Transcript Overview of the Commission’s complaints handling functions

The Commission’s
Early Resolution Project
Kieran Pehm
Commissioner
Travis Brown
Manager of Assessments
Overview of the Commission’s
complaints handling functions

The Commission is an independent body dealing with complaints about
health service providers in NSW.

The Commission is a co-regulator with the health professional councils.

The Commission receives, assesses, attempts to resolve, investigates
and prosecutes health care complaints in NSW.

The Commission’s object is to protect public health and safety.

The Commission received 10,187 inquiries and 4,767 written
complaints in the 2013-14 year.
Breakdown of assessment of
complaints 2013-14

2.6% referred to another body or person

4.3% referred for investigation by the Commission

5.5% resolved

8.1% referred for local resolution

9.3% referred to the Commission’s Resolution Service

17.8% referred to a health professional council for further action

52.4% discontinued
Usual complaints assessment
process

60 day timeframe

Written response required from provider

Providers are to respond to a complaint within 21 days

Usually medical records are requested when the complaint raises a
clinical issue

Correspondence heavy

Minimal verbal contact with the parties
Reasons for establishing the Project

To reduce the discontinue rate from 52% to less than 40%.

To increase the resolved rate from 5.5% to 15% or higher.

To address feedback and perceptions that the Commission does not
deal with less complex complaints in a serious manner.

To assist in reducing the caseloads of Assessment Officers in the face
of an increasing caseload of 6-7% annually.
Identifying complaints suitable for early
resolution

The Manager of Assessments receives and reviews all complaints prior to
distribution to the Assessment Team Leaders.

Complaints where:

there is no identifiable risk to public health and safety

there is no significant clinical issues that will require a response and
medical records

the complainant has clearly identified what they want as a result of
lodging the complaint
are suitable for early resolution.

In other words, is a formal response required or is this something that can
be resolved with a few phone calls?
Most common categories of complaints
suitable for early resolution

Access to medical records

Billing issues

Arranging appointments

Apologies for disrespectful behaviour
Early Resolution Process

The Early Resolution Officer (ERO) submits an assessment plan which
essentially sets out how he or she proposes to resolve the concerns
raised in the complaint and this is approved by the team leader

21 day timeframe to resolve or otherwise assess the complaint

Intensive telephone contact with the parties

May assist parties eg. educate a party as to their rights and obligations
on a particular issue or assist with drafting an apology

Voluntary process

If in attempting to resolve the complaint the ERO discovers significant
clinical issues / issues that pose a risk to public health and safety, the
ERO can remit the complaint back to the team leader to be assessed
according to regular timeframes and processes

Consultation with the relevant health professional council
Case study 1
Complaint
A GP complained about a pharmacist who she says is rude and
condescending to her over the telephone when he makes enquiries about her
patients’ prescriptions. The pharmacist has accused the complainant of overservicing her patients because she does not issue a maximum number of
repeats.
The GP’s patients are mostly geriatric and from her experience they tend to
lose or misplace scripts. The GP feels the pharmacist is unprofessional and
should stop interfering in her practice. Both feel they are acting in the
interests of the patients.
This complaint has been made to the Commission twice.
Case study 1
Outcome of first complaint – usual assessment process

The complaint was assessed according to regular processes and
timeframes.

A formal response was requested.

The pharmacist denied the tenor of the conversation with the GP. He
claimed he was making an objective phone call to a doctor to confirm the
number of repeats in the context where 2 repeats had been issued for a
chronic condition where a maximum of 11 was allowed.

The Commission discontinued the matter because:

the complaint concerned a dispute between two practitioners as
opposed to clinical issues or treatment of a patient

the complaint did not raise serious issues of public health and safety
Case study 1
Outcome of second complaint – early resolution project
The GP’s colleague made a similar complaint to the Commission about the
pharmacist. The complaint was identified as suitable for early resolution.

An ERO telephoned the parties.

The pharmacist was defensive. The ERO suggested to the
pharmacist that perhaps both he and the GP were looking out for the
best interests of the patients but that they disagreed about their
management. He agreed to draft an apology.

The apology was never forthcoming however the complainant was
grateful that the Commission had spoken with the pharmacist and
hoped the message about his unprofessional behaviour got through,
despite not achieving the outcome she had initially hoped (an
apology).

The complaint was resolved.
Case study 2
Complaint
An elderly lady had elective surgery postponed on two occasions, and by chance
the hospital’s operating theatres were closed at the time whilst they transitioned
to new theatres which resulted in further delays.
Admission staff communicated the situation poorly to the complainant and told
her they were unable to provide her with a date for surgery in the future. After
speaking with the administrative staff, the complainant was under the impression
that the operating theatres had been closed permanently and that she would not
be able to have elective surgery.
This was an unfortunate situation combined with a logistical event and poor
communication by the hospital.
Case study 2
Outcome

The ERO contacted the Director of Medical Services at the hospital,
who in turn immediately phoned the complainant to apologise, explain
what had happened in her case, reassured her that her surgery would
be taking place, and arranged for her to be placed on the priority list
given what had transpired.

The complainant had been on the waiting list for one year and after
speaking with the Director she felt reassured her surgery would go
ahead later in the year when the operating theatres re-opened.

The complaint was resolved.
Case study 3
Complaint
The complainant made several requests to obtain her medical records from her
ophthalmologist. The requests were in writing and accorded with the
requirements of the Health Records and Information Privacy Act 2002 (HRIPA).
Her requests were ignored by the provider for 6 months.
Outcome

The ERO spoke with the doctor. The doctor said he hadn’t received a
complaint or request for records in 22 years of practice. He was offended
by the request and presumed it was motivated by concerns about his care
and treatment. The ERO explained the various rights and obligations
pursuant to HRIPA to the provider. After much discussion, the provider
understood his obligations and a full copy of the records was provided to the
complainant. The complainant was effusive in her praise and gratitude, and
said she was so grateful the Commission could help her.

The complaint was resolved.
Key elements to resolving complaints
early

Early contact with the parties

Clear expectations

Blocking out the background noise that often comes with complaints and
identifying the key issues

Developing trust

Negotiation

Be clear and concise about the process and potential outcomes
Who is contacted ?
If the complaint involves a provider and/or facility in a Local Health
District

Depending on the nature of the complaint, the ERO may contact the
provider or facility directly.

In some cases, the LHD will be contacted in the first instance, for
example, where a provider has not been identified in the complaint and
the ERO requires assistance to identify a provider or key contact.

The LHD will be informed of the outcome at the close of the complaint by
correspondence and provided with a copy of the complaint.
If the complaint identifies a health care provider not employed by an
LHD

The ERO will contact the provider directly to extract what they may be
willing to do to resolve the complaint.
Justice Health Complaints
Complaints that are made by inmates at correctional facilities

Generally these are referred for local resolution.

The ERO will make contact with the Justice Health client liaison officer.

Complaints suitable for early resolution are those where an inmate is
complaining about a waiting list or where an inmate has requested to
speak with the Nursing Unit Manager or a doctor.

Because the Commission is unable to contact inmates these complaints
are often referred to the client liaison for further action and the inmate is
informed by correspondence. A further complaint can be made if the
further action is not taken.
Statistics
Resolved rate 2013-14 = 5.5%
With the commencement of the early resolution project in July 2014, the
resolve rate has increased significantly:

1st Quarter 2014-15: assessments resolved rate = 14%

2nd Quarter 2014-15: assessments resolved rated = 13.9%
Percentage of complaints referred to project resolved

1st Quarter: ERO’s resolved 45.1% of complaints referred to the project*

2nd Quarter: ERO’s resolved 39.7% of complaints referred to the project*
* ERO’s are also given straight up referrals to Council matters to supplement
the workload which accounts for another 20-25% of their outcomes.
Lessons learned so far

Quick and efficient

Excellent client feedback

Avoids bureaucratic delays

Important to carefully select appropriate complaints

Important to keep both parties’ expectations clear

Follow up result with documentation
Feedback
“I cannot give enough thanks to HCCC for the help and courtesy I received. It was
so much more than I expected. In no way did I expect to be treated so well and
made to feel that my complaint was legitimate. I felt like I had someone on my side
and to stand up for me. I felt empowered. Thank you once again. I’m very grateful.
Dr X’s practice treated me unkindly and you guys were my island.”
“I wish to let you know that I visited the XYZ centre this afternoon for my dental
appointment with Dr Z. He was a very kind man and was able to explain everything
to me in a clear fashion, which I really appreciated. He was also able to honestly
answer some questions that I had been asking for some time.
I am glad to say that I was no longer just brushed off and was told the crown would
be replaced at no further cost to me and a further date has been set in February
2015. Nor did I have to pay for today's consultation. I am also aware that the
above has taken place because you have assisted me greatly and for this I thank
you very much. Thank you.”