CLEAR 2011 Annual Educational Conference September 8-10 “I just don’t want this to happen to anyone else”: Effective Management of Consumer Complaints Anna Wyse, College of Nurses of Ontario Kevin McCarthy, College of Nurses of Ontario Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Session Goals Addressing consumer complaints Complaints Backlog: key learning Innovations for managing complaints + enhancing public confidence Dialogue with regulatory colleagues Overarching goals of the session Our Board’s story. The stories of stakeholders too. Value of complaints: risk, safety confidence. Can be a mediae issue if not managed sufficienty Meta theme: regulatory role - engaging stakeholders improves process (consumers and members) Use of iclicker a few questions to share some information in the large group, too. NO right or wrong answers!!! Use your time wisley. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Background Public Protection and Confidence: the Social Contract Define terms: Complaint + Report Legislation: The Regulated Health Professions Act Background: addressing consumer complaints. A few key elements of the College’s consumer complaints process. The College’s, with a membership of over 150,000 nurses, with a of the protection of the public. One way we consider this mandate is utilizing the concept of the social contract. Often view this as a social contract between the public and profession. The public expects the profession to establish who can join the profession, maintain quaility , develp standards and enforce these standards. The profession agrees to provide safe and ethical care, and licencees will be accountable for the care they provide. When standards are not met, there are ways to ensure accountalbity and support the reconcilliation with standards. Consumer = complainant Complaints and Reports – this distinction became a key part of our success. Consider later in presentation. Complaints deal with the public. Unique. Reports deal with mandatory reports from employers (terminations), registrants self-reports and all other information received by the regulator. Rational: the legislation for these suggests they are unique – different creatures. Complaints is by far the smaller of the two process ( 350 – 400 complaints, appoximately 800 reports)– but…we know there can be significant attention on our orgainzations, not just on the public interests broadly, but how we manage the very direct contact with specific members of the public. Complaints is the vehicle for the public to express concerns about registrants practise and conduct. Public confidence is the heart of our process and therefore our presentation. In theory and practice, our discussion revolves around the notion of ensuring the public’s confidence is sustained in the regulator’s ability to effectively regulated the profession….in the public’s interest. Legislation: applies to a number of health regulators in Ontario, yet each regulator has some unique approaches. Follow up on issues, timelines, Investigations/ADR. CNO takes a particular approach with areas, not inconsistent with the legislation. Much of the process for complaints is set out in legislation: Notice requirements Notice of investigation delays – ongoing Seek intervention from an external oversight body related to delay Written decisions and reasons Right of review of final decision by the external review body. ADR: voluntary, ratification by a statutory committee Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Complaints: a story A little more on the story of the complaints process… A vehicle for the public to express concerns... Its viceral, emotional A remarkable element of professional accountability for health professionals – « Yes, someone can complain about your practice ». Complaints (in our definition) are not disinterested, like an employer, rather they are very interested. This jumble simply captures some themes found in many of our complaints. These are people, possible the client, often family members, who have concerns. These are not disinterested parties, rather they are VERY interested (urgent, shocked, crisis, humilitated, abuse) We appreciate, that somehow, someone has navigated the system and found this process. We know…. A range of issues: parents deeply concerned the parents whose post-surgical daugther wallowed in pain while nurse chatted and joked at the nursing station, the family who was shocked their 93 yer old grandmother died suddenly and without one more chance to say goodbye; she was up talking and eating, animated, one day then suddenly things turn….to the complaints about abuse, that not recieving ice chips with 5 minutes was likened to abuse, and the neigbour who thought it unethical that his neighbour (a nurse) failed to rake her leaves and bag them (nurse only racked them into a pile on the road) is not suitablity to be a nurse. No questions, these are real to the individuals. While we have legislation and a complaints process, each complainant no doubt views their concerns as unique and important. Intro to next slide: We have told you some background on the College and our consumer complaints process. Briefly we want take some time to cast back into time and share some of less than stellar or challenging aspects of our complaints process. Some hollywood-esque comment about overcoming adversity inorder to come through the other side stronger?? We dont want anyone worrying, so we thought we would suggest how this story works out in the end…. Pittsburgh, Pennsylvania

Consumer Complaints: A cautionary tale CLEAR 2011 Annual Educational Conference September 8-10 Consumer Complaints: A cautionary tale See notes page for revisions. Part of the story of our consumer complaints story . We think this could be the subtitle for our presentation. Your organization may or may not have experienced similar challenges that we are going to briefly review. Bottom line: A warning or a hope - that your organization not go down this road. We hope to wave you away from the kind of situation we found ourselves in. (debt analogy??) Pittsburgh, Pennsylvania

…and they all lived happily every after. CLEAR 2011 Annual Educational Conference September 8-10 …and they all lived happily every after. See notes page for content Its Saturday afternoon, so we don’t want to have you waiting anxiously for how this all turns out s, so please know that things work our in the end for our complaints process. Before we begin, we want to explain how this story ends. Pittsburgh, Pennsylvania

Once upon a time

CLEAR 2011 Annual Educational Conference September 8-10 Our Original Approach Not hiding, rather the realization that a task lies before us. Issues that require attention. Can be daunting, uncomfortable. Tongue in cheek – poke fun at ourselves. What was clear was our unacceptable the backlog had become and that action was required. There was no backlog/queue. Everything was assigned to an investigator. Sounds good, but backlog was simply divided out on individual desk. Admirable, but not effective management. Most things that were a complaint, were not the highest risk. So, they often ended at the bottom of growing stacks of cases. SOMETHING HAD TO BE DONE. What do you do when something MUST be done? What to do?! … Hire a consultant. Pittsburgh, Pennsylvania

Business Process Redesign CLEAR 2011 Annual Educational Conference September 8-10 Business Process Redesign Incremental change leads to paradigm shift Make at least one thing better, not other things worse Produce more value for your stakeholders Don’t lose sight of your purpose We did have a backlog and did what you do in such a situation…get a consultant. (Angelo Baratta, More Perfect By Design, iUniverse 2010) Crack team including manager, coordinator and various team members, but the external eye was very useful. The approach was not to meet staff, then offer recommendations. The approach was to review (sometimes painfully) the process and probe, ask question about the process and assumptions (often held collectively – “GROUP THINK”) You know the phrases: “this is how we have always done this thing”. Sadly, we learned much about improving process design but it was for us to identify what that meant for the organization and how to implement change. Armed and encouraged with our developing understanding, like Don Quixote, we set out upon our journey to improve how we address complaints from the public. Pittsburgh, Pennsylvania

iClicker Question: Do you have a backlog? CLEAR 2011 Annual Educational Conference September 8-10 iClicker Question: Do you have a backlog? Yes, it is very l o n g Yes, but it is manageable Not currently, but we have in the past No, but employees have large caseloads Never No solutions or innovations discussed at this time. Query Iclicker use. Pittsburgh, Pennsylvania

Business improvements CLEAR 2011 Annual Educational Conference September 8-10 Business improvements Centralize the backlog Improve flow of work ADR first! Increase focus on what’s unique about complaints Key learnings: Lets see the backlog. A painful day. Stop assigning ALL cases, knowing the backlog existed, but was in parts and scattered. Re-work. Investigators could not possibly know the status of every case on their desk. When you go back to something, time was required to review and re-familarize yourself with the matter. This added time. Reduce caseload sizes. Work on a file until you couldnt do more, then move to another. ADR is more efficient than Investigate (everything). Resolution first! With best intention and effort an number of interventions were attempted, in hopes of having an impact on the backlog and reducing it. No fear of outside review body (small number to be siignificatn) Pittsburgh, Pennsylvania

Interventions: a retrospective CLEAR 2011 Annual Educational Conference September 8-10 Interventions: a retrospective Next To briefly detail a few of what we called “interventions” (very active) Take our learning and reflection with consultant and apply Surprise! It didn’t always work perfectly. We know so much…on reflection Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Intervention: 1.0 small focused team Stickers on files Can’t investigate everything. ADR!!! Letters to consumers: from the ED, apology for delay, changing process, ADR At this point in time, we approximate our backlog to be 350 outstanding cases. Timelines: between 2 to 3 years for an investigation to be completed. Outcome: backlog slightly increased Assumption: there is a panacea – one thing that, if we found it, would make all things good. (group questions on panacea – what failed for your org? - mention when we get to our failed 2.0) Feedback: appreciated the clear acknowledgment of delay and related apology. May have been the strongest, most clear, acknowledgment to members of the public engaged in the process. Update of ADR minimal at best. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Intervention 2.0 An even smaller group More stickers on files Lo – fi Learning: people are invested, interested. We can cold call them about their concern, tell them about a details legal process and see if they would be open to ADR. A budding intake team. Assess, assesss, acess Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Intervention 3.0 Re-assessed all files Criteria for a complaint – if not engaged, why push forward? Letter: apologize, changes to legislation, if you wish to continue contact the Board New legislation which imposed monthly letters to all stakeholders when cases were delayed would have meant a massive increase in work Paradigm shift Enhances engagement with stakeholder. Developing/improving with each intervention (regulator knows its role) Organization as reflective and accountable STARS --How many matters lost with this intervention Now we’re getting serious. Risks associated with the queue (losing the public’s confidence in self regulation). Organization commitment to addressing queue (CC, leadership, Council, membership and the public) expressing concern (don’t over represent) 2009 Amendments to legislation. Truly, an opportunity to enhance our process. Learning from business redesign to our attempts to change. ADR written in the legislation. We knew from our redesign that investigations took 50% longer to complete. Many had been reviewed by an external review body, while no ADR had been appealed (because of the level of engagement?) Review of process – feedback from members of the public Most are appropriate for ADR Learning: We took the opportunity. We ought to manage the process. We have no control over volume, but we can manage the process more effectively and efficiently. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Key lessons No single right approach Acknowledge challenges and apologize Attend to feedback from stakeholders Greater transparency Data review No single answer. Improve data analysis. Acknowledge and apologize (the regulator as model of professionalism) Sysiphus Pittsburgh, Pennsylvania

The Backlog or The Queue CLEAR 2011 Annual Educational Conference September 8-10 The Backlog or The Queue Brief pause in our review of interventions and learnings. We mustn't forget the impact on stakeholders, and their confidence in the process. This is not abstract legislation but something of some stake: personally and professionally We call it the queue. It suggests orderly waiting. But these are members of the public who want their concerns addressed in a timely fashion. Are we sustaining the public’s confidence? Even given a cute name: « Taming of the Queue » Its a backlog – pure and simple and VERY uncomfortable. the slow process was not giving the public confidence in our ability to regulate - the backlog was so large that it was preventing us from being innovative - instead we were putting out fires. the slow process was not giving the public confidence in our ability to regulate - instead we were putting out fires. NOT confidence producing!! Anna’s uncomfortable debt analogy. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 What the public say Timeliness Accountability “I just don’t want this to happen to anyone else” Over time and through our various attempts to address the backlog, consumers continued to provide their complaints. I also believe that we enhance our ability to hear and be informed by the messages we were being told. STORIES Confidence in the Board and profession Frustration with timelines, insufficient people to do the job and limits on outcomes. Legislative requirement to follow up (a vehicle for the public to express concerns). Consumers have a reasonable expectation that their concerns will be addressed as quickly as possible. - Accountability (ours and the registrants) - the backlog was preventing us from meeting legislative timelines - the public was receiving unexpected take no actions after years of engaging our process - reflection - licensees were frustrated that there was no vehicle to tell "her side of the story" to the regulator in the resolution process (opportunity to provide reflection to College. They look to the regulator to support their reflection) - The bottom line or foundation for so many complaints: “I just don’t want this to happen to anyone else”. Remarkably, this is not a paraphrase. It is the single most common comment we hear from consumers…. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 A letter of complaint We are aware that there may various expectations on how this professional accountability might look to consumers: revocation, termination, investigation, ADR. But at its heart, most complaints express a particularized concern with a hope or desire that how it is addressed will be related to the issues. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 iClicker Question: Are the stories you hear from the public similar or different? That is exactly what we hear Close, but they are mostly conciliatory Close, but they are looking more for punishment (revoke!) No, our complainants only want to tell what happened then move on No clear theme from consumers Pittsburgh, Pennsylvania

What members of the profession say CLEAR 2011 Annual Educational Conference September 8-10 What members of the profession say “The Shock of Accountability” Reflect on performance To improve To meet professional standards Specific and general Both reflecting the same thing – fulsome accountability and reflection Active - transparency - we began by providing clear information about timelines and outcomes, this allowed the public to more accurately weigh the pros and cons of investigation and resolution - legal processes often have evidentiary issues - resolution is faster with a guaranteed outcome - accountability - the backlog was preventing us from meeting legislative timelines - the public was receiving unexpected take no actions after years of engaging our process - reflection - licensees were frustrated that there was no vehicle to tell "her side of the story" to the regulator in the resolution process (opportunity to provide reflection to College. They look to the regulator to support their reflection) - the slow process was not giving the public confidence in our ability to regulate - the backlog was so large that it was preventing us from being innovative - instead we were putting out fires. - communication - we were not clearly communicating with our stakeholders (public and nurses), this is not something we allow nurses to do (consent and therapeutic communication is nursing is key)   To reconcile with the social contract. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Question How have your licensees reflected their professional accountabilites in your process? Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Innovation (practical strategies) Strategic plan reference?? So, we have learned much from statkeholders and from our approach(es) over time to meet our legislative requirements while engageing stakeholder in the process. The next few slides will capture a number of specific activities, we believe have helped us acheive the goal of reducing the College’s backlog of consumer complaints. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Innovation Complaints intake (communication) Alternative Dispute Resolution (ADR) Staff engagement and training Timely, adequate and reasonable investigations (FOCUS ON TOP THREE) Not rocket science, but these have had appreciable impact on the process Using our own reflection, stakeholder feedback, and informed by other requlators and research we began to identify and develop ways to make the complaints process increasingly effecient an effective. Intake assessment, communication, ADR first Get outt’a debt – stop the addition of new matters to the queue ADR Regulator’s assessment Terms: Standards, meeting with manager, facility resolution. Meet with manager: research on these meetings Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Complaints Intake Establish a dedicated complaints intake Early contact Develop approach and clear message Risk Asssessment A Complaint = 5 point criteria Get them early and vet them early Practical info: jurisdiction, no money, clear messaging oral and written Intake team:(three investigators, one administrative support, support from coordinator and manager) Complaints from the public are unique Acknowledgement letter – sent withing days of LOC, contact person for immed follow up otherwise the investigator will be in direct contact shortly (ver occassional calls now) Investigator attempts to establish direct contact (typically phone, but sometimes in person). Direct communication more nuianced than written. Feedback: quick (though: its been 3 days since my LOC, sometimes arises), authorative, and knew what to expect next. (Next slide) – Investigators knowledge on specific messages (27 Dresses). We need to know the process, the legislation, etc, to be able to communicate it. We began by providing clear information about timelines and outcomes, this allowed the public to more accurately weigh the pros and cons of investigation and resolution: - legal processes often have evidentiary issues - resolution is faster with a guaranteed outcome Risk Assessment: Gather information, assessing it, in relation to anything else known about a nurse in PC. Most consumer complaints are not the highest risk matters the CNO receives, but everything is assessed toward our consideration of the appropriate regulatory action. Important contact with our Reports colleagues who receive ALL other information. Is it a complaint? Is there a nurse(s)? Are there nursing issues? ? ?Is there intention to complain? Similar to our early back log attempts, if someone does not wish to complaint, then we need to address the matter differently (Reports). Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Complaints Intake Learning from business improvement – manage incoming information as soon as possible Establish a Pittsburgh, Pennsylvania

Complaints Intake

CLEAR 2011 Annual Educational Conference September 8-10 ADR Legislation – a formal process Review of standards Reflection Terms: Meet with Manager Facility resolution Add notes pages Not sweeping something away Broad and permissive legislation. A formal process. Like investiagation outcomes Evidence informed Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Meet with Manager Evidence informed Facilitated reflection Stakeholder feedback First learning of research at CLEAR Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 ADR: Meet with Manager Pittsburgh, Pennsylvania

ADR: Facility Resolution CLEAR 2011 Annual Educational Conference September 8-10 ADR: Facility Resolution Systems issues Broad accountability + reflection Feedback from stakeholders 14 last year – up from a high of 7 ER nurse – establishing a therapuetic relationship in 3 minutes. These special cases typically would see many nurses named for a very small nursing issue or for a systems issues. A College investigator attends at the facility to do a presentation of the standards relevant to the complaint with a primary goal of engaging the staff to develop solutions to the facility’s nursing issues. We often get complaints about nurses that center around the nurse not follow up or not focusing on his or her duties. In one instance, the complainants were very upset that the nurse did not provide blood products in a timely manner. From the complainant's perspective, the nurse said she was going to get the blood product, and then didn't return to the client's room. The nurse on the next shift administered the blood product within fifteen minutes of the beginning of her shift. The complainant felt that the first nurse had clearly either forgotten, or simply did not want to attend to the client's needs. In discussion with the nurses who work in that unit it was discovered that the process for obtaining blood products to administer to patients is quite complicated. The product has to go through many safety checks to ensure that the correct blood is going to the correct patient. One of the experienced nurses reflected that in order to alleviate the stress that patients could experience while waiting for a blood product, her practice is to explain the process for obtaining blood at the outset, and then updates the patient as the blood moves through the system. So the patient, and his or her family, expects the delay and knows the reason behind the delay and, most importantly, feels that his or her needs have been attended to.   Much like this story, we always have the same desired outcome for our process. In blood administration, the nurse always wants to ensure the safety and health of the patient and wants the patient to feel confident that he or she is getting the best possible care. In our process we always want the public to be protected and to feel confident that we are protecting them. Once you have indentified the desired outcome you ask - how do we get there? The backlog was our biggest obstacle to providing a process that could make the public feel confident in our ability to regulate nurses. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 Staff Engagement On-going training and support Clear goals and expectations Director: “30 by December 2011” Taming of the queue meetings: develop messages, share knowledge, identify areas of challege, quick wins (letters updated), platform for recognizing regulatory role and importance of team function. A bit of humour. Organizational support Vague – shared focus- common enemy Survey:Goals and Objectives Trust and Conflict Control and Procedures Interpersonal Communications Problem Solving / Decision Making Experimentation / Creativity Pittsburgh, Pennsylvania

How creative are we talking? CLEAR 2011 Annual Educational Conference September 8-10 How creative are we talking? Key is to find the boundaries Legislation Resources Other legal constraints Public perception First you have to find the box that you need to work within We only have the constraint of no resolution in sexual abuse – everything else was fair game (ED referall) We had specific legislative timelines Case law and feedback from our appeals law define the marks we had to hit every time The public wanted a fast process that is responsive in a fullsome way. Pittsburgh, Pennsylvania

Question What innovation has your organization developed that addressed your volume issue and sustained consumer confidence in your processes?

CLEAR 2011 Annual Educational Conference September 8-10 Effective Management? Do these processes: Protect the public Maintain confidence in self-regulation Model a principled approach to regulation and the accountability of those regulated We said in our agenda that we would highlight effective management. Have we been effective? What of confidence of the consumer? Pittsburgh, Pennsylvania

Evidence of Effectiveness CLEAR 2011 Annual Educational Conference September 8-10 Evidence of Effectiveness Qualitative: Professionals Consumers Make the numbers meaningful Qualitative: members express familarity with reflection on practice. What’s new is the complaints process. The accountability. Difficult at first, but believe it is an opportunity to learn and improve. Some gained awareness about practice standards. Concerning, but hopeful. Large union indicated the resolution process is constructive and is supportive. Public are disappointed with outcomes of invesigations, despite information about limits to process and decisions. Suggestion that the fix was in –the regulator protects its licencees. (a concerning point given the mandate of public protection. Can these process be a sorce of building – sustaing confidence, but can they also be a vehicle for undermining confidence? Public intake that resolution may not have acheived all hoped for goals, but the outcome met some of their goals for making the complaint. Hope: this not happen to anyone again that the nurse will learn from the experience. Pittsburgh, Pennsylvania

Evidence of Effectiveness CLEAR 2011 Annual Educational Conference September 8-10 Evidence of Effectiveness Quantitative: ADR agreements: 125 Meet with Member: 42 Facility Resolution: 14 Complaints to Reports: 47 Difference with Invt and ADR significant, not as much as we thought. This makes sense. Investigation: 240 days (average) (100 in 2011/ 75 - 2010) ADR: 190 days (average) Complaints to reports: 47 Facility Resolutions : 14 (up from 6 in 2009, 7 in 2010) Meet with Manager : 42 Continue to identify workflow issues that impact time under investigation and ADR. Verbal: some additional information on timelines compared to years. This slide focuses on 2011 but will address 09 and 10. Pittsburgh, Pennsylvania

CLEAR 2011 Annual Educational Conference September 8-10 BIG FINISH Big finish!!!! Anna’s chart We almost forgot to mention. Pittsburgh, Pennsylvania

Next Steps Vigilance Stakeholder feedback: Complaints survey Members of the public + profession Tools to support reflection LeSage Report for Ontario College of Teachers

Final Thoughts Its not easy to take my problems one at a time when they refuse to get in line. Ashleigh Brilliant Experience is that marvelous thing that enables you to recognize a mistake when you make it again. Franklin P. Jones

Questions

CLEAR 2011 Annual Educational Conference September 8-10 Speaker Contact Information Anna Wyse, Coordinator, Complaints, Professional Conduct, College of Nurses of Ontario, awyse@cnomail.org Kevin McCarthy, Manager, Complaints, Professional Conduct, College of Nurses of Ontario, kmccarthy@cnomail.org Karen McGovern, Director, Professional Conduct, College of Nurses of Ontario, kmcgovern@cnomail.org Pittsburgh, Pennsylvania