“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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Framework for Resolution Backdrop Past Processes Current Processes Case Examples Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Issues Involved in Public Complaint Investigations Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Backdrop: Committee Decisions Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Past Resolution Processes 1990-1998 Committee Resolution 1997-2001 Informal Staff Resolution Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Committee Resolution (1990 – 1998) Complaints Committee Directed Resolution by: Staff facilitators External mediators Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Informal Staff Resolutions Results -2001 40% vs. 20% resolve 157 days vs. 547 + days $500,000 vs $600,000 Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Complaints Process Survey 2001 Telephone Interviews Satisfaction Indicators process quality outcome Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Proactive Staff Resolution Current Process 2001 – present Proactive Staff Resolution Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Complaints Per Area of Practice Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Investigator on Call Calls from our general inquiries area letters Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Investigator on Call 2005 366 telephone inquiries forwarded to on-call investigators; 26 converted to complaints. Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

Benefits Support for Process CMPA Chiefs of Staff Hospital Risk Managers/Patient Reps Individual Physicians Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Benefits Educational Value System Improvements Increase in satisfaction for all parties, including investigators Positive College Image Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

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 14-16 Alexandria, Virginia

QUESTIONS ??? Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia

Speaker Contact Information Irene Clarke, Katja Lutte, Cheryl McDougall College of Physicians & Surgeons of Ontario 80 College St., Toronto, ON, M5G 2E2 (416) 967-2600 ext: 408; 674; 494 (respectively) iclarke@cpso.on.ca klutte@cpso.on.ca cmcdougall@cpso.on.ca www.cpso.on.ca Presented at the 2006 CLEAR Annual Conference September 14-16 Alexandria, Virginia