I do well is getting physicians to apologize
Today, I want to share my experience with you on obtaining physician’s apology, how to get buy in from both the physician and the complainant, what the letter should include, what it should not include and will conclude with a couple of examples
At the College for three (3) months and assigned a complaint where the complainant stated in her letter, she wanted an apology
Asked colleagues for samples: “we do not do that” – “cannot compel a physician to apologize”
Cannot compel but can ask
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

34. Negotiating an Apology
The complainant request apology and the physician volunteers to apologize
The complainant wants an apology and the physician needs encouragement
No request for apology, but one would be the best way to resolve a complaint
To the patients, we say the College cannot compel physicians to apologize but can ask –” many physicians have done so”
In this case, had to ask a young physician to apologize when she did not feel she had any reason to do so
Had to elicit physician cooperation or” buy in”
Required to be fair and impartial – cannot assume the physician is guilty, because this might be conveyed inadvertently and compromise the negotiations
“I was not there Dr. and I am not saying that you did or said the things the complainant alleges”
But it was a pretty busy day at the office, the patient was insistent on getting her passport application signed even when you had said you did not recognize her picture. Is it possible Dr. that your secretary conveyed annoyance and added her own interpretation to your message?”
If we cannot resolve this, will need to send to CC
The patient is willing to resolve with a “suitable” letter of apology
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

35. Myth: Apology = Admitting Guilt
One of the reasons physicians do not want to apologize is because they have been told by their lawyers that apology is an admission of guilt
So there was a need to write an apology without admitting guilt, and include the components of a “suitable” letter of apology
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

36. Apology without implied guilt
I apologize if my behavior…
I apologize for causing you to believe I was angry
Please forgive me if I offended you, it was not my intention
How do you apologize without admitting guilt?
May be seen as “conditional” apology – but acceptable to complainants……..
Use to provide a sample and still do on occasions, but I’ll often say “you sound like a caring person, let your heart speak”
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

37. Components of suitable apology letter
Apologizes/regrets the behavior
Explains what happens
Conveys sincerity by expressing remorse and displaying empathy
Reflects on the learning experience
Reiterates regrets and apology
Starts and ends with apology or regrets
Conveys empathy/sincerity “ I very much understand your frustration” – I recognize this can be an unpleasant experience…”
Reflects on learnings: “I have given much thought to this incident and will make every effort to prevent similar situations in future patient encounters” – “I cannot change past events, I can only learn from them”
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

38. Apology Busters Presented at the 2006 CLEAR Annual Conference
My first experience, the letter contained a “buster” , was able to resolve nevertheless – a good letter until the physician said “during the disruption in the office cause by you and your husband’s discussion with the office manager…”
As a result I now ask for a draft to check the letter does not contain any busters such as excuses like “I was not feeling well that day”
Other busters: I apologize if you perceived… I am sorry that you thought …
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

39. Wrapping it up Ask the physician to cc me on letter
One to two weeks after letter sent, I contact the complainant to discuss
Obtain agreement to close the file
Obtain authorization to close the file from the medical director
Notify physician and complainant of closure
Often the complainant has feedback he/she would like to be passed on to the physician and this is done as requested
The complained and the physician are informed the matter will remain on file at the College
The physician is informed that another complaint of the sort may not be resolved in the same manner (avoiding similar complaints)
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

40. Example # 1 28 years of age, TB, previously healthy
Same Dr. for extended family
Pt so stigmatize, she can’t ever utter “T.B.” – “ I have a disease”
In following up the contacts, the secretary confirms the identity of the index case to a family member
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

41. Example # 1 (cont’d)
The complainant wants the Dr. to be disciplined and to apologize (LOC)
The Dr. was very stressed about the complaint, wanted to apologize, did not know how to begin
A sample letter was provided
In the first draft, Dr. provided long explanations and sent draft to investigator
Feed back and edits
Finally letter with short sentences, giving explanations, apology, how a post-mortem was done at the office to avoid future errors, apology reiterated
Diagnozed in the Fall, LOC in January, Letter of apology dated July 5
many communications with C. during those six months – time and the message the matter was taken seriously both at the College and by the Dr. helped in resolving the matter
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

42. Example #2
16 year old in ER with back pain, swollen abdomen, urine positive for pregnancy, the nurse hears fetal heart beat, patient never had sexual relations
Patient told she is pregnant, in denial
Mother not told anything because the patient is 16
Patient is discharged
Both mother and daughter are shocked
Next day they go to an abortion clinic who orders US and given a referral to a gynecologist
Turns out the daughter has a tumor, an Immature Terratoma – she underwent surgery and chemotherapy
The hospital apologized but the mother also wanted the Dr. to apologize
He only did so b/c he did not want it to go to CC
He required a sample which he followed to the letter– the sample was phrased suitably to promt reflexion
It is too early to know what this physician learned
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

43. Is “I’m sorry”, an apology?
A physician once wrote a two page letter stating he was sorry for many things…and said this was not an apology. The complainant thought it was an apology and accepted it.
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

44. Is “I’m sorry”, an apology?
A physician once wrote a two page letter stating he was sorry for many things…and said this was not an apology. The complainant thought it was an apology and accepted it.
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

45. QUESTIONS ??? Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia

46. Speaker Contact Information
Irene Clarke, Katja Lutte, Cheryl McDougall
College of Physicians & Surgeons of Ontario
80 College St., Toronto, ON, M5G 2E2
(416) ext: 408; 674; 494 (respectively)
Presented at the 2006 CLEAR Annual Conference
September Alexandria, Virginia