is anyone listening? a literature review of in tern a ......a literature review of in tern a tional...

INTERNAL REPORT

IS ANYONE LISTENING?

A Literature Review ofIn tern a tional ComplaintSystems

Ruth Greenaway

February 1994

MANATU HAUORA

NEW ZEALAND HEALTH INFORMATION SERVICE - 1994

MOH Library

lI92269M

IS ANYONE LISTENING?

A Literature Review ofInternational ComplaintSystems

Ruth Greenaway

February 1994 092269

MANATU HAUORA

NEW ZEALAND HEALTH INFORMATION SERVICE - 1994

Information C'i:Miiy ofWellington

CopyrightNo part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means, electronic, photocopying or otherwise,without the prior written permission of the Ministry of Health.

DisclaimerThis report was prepared by Ruth Greenaway of Health Research and AnalyticalServices, Ministry of Health for the Health Sector Provider Policy section of theMinistry of Health. Its purpose is to inform discussion and assist future policydevelopment. Therefore, the opinions expressed in the report do not necessarilyreflect the official views of the Ministry of Health.

This is an internal report not intended for wide distribution outside the Ministry ofHealth. As such it has not been reviewed outside the Ministry of Health.

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Table of contentsCopyright......................................................................................... iii

Disclaimer......................................................................................iii

Executive summary ....................................................................................viii

Rationales..............................................................................viii

International models of complaint systems ......................................viii

Policies.................................................................................. ix.

Consumer rights and codes of practice ............................................. ix.

Procedures...............................................................................x

Advocacy................................................................................x

Monitoring and evaluation of complaint procedures.............................xi

Chapter one - Introduction ...........................................................................1

Purpose of the report .........................................................................1

Method..........................................................................................3

Chapter two - Rationale and principles for complaint systems.............................. 5

Introduction .................................................................................... 5

2.1 Consumer perspective.................................................................... 5

2.2 Health care provider perspective.......................................................6

2.3 The principles behind an effective complaint system...............................8

Management principles..............................................................8

Management approach...............................................................8

Lodgingcomplaints ..................................................................9

Documenting complaints............................................................9

Complaint investigation .............................................................10

Chapter three - International models................................................................12

3.1 Different types of systems ..............................................................12

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Informal - Provider based . 12

Formal units - Provider based .....................................................12

Centralised models ...................................................................12

Consumer representatives/advocacy ..............................................13

Informal community groups........................................................13

Medicalaudit..........................................................................13

Health Commissioner................................................................13

Litigation..............................................................................13

3.2 Provider based - Informal procedures.................................................14

3.3 Provider based - Formal units..........................................................14

3.4 Centralised.................................................................................16

3.5 Consumer Representatives and community interest groups .......................18

Careof the elderly ....................................................................19

MentalHealth.........................................................................20

3.6 Community Groups ......................................................................22

Community Health Council ........................................................22

Multi-Ethnic Projects ................................................................22

3.7 Audits and cases of clinical judgement . .............................................. 23

3.8 GP organisations .......................................................................... 24

3.9 Medical associations and Health Commissioners ...................................25

3.10 Litigation.................................................................................26

3.11 Going public.............................................................................28

The Cartwright report...............................................................28

Chapter Four - Key Issues for Consumers.......................................................31

4.1 Hospital complaint issues ...............................................................31

4.2 GP complaint issues......................................................................31

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4.3 Mental Health complaint issues .32

4.4 Disability complaint issues..............................................................32

Common themes......................................................................33

4.5 Advocacy...................................................................................33

4.6 Cultural sensitivity .......................................................................34

4.7 Consumer rights ............................................................................35

The Citizen's Charter................................................................35

4.8 Geographic implications ................................................................. 37

4.9 Developing appropriate complaint procedures ......................................37

Chapter Five - Key issues for Providers .........................................................39

5.1 Collecting and analysing data...........................................................41

5.2 Complaints against G. Ps and Physicians/hospital staff ............................43

GPs.....................................................................................43

Independent review ..................................................................44

Peerreview............................................................................45

Hospitalstaff .......................................................................... 45

Chapter Six - Outcomes .............................................................................48

6.1 Policies .....................................................................................48

Cultural awareness ..........................................................49

6.2 Standards ................................................................................... 50

6.3 Evaluation..................................................................................52

Chapter Seven - The essential elements of a complaint system .............................. 55

7.1 Political will ...............................................................................55

7.2 Management of complaints.............................................................. 55

7.3 Protocol .................................................................................... 56

7.4 Organisations ..............................................................................57

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GPs .57

Hospitals .57

Long-term care .57

7.5 Procedures ................................................................................. 58

7.6 Client focus ................................................................................ 59

Chapter Eight - Summary and Implications ..................................................... 61

Political will and legislation........................................................ 61

Management of complaints and accountability.................................. 61

Provider based procedures.......................................................... 62

Advocacy ..............................................................................63

Implications for New Zealand ..................................................... 63

Bibliography .............................................................................................65

Executive summary

This literature review has been prepared for the Health Sector Provider Policy sectionof the Ministry of Health. The intention is that it will be distributed to RHAs andCHEs to identify the types of complaint resolution processes that have beenimplemented in comparable countries. A range of literature has been considered,including peer review and administration articles.

This review considers possible mechanisms that can be put in place to address thelevel of consumer dissatisfaction within the health and disability sector. Independentresearch has identified important areas of concern for providers to consider whenimplementing procedures for resolving consumer complaints.

Within the proposed Health and Disability Commissioner Bill there is at present nostatutory obligation for any RHA to require a provider to utilise an independentarbitrator for complaint resolution.

"RHAs are to purchase consumer complaint services, including an appropriate systemfor dealing with complaints concerning providers of services with which the RJTIA haspurchase agreements, and an appropriate system for dealing with complaintsconcerning the RHA. "(Funding agreement, 1993).

The Health and Disability Commissioner's Bill suggests procedures for complaintsdealing with "service coverage" to be agreed upon between the RHAs and the CHEsbefore entering into a process of arbitration (Funding agreement, 1993).

Rationales

This review has concentrated on the benefits of an active and efficient complaintresolution process, from the perspectives of the consumer, provider, and healthprofessionals.

International models of complaint systems

Complaint systems in other countries have shown that there are two fundamentalmethods of resolving complaints. One is to rely on an informal system whichdelegates authority to a designated member of staff who resolves complaints at thelocal level. The other system relies on an independent complaint unit either withinthe health service or outside of it. Either system for complaint resolution needs toensure the consumer of an impartial and prompt investigation.

Executive summary ix

There are essential elements that any complaint system needs to incorporate:

policies which show flexibility, and invite new initiatives for complaintresolution

•consumer rights and codes of practice, (including legislation and policiesdeveloped at the local level)

•standardised complaint procedures, for reporting and documenting complaints

•independent advocacy services, and the use of complaints officers

•monitoring and evaluation processes for complaint resolution procedures

Policies

Policies will ultimately provide guidance to the staff who are delegated authority toresolve complaints. Policy makers need to be aware of the barriers experienced byconsumers who wish to make a complaint. Issues relating to policy development wereidentified as:

cultural sensitivity

geographical implications such as access, especially with regard to the choiceof health providers within rural areas; how this might effect a consumers'motivation to lodge a complaint.

•utilisation of independent advocacy services, in both urban and rural centres

•staff training and staff involvement in the resolution process

•codes of practice, and standards for measuring the effectiveness of procedures

•accountability of health professionals and providers

•monitoring and evaluation of procedures used to resolve complaints

Consumer rights and codes of practice

An essential part of. publicising the complaint resolution procedure to consumers is tocommunicate their right to voice their concerns and grievances. An established codeof consumer rights needs to outline the procedure for complaint resolution to theconsumer and to inform them of their right to have their complaint reviewedindependently at any stage of the investigation. Systems may operate in many waysthat seem appropriate to the needs of the community.

Executive summary x

All systems need to offer the consumer a standardised approach to complaintresolution. Policies developed by each individual CHE at the local level need toreflect the set standards and goals of their complaint resolution procedure. This notonly provides the consumer with continuity, but allows for the evaluation of complaintresolution procedures at a national level as well.

Procedures

Complaint procedures are effective if they are able to screen out frivolous complaintsand inquiries. The resolution process needs to be an interactive one betweenconsumer, advocate, medical professional and the health provider.

There were many reasons identified in the literature, why consumers lodgedcomplaints. The most common reason was to ensure that the same unfavourableexperience would not happen to someone else another time.

Problems need to be expressed as opportunities to improve customersatisfaction, and not as hassles that people have created through their ownnegligence, oversight and incompetence. (Leebov, 1990)

In general the view has been that consumers need a formally recognised system forreceiving and resolving their complaints and concerns; even if the complaint wasreported in an informal way. One option for this can be a recognised and wellpublicised informal procedure. Alternatives can be formal independent complaintunits and resolving complaints situated within the provider organisation. Again sucha unit and it's service needs to be publicised to all consumers. It is feasible thatcomplaints can be dealt with under a combination of the two systems.

Procedures need to:

•recognise and include the complaints of third parties; friends, family, andrepresentatives of consumers

•assure the medical profession and the consumer, of an impartial and promptprocedure

•employ staff in the resolution process

•show flexibility in the initiatives used to resolve complaints

•ensure satisfactory outcomes for all parties, whether this is in the form offinancial compensation or an apology to the person concerned

•include policy on the level of compensation given to consumers, and how thiswould be agreed upon

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Executive summary xi

Advocacy

Independent advocacy services have been identified as a means of ensuringconfidentiality and impartiality to the consumer. Research has shown that whenhealth providers include members of the community as consumer representatives, orpublicly value their local community's feedback through customer surveys etc, theymaintain a good level of satisfaction for all, and they lessen the need for law suits orindependent review.

Monitoring and evaluation of complaint procedures

A system for resolving concerns of consumers and providing appropriate forms ofcompensation is effective when the provider takes the opportunity to improve an areaof service, and increase consumer satisfaction.

To ensure sucessful independent monitoring of systems, mechanisms need to beimplemented by authorities as part of all purchasing contracts which require eachprovider to submit all relevant data concerning all complaints, and outcomes ofinvestigations.

The effective monitoring of complaint handling systems by RHAs and ultimately bythe Health and Disability Commissioner will be needed to ensure that any policyaffecting consumer rights or the resolution process within any system, ensures a levelof provider accountability.

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Chapter one - Introduction

Purpose of the report

A system for addressing complaints should be an interactive process between theprovider, and the consumer. Ideally when a consumer expresses a concern orgrievance, there should be a clear and visible procedure for a complaint to be lodgedwith the provider. Systems need to provide ways of processing the complaints.

The ideal goals of a successful complaint system are to:

• ensure accessibility to all, to have publicity about the resolution process, given toall consumers (available in many languages);

• receive complaints in both an informal and formal manner, yet to ensure that thecomplaint is heard within a formal structure;

• enable the complaints and concerns of third parties (friends, relatives, guardians)are heard and investigated;

• promptly address and investigate any degree of complaint, in an impartial andconfidential way;

• enhance the quality of services;

• ensure that the consumer is satisfied with the outcome;

• ensure accountability to the individual consumer, community, and RHA, and;

• not in any way jeopardise the future care of the consumer.

This review has been prepared for the Health Sector Provider Policy section of theMinistry of Health. It comprises a review of international and national literature oncomplaint systems operating in the health sector.

This review examines these issues from the perspectives of consumers, families ofconsumers, administrators, providers, and medical boards. This review is concernedwith the mechanisms that need to be put in place to offer some form of redress to aconsumer or a consumer's friends and family.

This review is concerned with ways to measure and address levels of consumerdissatisfaction, not the use of surveys or questionnaires that encourage the consumerto praise the level of service provided.

Chapter One: Introduction 2

Unlike mechanisms that are in place for the consumer to give feedback on theirsatisfaction with a service, complaint systems are there to address the level ofconsumer dissatisfaction within an organisation. The subsequent collection of dataand analysis of reported complaints can also be used to measure the standards ofservice given within that organisation. Data can be used to track the frequency ofcomplaints, and to reveal areas where there may need to be improvements or policychanges.

As well as being accessible to those who wish to complain, any system that isestablished needs to encourage complaints as an essential part of their overall serviceto the consumer. A service that receives no complaints is not necessarily an efficientand quality service. Health providers need to acknowledge that cosumers have theright to complain. Quality assurance initiatives such as complaint resolutionprocesses need to emphasise this right.

Complaints could be viewed by health providers as a means of identifying problemareas within service, and viewed as a chance to remedy those areas of concern. Withthis view of complaint systems, consumers and service providers can work togetheron issues of quality assurance.

The varying policies behind the implementation of such procedures have beenexamined in this reveiw. How a system responds to complaints from consumers iscrucial. This report has included an analysis of the differences in policies andprescribed out-comes of state funded health providers, and a commercially drivenhealth services.

The report is concerned with the management of complaint systems, and how suchsystems are established, and whether or not legislation is needed to standardise asystem for dealing with complaints.

This review focuses on how complaints were reported, documented, and how theywere investigated, as well as who represented consumers in this process, and howhealth providers were themselves represented. The principles of an independentreview and other ways of providing systems for independent facilitation have beendiscussed. Managements' process of evaluating these procedures was also examined.

The aims of this review are to explore:

• the format of complaint systems in a number of countries;

• the method in which these are organised;

• mechanisms within systems which ensure the investigation and resolution ofcomplaints;

• the policies of providers when implementing complaint systems

• legislation, codes of practice, and consumer rights;


systems management, evaluation, and monitoring;

roles of staff, consumer representatives, and consumer interest groups, and;

the ways providers have incorporated complaints into the quality of service given.

An analysis of the research and evaluation of these systems are given. Those modelsthat are defined as working effectively have been examined and the principles of asuccessful complaint system summarised.

An overview of the current situation in New Zealand is provided andrecommendations are given for future policy development regarding complaintprocedures for health providers including methods of monitoring those procedures byregional health authorities.

Areas in need of further research

One notable area of concern that has has had little research is the need to have acomplaints system which identifies and responds to issues of cultural sensitivity. Thisissue will be discussed further in relation to New Zealand.

There is a need for more research in the area of local accountability; to investigate therelationships of physicians and consumers and whether or not a difference in genderaffects the consumer's decision to complain or not?

With the present climate of health reforms here in New Zealand there is currently anidentifiable lack of literature about the kinds of systems our health providers have inplace for dealing with complaints, as well as the methods used for monitoringcomplaint systems. There is also a need for further research examining the process ofaudit review and their effectiveness.

Research at a local level (within hospitals and general practices) would help assess thevarious methods used in reviewing different types of complaint systems, and theeffectiveness of independent reviews, advocacy services and so on.

Method

Literature on complaint systems has covered services in primary and secondary healthcare, as well as those in the voluntary sector. These have included services for theelderly, people with disabilities, and residents of mental health institutions.

The range of literature reviewed included government documentation of healthreforms and legislation; peer review articles; administration articles from within themedical profession itself and independent research that has investigated the efficiencyof existing complaint systems and the pitfalls or limitations of those systems. Therewere also a number of guides reviewed which had been written specifically for thehealth provider and the consumer. These described how to deal with complaints andadvise the consumer on how to go about complaining.


This review looked for the underlying principles of an effective and efficientcomplaint system. It has questioned whether or not there are definable essentialelements that every complaint procedure should have. Issues raised include whetheror not there are controversial elements that continue to cause unavoidable obstacleswithin complaint resolution systems. Such issues include issues of ethical or clinicaljudgement, administrative or other reasons for delay, conflict over whose authority itis to resolve complaints and so on.

Chapter two - Rationale and principles forcomplaint systems

IntroductionA package system which recognises the right of the consumer to complain and whichimplements an effective complaints system can undoubtedly contribute to more equaland effective consumer/provider relationships and increase service providerresponsiveness to consumer needs as identified by the consumer (Ednie, 1986).

2.1 Consumer perspectiveMost of the literature reviewed emphasised that effective and efficient complainthandling services were a crucial factor in determining the overall success of anyhealth organisation (Leebov, 1988, 1990, Ednie, 1986, Payne, 1990, Williamson,1992).

Complaint services need to be designed specifically to address the grievances ofconsumers, as well as the friends and family of consumers. It has been observed thatthere were many factors within the provision of health services that depend on theoverall rationale of the providers who instigate systems for complaint resolution.

The consumer requires an avenue for lodging a complaint, in order to receive someform of redress and recognition of what went wrong. It was apparent from much ofthe literature that consumer's satisfaction increased if they perceived that theiropinions of the service are valued and actively sought by that provider.

Ednie (1986) identifies complaint procedures as a way for consumers to contribute toinitiatives including complaints procedures, which were aimed at improving thequality of services from a consumer perspective. In this context, it was believed thatconsumer input would contribute to:

increased consumer awareness of their basic entitlements as health careconsumers;

• more equal and effective consumer/provider relationships;

• greater consumer responsibility in using services and making informed decisionswhich affect their health care;

• increased consumer identification of the areas where deficiencies are experienced,and;

• increased service provider responsiveness to consumer needs as identified byconsumers (Ednie, 1986).

Chapter Two: Rationale and Principles for Complaint systems 6

Carmel (1990) observed that above all the consumer required a satisfactory level ofcommunication and attentiveness from staff. The consumer was satisfied if theircomplaint was received in a positive manner and it's investigation was given promptattention.

Ednie (1986) has stressed that the women's movement was a great contributor to themovement of empowering consumers. She has identified an imbalance betweenconsumers, (the majority of which were women) and service providers. Thisimbalance of power and the inequalities in treatment it has created, will continue toencourage initiatives for change to complaint systems, in the future.

Friends and family of consumers who are given knowledge of a workable complaintssystem need to feel assured of a process that will go towards addressing theirconcerns, especially if the consumer is unable to represent themselves. A system thatprovides for impartial consumer representation greatly enhances this process.

2.2 Health care provider perspectiveThe way in which providers actually conceptualise any process for reporting andinvestigating complaints has been identified as a major factor in the effectiveness ofcomplaint resolution. Where do health providers situate complaints within the overallstructure of their organisation? Are complaints seen as a measure of quality assuranceor only a concern for management in cases of clinical judgement?

There are many incentives for health providers who implement complaint handlingprocedures. They help to:

• assess standards of service, ie; quality assurance;

• ensure continued consumer patronage of any provided service;

• identify areas of inefficiencies;

• act as a centralised point of contact for staff and complainants, within theorganisation as a whole or on a departmental basis (in hospitals);

• provide another way of ensuring consumer satisfaction, through promptinvestigation and remedial action;

• delegate authority amongst staff to handle complaints;

• save time and administrative costs, and;

• involve providers from the start, this leads to less need for independent reviewsand outside facilitation (Payne, 1990, Unattributed, 1980, Stacey, 1993, Truelove,1985 Allsop, 1987).


Payne (1986) observed that staff and management who failed to change their practiceswhen valid complaints had been laid missed out on a valuable source of feedback andan opportunity to improve standards of consumer care.

The World Health Organisation (WHO) has identified the following as essentialcomponents of any strategy designed to address the issue of quality assurance:

performance reviews, both technical and professional;

efficient use of resources, including staff allocation;

risk management;

policies concerning the monitoring of practices, and;

• the monitoring of consumer satisfaction with the use of complaints,correspondence, and consumer surveys (Payne, 1990).

Commercial incentives for providers were re-emphasised in literature which examinedthe side affects of litigation and how this process of dealing with complaints affectedthe relationship of health providers and consumers (Holthaus, 1988 Koska, 1989,Localio et a!, 1993, Rode, 1990, Sloan, 1989). This argument implied that by justappearing to respond to grievances/ complaints as they arose, was not enough toensure that the consumer will return. A complaints system needed to assure theconsumer that any complaint reported would be handled in the most appropriate andactive manner possible.

Systems for addressing consumer complaints inevitably reflect the priorities of theprovider, whether they are concerned primarily with organisational structure or thelevel of consumer dissatisfaction (Stacey, 1993, Unattributed, 1991, Caples, 1989).

It was agreed through-out the literature that a complaints system should be able toaddress any complaint promptly, and arrive at the most satisfactory outcome possible.

This is acheivable if the aim of any organisation is to ensure that consistent levels ofservice and medical care are provided, aswell as keeping the organisational andadministrative structure intact,

Complaint resolution procedures give the provider another means to review theirpractices and to offer the consumer any remedial action needed to prevent any furthercause for complaint. They can also offer providers the opportunity of appearing as"the human face of bureaucracy" (Truelove, 1985). Complaints procedures are notjust the domain of hospitals. They need to be less of a hazard for GPs as well asconsumers (Stacey, 1993, Allsop, 1987).


2,3 The principles behind an effective complaint system

Management principles

It has been recognised that if complaints procedures are to reflect the level of servicegiven, and to in turn measure the level of consumer satisfaction, then there wereessential elements that such systems needed to employ:

policies that reflect the goals of management;

• a shared vision from management and staff;

• staff participation and training, and;

• adequate publicity of systems, and policies regarding complaint procedures (Eddy,1990, Longley, 1992, Payne, 1986).

Payne (1986) observes that within the cycle of quality assurance measures, complaintsshould be seen as an indicator of the areas of practice which need improvement and bea focus for standard setting.

It is an important principle behind the management of a complaint system to assesswhether the cause for complaints is a systems management problem ie:communication, administration, or whether the problem is of a purely clinical nature(Leebov, 1989, 1990).

It was agreed that, systems for identifying complaints, need to:

• report complaints efficiently;

• monitor the occurrence of complaints, especially those that are often repeated,and;

• ensure a method of self evaluation:

• screen out complaints that are frivolous or that can be handled without the processof investigation;

The National Association of Health Authorities (Drummond/Morgan), has identifiedtwo different approaches often taken by management when handling complaints.They were either an overly defensive one or a system which defends consumer rightswithout learning from the identified problem areas.


Management approach

It is recommended that management should take a "learning approach" which hasbenefits for both provider and consumer. There are five basic assumptions to thistheory. They are that recognition that:

• users have a legitimate and important point of view;

• users' views should be taken seriously and their opinions actively sought. For thisto happen it means that all information gathered from consumers should beappropriate to all racial and age groups that use the service;

• most people don't make complaints easily, and don't complain about things thatare unimportant to them;

• only a minority of dissatisfied users go as far as complaining, and;

• services exist to benefit users and should respond to and reflect their preference.These should be willing to invest effort and resources to seeking ways ofimproving the service (Drummond).

Lodging complaints

Leebov identifies four basic needs of consumers when lodging a complaint. They are:

• to be taken seriously, and listened to in a positive sense;

• immediate action;

compensation in various forms (not always financial), and;

• outcomes/corrective action taken, and assurance that this will happen (Leebov,1990).

Much of the literature identifies advocates or consumer representatives as one way ofinitiating and following through the process of lodging complaints. Complaints maybe lodged by third parties, but it was stressed throughout the literature that to ensurethe voice of thrid parties was heard, information and policy about complaintresolution processes needed to clearly include the role of third parties in the resolutionprocess.


Documenting complaints

Researchers identified the documentation of complaints as one of the most importantmeans of measuring the frequency and pattern of complaints. When documenting acomplaint it is important that the staff:

have all the facts about the complaint confirmed by the consumer;

• acknowledge what the consumer wants/expects as a resolution;

• give the supervisor the recommendations they may have made to the complainant;

• complete summary sheets that are kept for future reference and for theinvestigation of any complaint, and;

• document written and oral complaints well (Leebov, 1990, Netting et al, 1992).

Once the mechanism for gathering this input from consumers is in place there is aneed for formal structures to be established so that complaints can be investigatedpromptly.

Complaint investigation

It has been observed that when management implemented a system for complaintinvestigation it was important to:

• clarify the roles of staff;

• screen out inquiries, or minor concerns from any investigation;

• recognise the level of complexity in any complaint, and;

• be as thorough as possible

(Payne, 1990, Longley, 1992, Leebov, 1990, Truelove, 1985, Owen, 1991).

The aim of an investigation should be to genuinely establish the facts of the situationand to identify any remedial action that could be taken. The investigation should alsobe able to stand up to any further independent enquires (Truelove, 1985).

There were many alternatives to independent reviews given within the literature. Oneexample of this were the recruitment of independent complaint officers, as well as anindependent complaints unit. This meant that authority was delegated to one specificperson and the reporting of complaints was kept in one identifiable locality (Owen,1991, Leebov, 1989, 1990, Truelove, 1985).


Any delay in the resolving of consumer complaints was decreased when the complaintwas dealt with at the lowest possible level, or the scale appropriate to theseverity/complexity of the allegation (Leebov, 1990, Truelove, 1985, Payne, 1990,Owen, 1991).

Throughout the literature reviewed it was emphasised that complaint handlingprocedures needed to be flexible enough to involve the active participation ofemployees, and to recognise the representation of consumers, whether that be aconsumer advocate, friends and family or an outside representative such as acommunity health organisation, interpreter, or an independent reviewer.

"A hospital that has no patient representatives has a painfully acute case of top-management myopia" (Leebov, 1990).

Facilitation and arbitration were recommended as positive means of resolvingcomplaints, and ensuring that complainants, and others such as third parties involvedin the resolution process were heard. Leebov gives examples of ad hoc problemsolving groups, employee focus groups, independent facilitations, interdepartmentalproblem solving groups and groups who employ systems for ranking the severity ofcomplaints and the immediacy of investigation. Such problem solving groups withinthe organisation could work alongside or separately from an independent reviewprocess. -

A system which required staff to give evidence in the investigation ensured that theconsumer's complaint was handled at the level closest to it's origin and avoided anyextra delays associated with a process of independent review. The complaintresolution system needs to be open to the possibility that the consumer may wish toseek litigation if they remain dissatisfied (Leebov, 1990).

Chapter three - International models

3. 1 Different types of systemsThere are a large number of complaint procedures and systems worldwide. Some areformally recognised systems which are part of the overall structure of an organisationthese are the main focus of this report. There are others that are more informal, andrely on the initiative of the complainant, and the goodwill of the provider. Oftenother avenues such as the media or a process of litigation are resorted to by aconsumer, this occurs when there is a breakdown or the non-existence of a formalcomplaints system.

Informal - Provider based

Complainants report their grievance directly to a member of staff. It is then that staffmember's responsibility to refer it onto the appropriate person within the organisationto investigate it. There are certain identifiable complications with systems of thissort. Very often a complaint will not reach the correct person or will get lost withinthe system. It depends on the policy of the organisation whether or not complaintsare something that staff are delegated authority to deal with, or not (Payne, 1986,Caples, 1989, Carmel, 1990).

Formal units - Provider based

There are examples of independent units within hospitals and other health services,whose specific job it is to handle complaints. These often have appointed complaintsofficers, or employ the use of consumer advocates/representatives. There are benefitsin this system for the provider and for the consumer. The independent complaintsunit acts as a mediator, taking the responsibility to oversee the process ofinvestigation and to keep all parties informed (Koska, 1989, Unattributed, 1980,Cornwell, 1984, Netting et al, 1992).

Centralised models

There are complaint units that act independently of any hospital or general practicebut which remain under a degree of centralised control, these systems were found tooperate from within the health department, or directly from the Minister of Health.Such units were open to all degrees of complaints, yet they were not part of anyindependent review process unlike systems within hospitals (Caples, 1989,Department of Health Tasmania, 1991, Department of Family services, 1992).

Chapter Three: International Models 13

Consumer representatives /advocacy

Consumer advocates were often the only means of redress for people in psychiatricinstitutions or for the elderly in rest homes. In these cases it was the consumeradvocate who sought redress for the consumer on their behalf. This role was a farmore permanent arrangement than for advocates dealing with complaints in generalhospitals (Karejewski et al,1992, Tesolowski et a!, 1983, Working party on legalissues. . .1987, Unattributed, 1980).

Informal community groups

Community health organisations offer the consumer a service specifically designed tolead them through the complaints procedures available. Often they are able toinfluence the policies of certain providers (Unattributed, 1991, Cornwell, 1984, Kalsiet al, 1989).

Medical audit

There are procedures for complaint handling and investigation outside of hospitals orgeneral practices, in the form of independent medical boards, or service committees.Usually these are places to which complaints of great severity are referred, and Whichrequire professional judgment of a medical practitioner's behaviour or practice. Theyalso act as an independent source of evaluation (Alisop, 1987, Geffen, 1990, Hart,1986, Hudspith, 1993, Localio et a!, 1993, Longley, 1992, Owen, 1991, Scott, 1985,Sloan et al, 1989, Stacey, 1993, Unattributed, 1991, Williamson, 1992).

Health Commissioner

If a complaint, has not been handled sucessfully at the local level, to the satisfaction ofstaff, and the complainant, the Health Commissioner provides the opportunity ofindependently reviewing the procedure.

The Health Commissioner, acts as an independent source of complaint facilitation, inthe cases involving clinical judgment. The Commissioner is able to intervene in anyinvestigation or initiate an investigation at any given time. Often the Commissioner isconsulted when the initial stages of complaint resolution have failed to satisfy eitherthe provider or the consumer (Hudspith, 1993, Scott, 1985, Netting et al, 1992).

Litigation

Systems that have severe limitations force the complainant to seek alternative forms ofredress by involving the support of community agencies, or seeking litigation, outsidethe health organisation in question (Hoithaus, 1988, Localio et al, 1993, Sloan et a!,1989).


All systems either provider based, or independent of the provider, require some formof monitoring, either by a medical board, Health Authority, Health Commissioner, orother independent means of evaluation.

The implications of such actions and options that are available to the consumer will bediscussed in this section.

In most countries more than one of these systems to address complaints can be found.No country strictly adhered to one or the other Often procedures varied a lot betweenhospitals and general practices.

3.2 Provider based - Informal procedures

Most National Health Service providers in Britain have a system for hearing non-clinical complaints, under the Hospital Complaints Procedure Act, 1985 (Payne,1990).

When lodging complaints against hospitals, clinics, and community services withinthe NHS, consumers are able to go directly to the person concerned or the designatedofficer. Complaints can be given either verbally or in the form of a writtencomplaint.

Only non-clinical complaints are handled by the designated officer at this local level.The designated officer was not an independent complaints officer, but rather amember of staff who took on this responsibility, (often the Unit General Manager).

The most minor complaints were dealt with through a process of conciliation betweencomplainant and the medical professional in question. In cases of more seriouscomplaints (non-clinical), once the designated officer or senior house officer hadreceived the complaint the consultant was requested to draft a response. This wasthen used by the hospital's administrator as the basis of the provider's reply to thecomplainant (Unattributed, 1991, Geffen, 1990, Alisop, 1987, Payne, 1990).

3.3 Provider based - Formal units

Koska (1989) noted that the National Society for Patient Representation andConsumer Affairs (NSPRCA) in Chicago, had formally recognised the formalstructures in place in hospitals. Statistics suggested that 47.2% of American hospitalshad consumer representatives.

More than 1,600 hospitals in America have one ombudsman and/or a whole unitdedicated to handling complaints. These units involve people from a range ofdisciplines; social work, human sciences, nursing, and administration work(Unattributed, 1980).


The Cleveland Clinic Foundation is an example of an efficient complaint system.This clinic has over 750,000 outpatient visits, and just under 32,000 in-patients peryear. About 4,000 complaints, inquiries or suggestions were expected to be filled outby the Ombudsman for 1989.

This clinic had a staff of 10 people to deal with complaints. It's complaint unit wasindependent from the hospital although it kept close contact with top executives andit's services were well publicised for consumers, physicians and personnel. Inaddition to monitoring complaints this unit kept a track of the trends and identified thechanges that were needed in the hospital's policies and procedures.

This clinic's complaint management was acclaimed by the Joint Commission onAccreditation of Health Care Organisations (JAHCO) because they recognised thatthere was an effort being made to link complaint systems with the hospital's standardsof quality assurance (Koska, 1989).

The New York Hospital received complaints within a unit for Patient ServicesAdministration. Three consumer representatives (advocates) had on average 20-25open cases at any given moment (Unattributed, 1980).

As they were an independent unit, consumer representatives were referred complaintsto physicians, social workers, nurses, nutritionists and from the accounting andadministration area of the hospital.

Complaints were written up on case sheets and taken to the weekly professionalliability committee meeting for discussion and recommendation. Members of thecommittee included the executive associate director of the hospital, the inhousecounsel and the hospital counsel, the hospital's insurance manager, a staff physicianand the consumer representative.

If there was a settlement involved, then the consumer representative informed thefamily and friends of the consumer and an insurance carrier contacted the family indue course. The role of the consumer representative did not include providing advicefor the consumer on whether they should sign a release, or sue a medical practitioner.

It has been noted that independent units work well for staff also. When there werequestions of a legal nature the unit was often called in to assist. Staff training wasalso a function of the unit, on both legal issues as well working within the complaintsprocess (ibid).

In Australia the state of Victoria was the only state to have a provider based complaintsystem (eg: within a hospital, as opposed to acting independently of a hospital).However, because it was centrally controlled by the state it had limitations:

it required a deposition from the Department of Health prior to any investigation;

it lacked the power to impose any disciplinary action in cases of a serious nature;

it could not investigate cases of clinical judgement;


• it did not have the power to prosecute, and could only refer serious cases tomedical boards;

• the system remained under the auspices of government evaluation, and;

• this system did not provide the consumer with an independent advocacy service.

This unit was limited in it's power by the legislation that created it (Health ServicesCommissioner, 1988, Caples, 1989, Department of Family Services, 1992).

The systems strengths included:

• inviting local resolutions for complaints;

• being independent from the Department of Health;

• having the legislative power to investigate and conciliate complaints;

• ability to work within a network of complaints officers through-out hospitals, and;

• the unit employed two investigation and two conciliation officers.

Under this system the consumer could:

• make a direct complaint to the unit;

• complain about a provider in private practice as well as public;

• have up to 12 months to lodge their complaint, but can be given longer at thediscretion of the unit;

have published material freely available, on the complaints procedures;

be represented by complaints liaison officers, available in public hospitals, and;

• the unit had the ability to investigate the way in which other relevant bodieshandled complaints.

3.4 Centralised

There were few provider based complaint systems in Australia. While there wereother examples of complaint systems in the literature that were influenced bygovernment legislation and under state control, Australia showed examples that wereonly situated within the Department of Health, or whose investigation Of complaintswas at the discretion of the Minister of Health.

In general the consumer was disadvantaged by the lack of conformity within thecomplaints systems through-out Australia. The level of protection for the consumerwas dependant on the state, and this tended to vary from state to state (Caples, 1989).


In the Northern Territory complaints were lodged with either the Minister of Health,the hospital board, or the Regional Director. It is also limited in that it only dealswith complaints concerning public services, not private (Caples, 1989).

Prior to 1993 in the state of Queensland the consumer was expected to write directlyto the Minister of Health when lodging a complaint. He could only deal withcomplaints about public hospitals. A complaint was only investigated at the discretionof the Minister (Department of Family Services, 1992). There is currently a HealthCommission Office which deal with complaints but the process is still under a degreeof centralised control.

New South Wales (NSW) and Victoria had independent complaints units also butremained under the influence of the state.

NSW has a well resourced complaints unit. The unit was established in 1984 withinthe Department of Health, and has a staff of 32, including 10 investigative officersand 4 lawyers. This is the largest unit in Australia. Based in Sydney, the office doesnot have a developed network of complaints officers in public hospitals, and only hasconsumer representatives in four of those hospitals.

The unit has delegated authority from the Department of Health to prosecuteregistered providers, and the legal proceedings are not a cost to the consumer. Theunit handles all complaints, and has the ability to review hospital and area healthboard systems for handling complaints. However the unit can only conciliatecomplaints on an informal basis . All reports from this unit are sent to the DirectorGeneral of Health for action.

Features of the system were that it allowed the consumer to lodge complaints that maybe up to 5 years old as long as the complaint was received in writing. The unit alsosupplied the consumer with publicised information on the complaints procedure andtheir role within it. However they do not provide the consumer with any form ofadvocacy service to assist in lodging a complaint.

Once a complaint had been received by the unit it was screened by a committeeconsisting of the director of the unit and the complaints manager. Complaints arethen channelled into three options for consideration; either legal issues, individualprofessional concerns or those to do with professional standards.

In general this unit works on the basis of a peer review system. Peers give theirprofessional opinion on the level of service provided in light of the complaint made.Abernethy (1993) notes that this unit only addresses what it considers to be "issues ofpublic interest". This unit do not address issues of financial compensation.

The unit is divided into four sections:

1 The impaired practice programme which deals with a medical practitioner'sinability to carry out their service. This professional standards committee ismade up of one doctor, one lawyer, and one psychiatrist.


2The individual provider section who give a peer review of the service provided

3The standards of care section, which looks into complaints dealing withprocedures and systems within any provided service. Complaints that reachthis committee are also dealt with by independent consultants, who recommendprocedural changes.

4 The administration section. This section of the unit deal with complaintsconcerning computer programmes, data analysis, reporting of complaints andreport writing, educational programmes, as well as the advertising andpromotional work of the commission (Abernethy, 1993).

This complaints unit, within the Department of Health, does not have the power toprosecute, nor is it able to conciliate between the provider and the consumer. It alsodoes not have the ability to review the way other bodies handle their complaints(Caples, 1989, Department of Family Services, 1992).

The government has not given these units any statutory basis or any on-goingcommitment. Currently none of these health authorities which handle complaintsreally have the authority or resources to cover the full range of complaints reported.(Caples, 1989, Department of Health, Tasmania, 1991, Department of FamilyServices, 1992).

3.5 Consumer Representatives and community interest groups

Consumer representatives, or advocates, have been identified as a crucial part of anycomplaint procedure within hospitals, psychiatric wards, in homes for the elderly, andin disability support services. They can also exist as independent community agencies(Truelove, 1985, working group on legal issues, 1987, Tesolowski et al, 1983,Netting et al, 1992, Unattributed, 1980).

It has been observed that independent advocacy services:

• raise the standards of care given to long-term residents in old peoples homes,disability support services, and in psychiatric institutions;

• highlight the avenues of recourse available to the public;

• provided conciliation and mediation services often not provided by guardians orfamily;

• ensure the consumer's autonomy is maintained, and;

• are an independent source of referral for both consumer and staff.


Consumer advocates were described as an essential element of a complaint handlingsystem for the consumer; because they were not part of the medical staff. Nor werethey part of the family of the resident who were involved in the emotional side ofwhat's going on. They were principally there to view the facts of the situationobjectively (Unattributed, 1980).

Just getting staff to recognise that the resident has the right to know, the right to sayno, and the right to be informed, and whose responsibility it is to inform the resident -this is a big step forward in some institutions (unattributed, GN, 1980). Consumeradvocates actively strive to keep staff and the consumer working and communicatingwithin the same framework.

In cases of compensation it has been observed that consumers would not sue if theinjury they had received was not permanent. Rather the consumer sought recognitionfrom medical staff and appropriate action taken (Unattributed, 1980).

It has been observed in the UK, that consumer representatives who had some medicalbackground, or specific medical training were far more likely to understand a medicalsituation from both sides. They were able to bring skills from a medical knowledgebase into both the interviewing situation and the documentation of complaints. Oftenthere was little training that consumer advocates could receive (Unattributed, 1980).

The example of a state psychiatric facility in Maryland showed that a system foraddressing complaints which utilised consumer advocates was able to resolvecomplaints of various descriptions. This system showed that advocacy can work in anon-adversarial way to resolve complaints early in the process. The largest numberof complaints were resolved at this first phase of conciliation (Krajewski et al, 1992).

Care of the elderly

In America in the area of long term care for the elderly, the consumer representativewas usually called in to facilitate issues concerning discharge from hospitals, toresolve concerns about who is going to look after the consumer once they have leftthe hospital as well as issues of abuse and neglect that concern the care of elderlypeople in nursing homes. The consumer representative often had to track downfamily and friends of the consumer, locate attorneys, and liaise with the attorney onbehalf of the consumer (Unattributed, 1980). It has been identified that the largestcomplaint category was in the area of resident care (Netting et al, 1992).

State agencies within America that run programmes to care for the elderly, arerequired by the Older American's Act (OAA), to operate directly, or under contractwith an independent ombudsman's office (Netting et al, 1992).

Chapter Three: International Models

Features of this system were:

investigating and resolving complaints for long term care residents;

• developing protocol for the Ombudsman's access to facility and consumer records;

• working within a state reporting system;

• ensuring client confidentiality;

• monitoring care regulations and policies of organisations affecting the care of theelderly, and;

• provision of adequate information to the elderly, the family and friends ofresidents, about their service (Netting et al, 1992).

Nationally there were 578 Ombudsman programs including both voluntary and paidstaff. In theory they provided the necessary community input needed to developfederal policy in this area (ibid).

The system was flexible enough to develop individual programmes to suit differentstates throughout the country. All states are required to submit data, in the form ofan annual report, to the Administration on Aging (AoA) and to the state licensing orcertifying agency on a regular basis. The health provider's annual report wasrequired to include policy, regulatory, and legislative recommendations to the care oflong term residents (ibid).

It was hoped that a national ombudsman data base would provide practitioners,researchers, and policy makers with an in depth knowledge of the variety ofcomplaints and the differing variables needed to be considered in relation to anymeans of addressing these concerns (ibid).

Mental Health

The state Psychiatric hospital in Maryland, U.S.A., uses a system of advocacy toaddress issues of abuse amongst it's residents (Krajewski et al, 1992).

Features of this system were:

• grievances resolved through mediation between residents, staff and theDepartment of Health and Mental Hygiene. This department in turn was overseenby the federal courts and an independent board of review. This board included,attorneys, physicians, mental health professionals and consumer advocacy groups;

• the system addressed any legal, administrative or ethical complaint;


• on admission to the facility consumers were given a copy of their rights, in theform of both and oral and written statement, and information on how to use theconsumer advocacy services. Signs and information were put up in every ward,and;

• consumers could lodge their complaint by calling or writing to the Rights Adviserassigned to their facility. The system is open to third party complaint also.

There was a four level system for the hearing of complaints. The consumer wasrepresented at every level by a Rights Adviser. They were responsible for theinvestigation of any complaint. The system worked as follows:

1

The rights adviser tried to come a resolution through mediating with theprofessional in charge.

2

The involvement of the physician's supervisor or the medical director of thefacility.

3 The grievance was heard by the Patient's Rights committee. This includedconsumers, families, staff and consumer representatives. The committee makesit's recommendations to the chief executive officer of the hospital. It was thentheir decision to implement the recommendation or not.

4 The complainant was offered a hearing before the central review committee ofthe Department of Health and Mental Hygiene. The committee included thedirector of the Mental Hygiene Administration, the director of the regionwhere the facility was located and the actual director of the complaint systemwithin the facility (Krajewski et al, 1992).

There were examples of outreach advocacy services in Canada. Ontario has it's ownindependent Psychiatric Patient Advocate Office, and had established "watch-dog"groups for "Concerned friends of persons in institutions". In Toronto there was anAdvocacy Centre for the elderly. Unfortunately, there was not much descriptiongiven of these (Working group on legal issues, 1987).

Without legislation made in specific relation to the provision of advocacy services forthe families and friends of, the disabled, mentally ill, and the elderly, the legislationthat protects the rights of these consumers will only have a limited impact (Workinggroup on legal issues, 1987).

This view was also expressed in relation to a pilot advocacy project in Austria, whereit was felt that because there was no legal backing from the state. The advocacyservices then relied heavily on the goodwill of staff and the courts who appointedthem (Forster/Vyslouzil, 1991).

Advocacy services also needed to be institutionalised so that the complaints orconcerns of third parties were not solely the domain of the advocate(Forster/Vyslouzil, 1991).


3.6 Community Groups

Community Health Council

In the U.K Community Health Councils (CHC) represent the consumer and provide arange of services which offer advice and explain how the NHS procedures forcomplaints works. They often helped the complainant draw up written complaints,and ensured that the correct people took up the complaint. As representatives theyoften went with the client to official hearings (Unattributed, 1991).

The Community Health Councils work in variety of ways and offer a range ofadvocacy services. There are subgroups within the CHC including:

• working party groups which act on behalf of ethnic, religious and other groupswithin the community (Kalsi, 1989, Cornwell, 1984).

• Action for Victims of Medical Accidents (AVMA), are a charitable organisationand their services are free (Unattributed, 1991).

• The Association for Improvements in Maternity Services (AIMS) acts as supportfor women and monitored the services they received from midwives andobstetricians (Williamson, 1992).

Consumer advocates within old people's homes and psychiatric institutions.

Multi-Ethnic Projects

Information was found on two community groups who offered advocacy services forethnic minorities (Kalsi, 1989, Cornwell, 1984). They were structured in a way thatensured:

• accountability to the steering committee. The steering committee includesrepresentatives from local community organisations, NHS staff, and the CHC;

• acceptability to both the CHC and the health providers of that community, yet thecommittees remain autonomous;

• workers are from within the CHC and comprise of both lay and medicalprofessional members, and;

• race relations advisers/development workers work in close relation to communityhealth groups (Kalsi,1989 ,Cornwell, 1984).


The Haringey multi-ethnic project established forums concerned with both mentalhealth services and services for the elderly (Kalsi, 1989). Features of these services toconsumers included:

• the employment of development workers, who liaised with providers. They alsoprovided community organisations with information on the Regional HealthAuthorities and the services they provided, including complaint systems. Theyworked within health organisations in a role similar to that of an advocate. Theyare independent of the provider's management and staff, yet they could work atany level within the hierarchy;

the provision of information in all languages, on all services;

• an ethnic switchboard to give users of these services advice on problems they mayencounter and where to go to get further advice and support, and;

• a specialist nurse visitor to work within community health services for the elderly.This person was accountable to the Community nurse manager, and was supportedby a group consisting of the Health Authority nurse member, the developmentworker, the manager of services for the elderly, the health education officer andthe specialist nurses line manager.

The primary role of the specialist visitor nurse, and the development worker was toprovide mechanisms for preventing problems and improving the quality of servicegiven.

While these advocacy services were primarily adversarial, they were accountable toboth professionals and community groups. This meant that they could provide theimpartiality necessary when resolving complaints.

3.7 Audits and cases of clinical judgement.

When reporting a complaint of a clinical nature, within the NHS (Britain) there areseveral options available to the consumer:

1 once the complaint was put in writing, the consultant is expected to inform theRegional Medical Officer and the District General Manager. However therewas no legal requirement for the consultant to be a part of this procedure.

2if this was unsuccessful the Regional Medical Officer would set a time for anofficial hearing or independent review.

3 the R.M.O make their decision, based on the recommendations of independentassessors, as to whether the complaint was substantial enough to warrant anIndependent Review. This stage did not come as a right to the consumer(Unattributed, 1991, Stacey, 1993, Geffen, 1990, Allsop, 1987, Longley,1992, Owen, 1991, Scott, 1985).


In America, the courts have the ability to review processes of independent review andto decide whether or not they are acting within the constitution in their representationof the consumer.

This system benefited the consumer by ensuring that all complaints dealing withmedical competency were able to be heard in front of a Medical Review Panel(Holthaus, 1988).

3.8 GP organisations

When making a complaint against NHS health professionals working in thecommunity (GPs, dentists, opticians and practice nurses), there are several optionsgiven to the consumer (Unattributed, 199 1).

1complain to the person concerned, or their professional organisation. ThereI are no time limits when doing this. The complaint is screened by an individualor committee who decide whether it should go to a hearing. The complaint hasto involve some degree of breach of service.

2 approach the Family Health Services Authority (FHSA). Here a complainthad to be made within 13 weeks. This service committee had a statutoryobligation to investigate complaints. They conciliate between parties to resolvecomplaints. The committee had an equal number of lay and professionalmembers and a lay chairperson. They will recommend what disciplinary actionis to be taken. The person who is being complained about it not obliged torespond at this stage.

3 if this proved to still be unsatisfactory to the complainant they could lodge anappeal to the Secretary of State. The complainant would be sent a letter askingwhether they want to lodge an informal or formal complaint. It was noted thatif a complaint was investigated formally and the case reached the Secretary ofState then the process lasted up to four years.

When lodging an informal or oral complaint the person or provider in question weregiven the opportunity to reply. After complaint was lodged, it was investigated by aservice committee (Unattributed, 1991, Stacey,1993, Scott, 1985, Owen, 1991,Longley,1992, Hudspith, 1993, Geffen, 1990).

In Israel, when complaining about a local GP the consumer must approach either theArea Director, or the Regional Director.

The Area director dealt with complaints of a minor nature whereas the Regionaldirector dealt with more severe cases of medical misconduct, and cases of an ethicalnature. It has been identified that the greatest disadvantage with this system was thatconsumers who saw the Area director could not lodge their complaints locally (Hart,1986).


The beneficial features of this system were: I

• the Area director acted as a safety net, to lessen the pressure on the Regionaldirector and prevented minor complaints turning into major ones;

• this system gave the consumer the opportunity of expressing their dissatisfactionas close to the time of it's occurrence and with as little bureaucratic inconvenienceas possible;

positive peer support, and;

• new initiatives for the resolving of complaints were found, at the initial stage ofresolution (Hart, 1986).

Carmel observed that while doctors in Israel were under constant scrutiny, just for theconsumer to be given the opportunity to express their complaint was often enough justto re-establish the doctor-consumer relationship, and to satisfy the complainant(Carmel, 1990).

3.9 Medical associations and Health Commissioners

When making a complaint to the District Health Authority (DHA), in Britain, acomplaint had to be given in writing to the District General Manager within threemonths. The complainant would receive a letter from the DGM within a week andagain within a month, advising them of the outcomes of the investigation.

If this process proved to be unsatisfactory then the consumer could complain directlyto the Health Service Commissioner (Ombudsman).

a complaint could be made within a year

• complaints about GPs or any medical authority such as the Family Health ServiceI'Authority (FHSA),or complaints dealing with clinical matters would not be heard

any recommendation from the Ombudsman would be given in the form of either,an apology from the health authority or a change in policy. On average responsetime is about two weeks (Unattributed, 1991, Scott, 1985, Owen, 1991, Longley,1992, Stacey, 1993, Hudspith, 1993, Geffen, 1990).

Hudspith (1993) has observed that there are an increasing amount of statutory and nonstatutory ombudsmen in Britain. They may act independently or within healthorganisations.

A trend has been identified among providers to rid themselves of documentation inrelation to complaints. In this instance the ombudsman is deprived of information forthe investigation of complaints. In such a case where evidence has been willinglydestroyed, the ombudsman is more likely to side with the complainant (Hudspith,1993).


A report on advocacy services in Australia, (Abernethy, 1993) found that inQueensland complaint resolution was entirely handled by the Health Commissionoffice (unlike other states in Australia, where the Health Commissioner may be usedas a final resort.)

Complaints were first received by the Inquiry Officer at the Commission. Complaintswere entered onto the computer and the hard copy was also kept. Complaints werethen divided and considered intotwo categories; formal complaints or problems,where further information was needed, or problems were dealt with immediately,though some were not always recorded.

The Inquiry Officer determines the level of "unreasonableness" of the consumersconcern, which then establishes whether or not it should be dealt with as a complaintor problem only.

The consumer is able to withdraw a complaint at any time and no further action willthen be taken unless the Health Commissioner considers the complaint to be of publicinterest.

Complaints are resolved through a process of conciliation. Only at a formal stage ofthe investigation can the Health Commissioner report to the Minister of Health orrefer the complaint to the disciplinary body of the provider's discipline. At presentthe Health Commissioner in Queensland does not have mandatory powers forarbitration or adjudication.

This Commission office has a 'special projects officer'. This person's role is one ofeducating and encouraging Aboriginal and Torres Strait Islanders to understand andutilise the commission and the services they offer. The person who fills this positiondoes not however have a role in developing Commission policy from an Aboriginalperspective. It should be noted that the person who currently filled this post wasAboriginal.

Abernethy (1993) noted that the Commission office in Queensland had identified aneed for an independent advocacy service outside of the Health Commission itself.The service would advise the consumer on the Commission's resolution process.Abernethy argues that the current conciliation process only provides a safe guard forproviders.

3. 10 LitigationWhen there are not consistent methods of lodging complaints and having themaddressed, alternatives for consumers include going to the media, or if the legalprocess allows, taking a grievance to court and pursuing a process of litigation.

Systems that have severe limitations also force the complainant to seek alternativeforms of redress by involving the support of community agencies, or seekinglitigation, outside the health organisation in question (Hoithaus, 1988, Localio et al,1993, Sloan etal, 1989).


In Tasmania, Australia, minor claims or grievances were taken to the small claimscourt, but in cases concerning medical malpractice the cost of litigation lay with theconsumer (Caples, 1989, Department of Health, Tasmania, 1991).

By 1970 America saw an upsurge in malpractice claims, and a civil justice system infavour of addressing complaints financially (Hoithaus, 1988).

A result was an upsurge in unnecessary surgery. Research that looked into the linkbetween the rates of caesarean deliveries and the rate of medical malpractice foundthat there was an association between the two. It identified that defensive practices ofmedical practitioners, caused by their fear of malpractice claims, as a factorcontributing to the high rate of caesarean deliveries (Localio et a!, 1993).

Since 1970 physicians premiums have increased and the result has been an increase inthe number of malpractice awards. Today, because of this, every state withinAmerica has passed legislation (tort reform) to control the crisis facing the justicesystem and the resultant costs of physician premiums. These current reforms meantthat the courts could decide whether the consumer had enough collateral. If so theirlevel of compensation was reduced. This has been done as a precautionary measureto lessen the amount of claims in the courts.

California and Indiana have shown success in restoring a reasonable level of stabilityto the medical malpractice climate. They have employed systems of consumercompensation funds (ibid).

In general though, hospitals are insured by a private insurance company and each bedwithin the hospital has a rate of insurance, based on the policies of that hospital, andthe occurrence rates of medical malpractice and consequent actions taken in the eventof law suits (Localio et al, 1993).

Complaints were kept within the repository system of the Office of ProfessionalMedical Conducts (OPMC). This office acts to monitor complaints and the level ofpremiums within each hospital. They also serve to monitor the initiatives taken tolessen the occurrence of claims.

It has been identified that there were four measures of risk for the likelihood of amalpractice claim:

• the level of premium relative to the physician involved;

• geographic location is perceived as a likely risk;

• claims are made against hospitals regardless of their speciality, and;

• claims were either taken against staff as a group, or against individual staffmembers.


It was found that premiums were the most visible measure of risk, and the life of amalpractice claim can usually last for several years. Localio (1993) argues that theinsurance paid out to complainant acts to insulate the physician financially. Hence theresult of paid claims rarely produces any significant change to medical practice orpolicies.

A Harvard Medical Practice study in the state of New York (1990) found that therewere eight times as many people who suffered an injury from medical malpractice asthere were the number of malpractice claims. Only half of those who registeredclaims with the OMPC actually received financial compensation through the existingtort system.

The OMPC have included those complaint that could be regarded as potential claimsalongside those that are formal claims. Providers have access to the OMPC registerto investigate a case prior to potential claim even being recorded as a formal claim.

Claims that are registered with the OMPC as either 'potential or observation claims'are referred to as "risk management". This study has revealed that such randomregistering of claims actually only served to inflate the situation for both the consumerand the provider. This study has shown that many potential claims do not eveneventuate. There are many reasons for this. The most frequent reason was that theappropriate information had not been received by the OMPC. A consumer mayreport a complaint to the OMPC, but if it is not considered by the OMPC to be aformal complaint then no further action will taken. Such claims were referred to as"incurred claims", meaning that the consumer had notified the OMPC but not theprovider concerned.

The levels of compensation and redress for the consumer varies from state to state inAmerica. In cases of medical malpractice it depended on the verdict of a jury as towhether the complainant would receive any financial compensation (Holthaus, 1988).

These reforms needed to be able to reflect a legitimate goal for each state, within theframework of government policy, such as improving the availability and theaffordability of insurance (Hoithaus, 1988).

3.11 Going publicIn extreme cases where a lack of explanation has been given to the consumer, or whenthe process of investigation was prolonged, this has lead a consumer to subsequentlytake their complaint to the media. In such cases it was observed that the hospital'sresponse was invariably one of haste and a speedy investigation (Unattributed, 1991).

Chapter Three: International Models 2.9

The Cartwright report

An official inquiry in New Zealand followed the publishing of an article by PhillidaBunkle and Sandra Coney, in Metro magazine, (June 1987). The story was told, ofwomen who were unknowingly victims of a medical experiment, and whosubsequently died. As a result of this, there was a public inquiry, instituted by thegovernment.

Results of the Cartwright report (1988), were for recommendations for standards oftreatment protocol to be developed, the appointment of a Health Commissioner, andthe introduction of consumer advocates, and interpreters. There was also therecommendation for a code of consumer rights and a recommendation that treatmentprocedures be subject to the informed consent of the consumer (Adams, 1991).

J,.

A study evaluating the formation of consumer advocacy services at Green LaneNational Women's hospital (Macky, 1991) found that advocates were fulfilling a needfor representation in the area of consumer rights.

Common issues, and reasons why there was a need for consumer representation at thishospital, were requests for:

• access to medical records;

informed consent;

privacy and confidentiality;

considerate and respectful care;

• full information about a consumer's illness and the treatment they are to receive,and;

• complaint resolution.

This study also identified the role of the advocate in influencing the development ofpolicy and service management. Areas of concern included:

• acceptability of the consumer having a support person;

• access to medical records;

• administration issues especially relating to appointments with physicians beingkept, and;

• respect of religious beliefs to be respected and upheld.

Macky has indicated that consumer satisfaction can not be measured by the provisionof advocacy services alone. Research has revealed that only two thirds of allconsumers who utilised advocacy services were satisfied that their needs had been


met. Reasons why consumers tended to be dissatisfied with the outcome of theircontact with an advocate were often due to the fact that their comaplaint had been leftunresolved. Hence, consumers dissatisfied with the complaint resolution process didnot resume contact with the advocacy service.

Macky recommended that the only way complaints can be fully resolved to thesatisfaction of the consumer is if the system allows for greater interaction betweenadvocates and those who investigate complaints. A lot of dissatisfaction resulted fromthe amount of time it took before the consumer received any reply to their complaint.

This study has shown that for advocacy services and complaint procedures to beutilised fully they need to be publicised adequately. It was the recommendation thatthe present advocacy service for maternity and gynaecology consumers be retainedand developed further.

Chapter Four - Key Issues for Consumers

When implementing systems for addressing complaints, it has been shown that it wasimportant to recognise the various types of complaints and the level of attention theyrequire. In many cases the consumer may want some form of compensation, notalways financial. It may be just some recognition and an apology for the pain orinconvenience they have endured and the assurance that it will not happen to anyoneelse.

4.1 Hospital complaint issues

There are a number of complaints made in hospitals. Some of the issues include:

. the amount of time a consumer spends waiting;

. consumers may complain about their bills, or the kind of reception they received;

relationships between members of staff and the consumer;

• the consumer may feel that their needs were not being met, ie: not being listenedto;

- • not receiving enough information about their condition or the medical or surgicaltreatment they were going to receive, and;

• the consumer experienced adverse outcomes as a result of the treatment theyreceived.

4.2 GP complaint issues

The following issues have been identified as the main reasons for complaints againstdoctors in general practice:

failure of a doctor to visit;

- • failure to diagnose;

• late diagnosis given;

• the administration and organisation of a doctor's practice;

• waiting times;

• lack of privacy;

• lack of communication;

Chapter Four: Key issues for consumers 32

• failure to arrange an emergen'y admission to hospital;

• prescription errors, and;

• the cost of treatment.

Owen (1991) has noted that the most common reason for actually complaining is toensure that the same thing will not happen again to another consumer.

4.3 Mental Health complaint issues

Karjewski et a! (1992) have identified the following areas of concern for residentswithin mental health institutions. These issues must be addressed when implementingsystems of redress for consumers and their families or guardians:

• an infringement on the human rights of the consumer in relation to their treatment;

• abuse;

• the environment of the institution;

• privacy and personal belongings;

• communication with staff;

• confidentiality;

•a lack of outside visits;

• neglect, and;

• food.

4.4 Disability complaint issues

Issues relating to services for those with physical, intellectual, and sensory disabilitiesinclude:

•living situation (privacy, food, clothing, and bedding);

•social communication (speech and leisure activities);

•independence (self reliance, lack of choice), and;

•physical skills (occupational and social).


Common themes

In general most complaints arise out of the consumer's need for:

• respect;

• correct information on treatment and the services available;

• prompt attention to inquiries;

• friendly service;

good communication with providers;

confidentiality, and;

• cost of treatment or consultation.

AThere are certain identifiable aspects of existing complaints systems that can becomeobstacles for the consumer:

overall accessibility to the process, (language), and;

time limits given when lodging complaints.

4.5 Advocacy.

In caring for residents of institutions such as the elderly or mentally impaired, it hasbeen identified that institutions can have a depersonalising affect on the lives ofresidents. The introduction of independent advocates helps to bridge the gap betweenresident and staff.

Often there are differing levels of judgement to be considered in these situations Themain issue to consider is whether the competence and autonomy of the resident are atstake. The absence of relatives, or of advocates, can sometimes lead to an attendantloss of civil rights for the consumer (Working group on legal issues.. 1987).

Sang and O'Brien (1984) have identified the need for residents and advocates withinlong term residential care to be able to choose each other without cause for any"social engineering", or imposed rules of selection from within the institution.

Institutional care can be characterised by "tensions arising from contradictory forcesand situations ", and the advocate could be involved in gaining information for theresident and offering support in areas where there may be an infringement of theresident's rights responsibilities. Advocacy alliance works when there is anestablished friendship between advocate and resident in a relationship that does notcompromise the independence of the resident.

I


In general throughout health care services, advocates need to encourage and tosupport the consumer in the complaint resolution process. An advocate may be theonly person a consumer has initial contact with. T,hey may need to provide all therelevant information to the consumer about the complaint resolution process.Interpreters are also needed to ensure the voice of the consumer is heard within anyhealth care setting.

Much of the literature stresses the importance of including many member of staff inthe complaint resolution process, so that the complaint handling itself does notbecome the sole responsibility of the advocate alone.

4.6 Cultural sensitivityConflicts resulting from a cultural difference often go unnoticed as ethnic groups facesystems that do not respond to their needs.

Complaints that have been discussed in the literature have been identified bycommunity groups representing ethnic populations, and in particular women fromthese communities (Kalsi, 1989, Cornwell, and Gordon, 1984). The primary reasonfor complaints was a lack of communication. This happened even when staff andconsumer spoke the same language. Hence the problem was greatly increased whenthere was a' language difference.

Cornwell and Gordon (1984) categorised community health schemes designed toaddress these problems into those that are seen to be supportive, and those that areoppressive in addressing the grievances of ethnic groups in the community.

Oppressive schemes were described as only fulfilling the service of interpretation.This was very limiting to the resident as it only served to represent the resident in oneway which did not relay the grievances of a resident to the provider.

Supportive services were a combination of both interpretative and advocacy services.They included the following:

• accountability to the community rather than the providers;

• shared knowledge with residents rather than guarding it from them;

• workers were chosen for their commitment to social justice, and concern ratherthan their qualifications;

• training was flexible and designed to meet the needs of the community and thesituation in which they work, and;

• offered a practical service.

(Cornwell and Gordon, 1984)


A survey of the Asian, Afro-Caribbean, Cypriot, Greek and Turkish elderlypopulation within the Haringey region of London, the main areas of complaint orconcern were identified as:

difficulties in communication;

• inappropriate institutional diets;

• shortage of relevant religious ministers

(Kalsi and Constantinides, 1989).

Recommendations from the development worker to overcome these complaints were:

• more bi-lingual staff;

the availability of ministers from all religions;

the translation of resident information into the different languages, and;

the improvement of accessibility of information, including visual and sonal media.

Cornwell and Gordon (1984) have argued that there are fundamental structuralchanges needed within any health organisation to create equal opportunities.However these will only be effective when the entire health service is madeaccountable to the community it serves. Identifying the values and social organisationof groups within any community helps to:

encourage cultural and religious awareness, and;

alleviate the confusion and lack of communication that often arises, whendealing with any grievance (Cornwell and Gordon, 1984).

4.7 Consumer rights

The Citizen's Charter

A code of patient's rights was introduced as part of the Citizen's Charter in Britain in1992. The ten consumer rights given included the right to a prompt written replyfrom the chief executive or the general manager in reply to any complaint about theNational Health Service. One of the major themes of the Patient's Charter was theimportance of informing citizens of service standards and what to do if they wereunacceptable.


Mechanisms for achieving this were identified as:

• comprehensive publication of information on standards achieved;

• more effective complaints procedures;

• tougher and more independent inspectorates;

• better redress for the citizen when things go wrong,

(Barraclough, 1992).

The government envisioned that the implementation of these mechanisms would bemade at a local level and made specific to their locality. Such specifics with regard toany local community are mentioned in one of the nine National Charter Standardswithin the Citizen's Charter, which included respect for:

• privacy;

• dignity, and;

cultural and religious beliefs.

These and other principle elements of the Patient's Charter were expected to beincluded in information on services provided by public hospitals and general practices(The Patient's Charter 1992, Barraclough 1992).

The Citizen's Charter sets out a series of rights and reasonable expectations, oravenues to be considered by health service providers, when dealing with complaints.

Barraclough (1992) has argued that this Charter only reaffirms a conservativegovernment's approach to individualistic consumer-provider service. This fosterscompetitiveness amongst providers but does not encourage a system that allows formethods of community evaluation of services. Nor can the system can guaranteecollective accountability from the medical profession itself. While these most recentreforms have stressed the delegation of power and responsibility to the local level, thebroader health policy still remains within the realms of central direction (Barraclough,1992, Davies, 1993).

The only legal force behind these rights were that they are governed by the existinglegislation that protects the confidentiality of a consumer's records. In general thecharter only expresses desired outcomes and there are no sanctions provided for, inthe event that these rights are not met (Barraclough, 1992).

Another example mentioned in the literature, where a consumer bill of rights had beenused was in the states of Minnesota and Massachusetts. The law required this bill tobe publicly displayed for consumers, and copies given to consumers on admission tohospital (Ednie, 1986).


One common theme within legislation, is for the provision of adequate information onthe grievance procedures available to the consumer. Information needs -to be freelyavailable and easily visible through-out the organisation. Part of ensuring theprovision of information is to ensure the provision of advocates. Consumer advocateswithin mental health services and services for the elderly, have needed legislation tobe fully accepted within the institutional structure (Working Group on legalissues.. 1987, Forster and Vyslouzil, 1991).

"Advocacy services inc" in Queensland offer the consumer an independent service andrepresentation for the consumer when complaints were refered to the HealthCommissioner's office. This group make reports and submissions on behalf ofdisadvantaged groups. They also produce a wide range of information on grievanceprocedures available to the consumer.

"Advocacy services inc", have questioned the Health Commissioner's office about thedissemination of information provided by the Health Rights Commission on complaintresolution processes and the levels at which they are reviewed, ie: legal, justice,personal, social. This group have expressed concerns about the lack of safeguardswithin current resolution processes, needed to ensure confidentiality, impartiality, andlegal representation (Abernethy, 1993).

4.8 Geographic implications.Geographic issues need also to be considered when analysing the rate of consumercomplaints, and the level of consumer satisfaction or dissatisfaction within rural areas(Hart and Weingarten, 1986).

If the consumer had no other experience of a health provider within their district, thenthey as individual members of their community had no guarantee of quality assuranceother than the provision of a system that adequately addressed their concerns. If thehealth provider had a system that had a proven ability to respond to the needs of thatcommunity then, not only would the health provider be able to more easily assess thelevel of consumer satisfaction, but the consumer would also feel less inhibited aboutcomplaining (ibid).

Community health councils or other such consumer advocacy services were greatlyneeded within both urban and rural areas both to represent the consumer at anyhearing, and to ensure that the complaints process is publicised adequately enough andto ensure that the consumer receives the appropriate and necessary information


4.9 Developing appropriate complaint proceduresComplaint systems that are easily accessible to the public and easy for the consumerto follow have benefits for the provider as well. The consumer should know whereand to who to approach with their grievance. The provider should know what processis needed for each kind of complaint. Procedures that are simple to follow willultimately save time and money for the provider. Complaint systems need to:

• set reasonable time limits for reporting complaints, as well as providing theconsumer with outcomes;

• provide clear and adequate information on the complaint resolution process;

• assign either a designated officer, or provide an independent complaint unit;

• include medical staff in the resolution process, and;

implement a system of consumer advocacy.

Researchers have identified that when complaint systems become too complex, theresultant system is:

too slow;

too complicated for consumers;

difficult to know who to complain to in the first instance;

• one that demands the consumer to complain to more than one official body beforereceiving any reply;

• very hard to get information, or access to information about the complaintresolution process;

very unsatisfactory for the consumer, and;

defensive.

(Unattributed, 1991, Longley, 1992, Stacey, 1993, Payne, 1990).

A complex system requires the consumer to take charge of their grievance themselves,to keep a record of all contacts, and the names of everyone involved, to seekindependent advice, or representation. Often the system in place, or lack ofcomplaint handling procedures can seem too daunting or discouraging for theconsumer (Unattributed, 1991).

Chapter Five - Key issues for Providers

Just as there are passive and active complainants so too are there passive and activecomplaint systems.

As has been shown there are vast differences between systems that were implementedwithin hospitals as a part of their organisational structure and those that required theconsumer to report their complaint with either the Minister of Health, or otherprofessional body, to pursue a process of litigation to achieve satisfaction.

Providers need to recognise that consumers complain so as to be heard, in the beliefthat they might have an impact and influence positive improvments in service. Whileit may be difficult to judge the main types of complaints and their frequency,complaint resolution processes can work towards identiying trends and areas inservice which need improvement.

Between 1989-1991, a survey of four health authorities in the inner and outer Londonarea rural and city districts, looked into the responsibility taken for the establishingand monitoring of complaint handling guide-lines within the NHS, in Britain.Interviews were conducted with the Department of Health, community healthcouncils, and the Association of Community Health Councils (Longley, 1992).

This study examined the Department of Health's guide-lines as well as a randomselection of complaints from each Health Authority. Complaint systems wereexamined on the basis of the amount of time it took to respond to a complaint as wellas the time taken to resolve a complaint, the processing and screening of complaints,the information and explanations given to consumers, and the action taken to preventany recurrence of complaints.

Overall this study found that complaints had a low priority in the managementstructure of these hospitals. With regard to the handling of complaints in general, thereceipt of complaints was quick. However the procedures failed to deal with manyserious complaints because of the strict adherence to the time limit for registeringcomplaints. Complaints had to be registered in three weeks. On average theresolution process took 7-8 weeks, though many were outstanding for months.Longley argues that the primary need in these procedures was for a well publicised,clearly communicated procedure. There needed to be a recognised point of contactfor the instigating and the investigation of complaints, as well as the monitoring ofthem.

While there was an officer appointed specifically to instigate the investigation ofcomplaints, in general the practice was that anyone could be approached. Thishowever, often lead to confusion, delays, and the duplication of effort taken, andrepetition in the recording of complaints. This was especially noticed when a hospitalward was housed on more than one location.

Chapter Five: Key Issues for Providers 40

It was found that despite clinical procedures being different, all complaints tended tobe processed the same way. Longley argued that clinical cases were the most difficultto resolve because medical staff acted defensively and were hesitant to hand overreports and other relevant information to be used in the investigation of suchcomplaints. Consequently this caused great delays.

While it was noted that there were personal phone calls with complainants early in theprocess, and that meetings were arranged between all parties, such interviews with thecomplainants were not greatly encouraged by the medical staff. The consumer wasgiven no indication as to whether they could bring any friends, or a CommunityHealth Council officer along with them.

One of the most prominent criticisms of the systems surveyed was the lack of stafftraining and poor communication between staff and management with regard to howcomplaint procedures were to be publicised and who consumers were to be referred to(Owen, 1991). This has been reiterated in a series of guidelines published for nursingstaff, midwives, and other health visitors. The role of the nurse was described assimilar to an advocate, in that it was their right to act on behalf of the consumerconcerned. They also had a duty to maintain confidentiality at all times.

If a complaint was about a member of staff, then that member should also have theright to their own form of representation (Nursing Standard, 1992).

It was identified that consumer vulnerability over their right to complain was a directresult of the structures or lack of, established by providers, within the health systemto address complaints. Complaint systems and their success or failure to addresscomplaints, was also reflected by the legislation in place or lack of legislation(Caples, 1989).

Providers need to recognise that a complaints system works effectively if:

• it responds to alternatives and new means of resolving complaints;

• recognises the degrees of complexity and severity of complaints;

• the reporting and investigation of complaints includes an impartial andindependent process of evaluation and resolution;

• medical staff and consumer representatives could negotiate through formal meansof conciliation;

• it acknowledges that complaints are not going to always be reported via formaldocumentation;


. it resolves complaints at the lowest level;

litigation were avoided, and;

there are no delays, lapses of time, or extra costs incurred.

5.1 Collecting and analysing data.It is important that complaints are registered and documented correctly. Complaintdocumentation needs to be accurately recorded for future reference in theinvestigation of any complaint. Data can also be used to evaluate the service of anyprovider, and to determine the patterns of complaints. Such information can then beutilised by management when analysing the levels of consumer satisfaction, and whenassessing improvements needed within the service. The key principles behind theefficient use of complaints data are:

clarity;

categorisation of complaints;

• identifying complainants, identifying patterns;

• standardised record keeping of complaints;

• correct documentation of recommendations and resolutions, and;

accessibility of data, ie: summary sheets.

If complaints are not accurately recorded, or the investigation has not been clearlydocumented, this can result in a problematic system:

poor record keeping;

unavailability of information for people conducting the investigations;

too much reliance on computer analysis, and frequency data, and lack of personal- input from staff and consumer;

lack of essential information needed to proceed with investigations;

• poor definitions of complaints, inquiries and minor concerns not dealt with in theinitial stage of complaint resolution, and;

• difficulties in determining the levels of consumer satisfaction and areas of servicethat needed attention.

(Longley, 1992, Stacey, 1993, Owen, 1991, Truelove, 1985, Netting et a!, 1992,Hudspith, 1993)

:2


Researchers have identified that often providers and health authorities who monitorcomplaint systems, put more emphasis on how complaint procedures keep track of theorganisational structure of their hospital and less on the actual reporting and followthrough of complaints (Longley, 1992, Stacey, 1993, Owen, 1991).

When there was a problematic system of recording and analysing data, complaintswere addressed by the provider, but there still remained only a minimal level ofcollective accountability.

There was an identified lack of emphasis placed on how complaint procedures couldreflect or influence the policies of the health provider. Few Health Authorities gavestaff training on the handling of complaints (Longley, 1992).

When there was a lack of the essential information needed to proceed with aninvestigation or when summary sheets were not completed, this defeated the objectiveof the entire system (Longley, 1992, Netting et a!, 1992). These inherent problemsreflected a passive approach to complaints.

It has also been emphasised that any investigation should not rely entirely on thewritten complaint. Staff and complainant need to. be interviewed, so that theperceptions from each side can be better understood. It is often far too easy to offerthe complainant a written reply, rather than meeting them face to face to discuss theirconcerns (Truelove, 1985).

Research examining the long-term care of elderly consumers in America, identifiedthat while there was a systematic process of reporting complaints and the investigationof complaints to health authorities, the categories of complaints reported did notreflect the varying kinds of facilities, nor how these affected the types of complaintsreceived (Netting et al, 1992).

There was also an inherent difficulty distinguishing between the levels of complaintresolution and consequently the level of consumer satisfaction; or to whosesatisfaction the complaints were resolved. Complaints were not always resolved tothe satisfaction of the resident/consumer.

Hence because of these inherent difficulties of gaining clarity within the system, itwas what these reports couldn't tell practitioners, researchers and policy makers thathad been the main problem. Complaints about the level of resident care needed to beclearly distinguish from complaints regarding resident rights.

The collection of data as a means of measuring consumer satisfaction andstandardising codes of practice, was identified not only as an issue for managementbut also for consumer representatives. It has been argued that Ombudspersons andadvocates need to recognise the importance of data analysis as much as management(Hudspith, 1993, Netting et al, 1992).


Commentators observe that, along with a separate record of complaints, a summarysheet or report of all complaints should be prepared by the designated complaintsofficer at least annually. This should then be made available to the public and tostaff. It should include in the report ways the provider proposes to improve the levelof service given (Nursing Standard, 1992).

Netting et al (1992) argues that information and data regarding the frequency ofcomplaints, and how those complaints were dealt with would not only help developregional standards, but also provide comparative data on a national basis.

5.2 Complaints against G. Ps and Physicians/hospital staff

Much of the criticism of the procedures taken when lodging a complaint against a GPor a hospital physician were that the procedures were too entrenched in the medicalprofession itself, and that investigations did not provide the consumer with animpartial resolution process (Stacey, 1993, Owen, 1991).

GPs

Complaint procedures against GPs need to assure the consumer that: -

their complaint is justified;

all complaints will be heard;

investigations into all manner of complaint including cases of medicalincompetence will ensure impartiality;

• procedures are easily accessible to the consumer;

• systems of redress are easy to follow and clearly communicated to the consumerthrough-out general practices;

• there is a system of peer review;

• lay representatives of the consumer and community groups can be consultedwithin the resolution process;

• there are open conduct procedures, and that;

• their future care with that provider • will not be jeopardised.

(Owen, 1991, Stacey, 1993, Klein, 1973, Longley, 1992, Geefen, 1990).

Systems that fail to address these issues are:

• confusing for the consumer;


time consuming and costly for consumers and GPs;

biased toward the medical profession, and; I -

unbalanced in the representation given to the consumer and the GP.

Owen (1991), Stacey (1993), and Longley (1992) have all observed that RegionalMedical Officers and the General Medical Council (GMC) in the UK who monitorcomplaints against GPs have failed to resolve complaints at a personal/local level.

While it is the's statutory duty to investigate doctor's competence, in general ithas only been the most severest cases that have been bought before the committee.

Stacey (1993) argues that even with changes to see more cases being brought in frontof the committee, any disciplinary action has tended to be comparatively lenient. Thissuggests that the GMC does not treat complainants as being of equal worth withdoctors. She also suggests that because of the complex complaint procedures atpresent the complainants sense of grievance is often escalated because of the verycomplexity of the system.

"Complainants have no idea where they should turn first. The proceduresappear as a jungle and their profusion is a 'multiple hazard for doctors"(Owen, 1991).

Independent review

Geefen (1990) has identified that independent reviews were often only needed becausethere had been a lack of communication between the consumer and medical staff.

Commentators observed that for many consumers their first meeting with the RegionalMedical Officer (R.M.0) was the first time they had had to discuss their complaintfully. Geefen argues that in this system, independent reviews were often unnecessaryand could be viewed only as a costly form of auditing. This process was also timeconsuming in the amount of administrative work required.

Stacey (1993) has emphasised the need for impartial and independent investigations ofcomplaints, to avoid independent reviews.

Currently the GMC has no statutory obligation to investigate complaints of a seriousnature. They were under no statutory obligation to ensure that any health providernow to submit to any code of consumer rights, nor were they legally bound to havelay representatives on their medical boards for any process of peer review; unlike thecommunity health councils who do have lay and medical representatives involved incomplaint hearings. Therefore, while general practitioners remain relativelyindependent, the process for the investigation of complaints remained entrenchedwithin the system.


Peer review

One way to examine the level of impartiality within the resolution process was asystem of peer review. While professional peers could provide examples of improvedservice for the consumer and were in the position to judge medical competence,system of peer review was viewed as not working to the benefit of the consumer.

There was also a recognisable and accessible system of conciliation and arbitration forall other disputes, excluding cases of professional competence (Stacey, 1993, Klein,1973, Owen, 1991).

Klein (1973) argued that professional competence and standards of medical carecannot be the by-product of any complaint or disciplinary process.

Stacey (1993) has identified that self-regulation worked only to a degree, as peersunderstood the nature of medical complaints and their criticisms may have be acceptedmore readily than those of outsiders. As this current procedure stands, it does notappear to provide the complainant with adequate personal redress, but was thereprimarily to improve and to monitor doctor's standards. This cannot be publiclyacceptable unless complainants are seen to be treated with equal worth as therespondent doctor.

Hospital staff

When lodging a complaint against a hospital physician or other members of staff, thesystem of redress should assure the consumer that:

• complaints will be investigated promptly;

• resolutions will be made as soon as possible;

• they will be informed of the proceedings and outcomes along the way;7

• information is given, stating clearly who to complain to;

• the medical professional will be required to participate in the investigation;

• all relevant information is available, and;

• complaints of a clinical nature can be dealt with out of court.

(Tribe, 1990).

Tribe (1990) argued that in Britain, systems for addressing clinical complaints neededto be standardised because currently they were not affected by the Hospital


Complaints Procedure Act, which oversaw all other cases of medical complaint. Itwas identified that system were:

• fragmented;

• investigations took too long, and;

• biased toward the medical profession.

(Tribe, 1990, Longley, 1992, Geffen, 1990, Unattributed, 1991).

In 1982 the Association of Community Health Councils in Britain passed a resolutionon the introduction of a "no-fault" compensation fund for the victims of medicalmishap similar to Accident Compensation schemes. This applied to both GPs and toHospital physicians.

Tribe argues that this would only apply to hospitals if there was already an effectivecomplaint handling procedure in place within hospitals. Such a system soughtcompensation for the consumer in relation to their needs and not purely in regard tothe level of fault involved (Tribe, 1990).

Sloan et al, (1989) argued that research in America showed that physicians inhospitals with adverse claims experience were less likely to make subsequent changesto their practices, such as quitting practice or moving to another state. Sloan et alhave observed that physicians were refusing to accept "high risk" consumers. Theywere also retiring earlier leaving specialist fields such as obstetrics. In practice theywere ordering more tests than were medically necessary so that in the case of alawsuit, they were able to defend themselves as much as possible. It was noted thatfewer than 10% of physicians with adverse claims were disciplined in any manner.The view was that traditionally State Medical boards have been reluctant to addressphysician incompetence (Sloan et al, 1989).

Hoithaus (1988) suggests that litigation in America could be avoided if contracts wereimplemented between health providers and consumers. These could be entered intoeither before the provision of care or after the event of an alleged wrong doing. Theadvantages of this system were identified as:

• a reduction in legal fees;

• a decrease in the level of defensive medical practices, and;

• reduced medical costs.


Hoithaus maintains that if such a system were introduced there would still be a needfor advocacy. Arbitration and compensation at the provider level was maintained asthe best alternative to litigation within America. Complaint resolution proceduresrequire:

• independent complaint units, and;

• the utilisation of consumer representatives.

Implementing complaint resolution processes is the responsibility of health providers,concilliation and arbitation processes to resolve consumer's grievances are necessaryfor building a basis of trust between consumer and health provider.

Chapter Six - Outcomes

6.1 Policies

Complaint systems ultimately reflect the policies and standards that precede them.Policies need to consider many areas:

cultural sensitivity;

• the parameters of complaint resolution procedures;

• the definition of complaints;

• delegation of authority to staff to handle complaints;

• staff training;

• the employment of independent advocates, complaints officers, or designated staffmembers to represent complainants;

• legislation, codes of practice, and consumers rights;

• accountability of staff and health providers, and;

• the types of systems to address complaints with regard to the types of servicegiven.

(Promoting better health, 1987, Holthaus, 1987, Barraclough, 1992, Eddy, 1990,Kalsi and Constantinides, 1989, Cornwell and Gordon, 1984, Klein, 1973).

Eddy (1990) defines policies for management and staff, as either:

standards;

guide-lines;

• or options.

Problem areas, resulting from inadequate policies have been identified as:

• a lack of adequate complaint resolution procedures;

• the leaving the evaluation of complaint procedures to the outcomes andrecommendations of independent research alone;

• lack of flexibility to invite new initiatives for resolving complaints

Chapter Six: Outcomes 49

• lack of stimulating research as a means of reviewing the initiatives introduced intothe process;

• rigidity of criteria for consumers to follow when lodging complaints, as well as inthe investigation of complaints, and;

• too much uncertainty, and variability of outcomes.

(Caples, 1989, Holthaus, 1988, Barraclough, 1992, Eddy, 1990).

Hospital management must be responsive to the various preference needs in outcomesfrom different consumers, and those desired from practice policies (Hoithaus, 1988).Both GPs and public hospitals need to be accountable to the individual consumer, andcollectively to the wider community. Complaint systems need to provide some wayof assessing how professionals interpret and carry out their responsibilities for themaintaining of standards (Klein, 1973).

"Accountability implies obligation on the professions to explain and justifywhat they do-both as individuals and as organisations-to a world at large"(Klein, 1973).

This theme is reiterated in other sources. Complaint systems need to be made moreaccountable to the needs of the consumer. To do this they need to be independent ofthe Department of Health, or any centralised governing body (Caples, 1989).

In 1986 the British government issued a paper proposing a number of ways toimprove the complaints system in the NHS. It's recommendations were:

• that oral complaints should be accepted, subject to certain conditions to safeguardimpartiality. ie ; the FPC officer who records the complaint would be excludedfrom the rest of the proceedings;

• the time limit for registering complaints was extended from 8 weeks to 13;

• the quorum for the hearing of complaints was increased from one lay and oneprofessional person to two, and;

• complainants could be represented by the CHC.

(Promoting better health, 1987)

The emphasis of these reforms was on improving understanding, and seekingconciliation to resolve matters at the most personal level.


Cultural awareness

Staff training was identified as a crucial factor in alleviating communication problems,especially between minority groups and staff. Just as there was an identified need formore female doctors for female consumers, so too was there the need for moremembers of staff, including advocates, and language interpreters from the differentracial groups of any community (Localio et al, 1993, Hart, 1986, Cornwell, 1984,Kalsi, 1989).

Both Kalsi and Constantinides (1989) and Cornwell and Gordon (1984) emphasisedthat cultural awareness could not be implemented through policy alone, unless itinvolved the active participation of people of different cultures from within thecommunity.

Kalsi and Constantinides (1989) observed that in the Haringey project there wereadvantages in having development workers representing ethnic minorities within anyhealth provider organisation. However there were also disadvantages with thissystem. The development worker must not become the repository of all concernsdealing with ethnic groups, even though they are able to work in areas that are notreadily open to other Health Authority workers. Their role was primarily to facilitatedialogue between providers and consumers, to exchange ideas from HealthAuthorities, local authorities and the voluntary sector.

Holthaus (1988) argues that within health service in America, policies which inviteintervention will alert the physicians and the consumer to any lack of informationwithin the resolution process. This will help to keep the process actually within morerealistic terms, and expectations. Such policies may even decrease the threat ofmalpractice, or media publicity.

Eddy (1990) emphasised that while it was difficult to discuss preferences andoutcomes with consumers, in the end involving the consumer in the decision makingprocess to some extent, would increase customer satisfaction and work towardspreventing various occasions for complaint.

When standards of care are clearly defined by the provider, and there is a sense ofownership from that organisation then systems for addressing complaints can also be"owned" and come under the definition of 'good practice' (Holthaus, 1988).

6.2 Standards

Codes of practice have been implemented within a number of services. Codes ofpractice are a means of:

monitoring and standardising systems of complaints;

establishing a bill of consumer rights;


ensuring positive outcomes for the consumer, and;

• enduring that the process of investigation and resolution are kept within onelocality so that complaints can be dealt with in the least amount of time required.

Standards, codes of practice and a consumer's bill of rights can be instigated via:

• legislation, or;

• independent commissions.

Standards or codes of practice not only remind the provider of their set goals, andensure the consumer of level of service. They also serve as means for healthauthorities to monitor and evaluate systems implemented by providers. The problemareas were identified as:

ways of enforcing standards;

ways of measuring hospital performance;

• consumer rights for the elderly and mentally ill;

• means of guaranteeing independent evaluations, and;

• co-operation between providers and authorities in independent evaluations andmonitoring.

In 1989 the Joint Commission on Accreditation of Health Care Organisations(JACHO), in Chicago set a code of standards for hospitals when dealing withcomplaints. These standards required systems to:

provide a mechanism for the receiving of complaints;

•

ensure that consumers were informed of this mechanism and of their right tolodge a complaint;

• ensure when the appropriate action was taken, the complainant and theirfamily were to receive a response from the organisation that substantiallyaddressed the grievance, and;

•

ensure that the lodging of a complaint would in no way jeopardise the futurecare of the consumer (Koska, 1989).

The only pitfall with this, was that JACHO could not legally enforce such standardson any service provider, and they themselves did not request the copy log ordocumented responses to any complaints of the organisation. This meant that theprocedure did not come under any process of evaluation from the JACHO system.JACHO emphasis was on the instigating of a process and not the evaluation of it.


There is a need to see evidence that hospitals receiving complaints were doingsomething to assess them and taking action at the appropriate times. In each case itwas the organisation that decided for itself the criteria for what it identified as asignificant complaint, and what they could or should do about it (Koska, 1989).

Official standards, guide-lines and legislation, do go towards ensuring that there is adegree of cohesion within complaint systems, as well as institutionalising complaintprocedures. However if there is no mechanism in place for a constant andindependent review of such systems then there can be no assurance given to theconsumer and the community in general, that the health provider is subject to aprocess of individual and collective accountability.

Codes of practice which act to monitor the standards of care given, need to beimplemented at a local regional level by district health authorities, local professionalcommittees, and family practitioner committees. These then act as a guide forprofessional and community groups who monitor such systems (Promoting betterhealth, 1987).

The advantages in having a code of consumer rights for example, are that consumersfeel less threatened by the system and more inclined to complain. This was anobservation made in relation to the Citizen's Charter in Britain where there was anincrease in the number of complaints reported once the Patient's Rights Charter hadbeen implemented. Codes of practice meant that when complaints were made thegrievance could more easily be measured to the level of service given. Complaintsbecame more justifiable (Butler, 1992, Davies, 1993).

Davies (1993) noted that consumers needing priority services, were not advantaged bythe Patient Rights Charter. In particular this included services to the elderly and thementally ill. It was emphasised that more legislation was needed to protect the rightsof these people.

"The priority services remain - with conspicuous exceptions - bastions of poormanagement, poor medicine, and poor care "(Davies, 1993).

6.3 Evaluation.

The general principles behind the constant and systematic evaluation of any complaintprocedure are to:

• provide a means of ensuring that the desired outcomes for providers, HealthAuthorities, medical boards, consumers, including staff, consumer representativesand community groups are met;

• assess the methods used to address complaints;

• monitor the level of consumer satisfaction with the outcomes of investigations;


monitor the frequency of complaints, and;

• assess efforts taken to remedy situations and to improve on services.

Commentators recommended that complaint systems in the UK should be reviewed bycommunity health organisations, services contracted to the Health Authority, and bystaff organisations (Nursing Standard, 1992).

In Britain the National Association of Health Authorities (N.A.H.A) has published acheck-list for it's members on the key areas that management need to concernthemselves with when evaluating their procedures for handling formal complaints.They are to check that:

policies are in place for the handling of complaints;

policies are frequently reviewed;

• management identify the underlying theme to their policies ie: is their approach adefensive one, focused on consumer rights or do they take a learning approach tocomplaint handling?;

policies are appropriate/freindly to all users;

include an awareness of different cultural issues;

providers review trends and patterns of complaints;

complaints are promptly dealt with;

procedures are monitored, and;

• adequate infromation is published for the consumer about the provider's polices andresolution procedures (Drummond/Morgan).

Feedback mechanisms for the evaluation of a complaint system can take a similarform to feedback mechanisms designed to survey consumer satisfaction. These are:

• consumer questionnaires;

• post-discharge telephone surveys, and;

• advocates and focus groups to monitor the progress or the regression of effortsmade to actively resolve complaints.

Within hospitals, data from consumer satisfaction surveys can provide the necessaryevidence for administrators about complaints, and statistical data from consumersurveys can provide back-up for consumer advocates when representing consumer'sconcerns (Koska, 1989).

I


In general it was agreed that the frequent evaluation of any organisations complaintsystem would not only preyent any debilitating problems to the system, but will alsoreflect whether or not the standards of care or levels of quality management whichhave been set by that provider were met (Leebov, 1990, Koska, 1989, Drummondand Morgan, no date, Nursing Standard, 1992).

Chapter Seven - The essential elements of acomplaint system

7. 1 Political will

To standardise complaint procedures within the health and disability sector it isimportant that there is sufficient support for:

• a code of consumer rights;

• codes of practice within services;

• methods of evaluation and monitoring of services by health authorities.

7.2 Management of complaints

Policies need to clarify:

• who develops the complaint procedure;

• levels of accountability within the complaint resolution process;

• delegation of authority amongst staff to resolve complaints;

• the approach to complaint resolution ie: a formal structure, or an informalprocess;

• format of procedure;

• remedial action to be implemented;

• methods of ensuring impartial investigation;

• method of determining when independent review, or further investigation isneeded;

• the type of procedures for various complaints;

• how information is conveyed to the consumer, and at what stage of the processthis happens;

• how information is conveyed to the provider, or person being complained about;

• the way that policies are conveyed to the public;

Chapter Seven: The Essential Elements of a Complaint System 56

• evaluation and monitoring of the process, is there a separate committee who dealwith this area?;

mechanisms for consumer feedback, as well as;

how to link complaint resolution efforts with quality assurance mechanism?

Policies will reflect the overall position of complaints within health services. It ismanagement's responsibility to advise the consumer whether or not the procedure fordealing with complaints is actually linked in with their quality assurance efforts. Thisin turn will affect the type of publicity used, and the efforts taken to gain feedbackfrom the consumer about the process.

7.3 Protocol

The protocol, and procedure of any complaint system will be determined bymanagement policies. Issues to consider when developing protocol/codes of practiceare:

• the nature of the complaint system. Is it formal or informal, or combined, howdoes this affect staff - consumer relations?; -

are complaints recorded verbally or written?, does the system permit both?;

• is there a designated staff member within each ward to deal with complaints, or anidentifiable unit/officer for complainants to approach, or an independent consumeradvocacy service that consumers can be referred to?;

accessibility of the system;

• levels of communication between staff, management, consumer advocate andconsumer;

• staff training in conflict resolution, and the;

• method of ensuring that the resolution process acts independently frommanagement, yet also a means of ensuring that complaints do not become the soleresponsibility or domain of the advocate or designated officer.


74 OrganisationsSystems for addressing complaints need to be standardised within services. These aresome of the issues to consider in relation to different health providers:

GPs

• clear and accessible information about the complaint procedure within practices;

• conciliation between consumer and doctor in the first instance, if appropriate;

• a system of resolving complaints prior to independent hearings, and to kept;

• open conduct proceedings especially in cases of medical misconduct and clinicaljudgement

HospitalsThere are three options for systems within hospitals. They are:

• the informal approach, which utilises a member of staff as a designated officerwithin each ward or unit to deal with complaints;

• a formally recognised complaints officer and an independent complaints unit, to beutilised by all members of staff and consumers;

• or if possible a combination of the two.

Both systems should require complaints to be handled within formal structures, bothto apply methods of conciliation and arbitration to resolve complaints, and to utiliseconsumer advocacy through-out the complaint hearing process.

Long-term careWithin services for the disabled, elderly and the mentally ill, there are issues whichconcern long-term care. It is important that systems for addressing concerns recognisethe permanent resident nature of many of these clients. These services mustimplement:

• long term consumer advocacy;

• interpretive services freely available;

• a code of consumer rights, and;

• arbitration and conciliation between staff, management, advocates, families andguardians.


In general these apply to all of the above services mentioned. It is especially notablefor the mental health and disability sector as there has been an evident lack of suchconsiderations, noted in the literature reviewed.

7.5 Procedures

Whether the procedure relies on a designated officer or an independent complaint unitthere are essential components within each. Much of the research has emphasised thata complaint system should require:

• complaints resolved within their locality, where appropriate;

• complaints of a clinical nature to be heard initially within an independent reviewprocess at the local level;

• the screening of complaints;

• prompt attention given to complaints;

• thorough investigation as fairly and quickly as circumstances permit;

• that the complainant and any persons complained about should be kept fullyinformed of reasons for unavoidable delay in resolving the issue;

• that any member of staff involved in a complaint should be fully informed of anyallegations, given an opportunity to reply and reminded to seek help and advice ofhis [her] professional association or trade union before commenting on acomplaint;

• the involvement of staff, as a contractual agreement;

• confidentiality;

• impartiality;

• independent advice/advocacy given freely to complainants;

• complaints of third parties are able to be heard;

• a system ensures that all parties will be heard;

• complaints given orally to be acknowledged;

• assistance given if the consumer needs help lodging a complaint;

• that any time limits should not in any way jeopardise the complainant;


• positive response from staff;

• accessible information on the complaint procedure, available in many languages,plus visual and sonal aids;

• cultural awareness, inclusion of extended family or community representativeswithin the resolution process;

• availability of religious ministers;

• the simplicity of the system and information provided, and;

• the procedure needs to be flexible enough for new initiatives in resolvingcomplaints to be taken, this means that any problem solving group includes theparticipation of independent reviewers, facilitators, staff and consumerrepresentatives.

(Kalsi and Costantinides, 1989; Cornwell and Gordon, 1984; Leebov, 1990; Ednie,1986; Barraclough, 1992; Cannel, 1990; Davies, 1993; Localio et al, 1993; Longley,1992; Stacey, 1993; Truelove, 1985).

Overall it has been observed that when a complaint is handled at the nearest level oforigin, the resolution of that complaint is more likely to be favourable to theconsumer, and the process less time consuming and costly for the professionals andprovider involved. The consumer's satisfaction with the service and the proceduresput in place is likely to remain or increase depending on the outcome.


• that complaints are documented accurately, and a copy made available to thecomplainant and the person being complained about;

• that records kept for investigation purposes;

• the complainants right of appeal to be clearly stated through-out the procedure;

• clear and accessible information on the resolution process;

• an agreed level of compensation based on the consumer's medical needs, given incases of medical malpractice. Compensation can come in many forms it may justinvolve recognition and an apology for any inconvenience of suffering, it may befinancial, the return of any costs, and so on, and finally;

• assurance to the consumer that their future access to health care with that providerwill not in any way be jeopardised. This concern is particularly emphasised withregard to rural communities, where there may be a limited choice of healthservices.

(Drummond and Morgan, no date, Unattributed, 1991, 1980; Tribe and Korgaonkar,1990; Stacey, 1993; Leebov, 1990; Longley, 1992; Netting et al, 1992; Owen, 1991;Payne, 1990; Ednie, 1986; Geffen, 1990; Hart and Weingarten, 1986; Barraclough,1992; Hudspith, 1993; Klein, 1973; Scott, 1985; Sloan et al, 1989; Ailsop, 1987).

The access and equity of any complaints handling service should be always questionedand assessed. The procedure must be stable, standards need to be set, outcomes mustbe realistic and fair for all parties.

There will be differences with complaints of a serious nature which will involve morepeople and may need to pursue some form of independent facilitation, or medicalhearing. Complaints that are purely administrative or do not involve any element ofclinical judgment should be resolved as soon as possible. Clear standards forprocedures will help facilitate the comparison and monitoring of complaints.

7.6 Client focus

When considering means of measuring consumer satisfaction, and linking these effortswith complaint resolution, it is vital that the needs of consumers are identified.Within any system for addressing consumer complaints there are certain areas ofservice that need to be considered:

• interpretive services (eg: sign language/total communication for the deaf, orlanguage interpreters);

• independent advocacy;

• advice and assistance in lodging a formal complaint;

Chapter Eight - Summary and Implications

Prior to the recent restructuring of health services in New Zealand, there existed afew Customer Relations Service units within hospitals. These units have dealt withboth verbal and written complaints as well as compliments. Quality management hasbeen the key focus for these services. In general these services only took on aninformative and preventative role (Manawatu-Wanganui, Area Health Board, 1992).

This literature review has emphasised the importance of implementing a complainthandling procedure which actually addresses ways of ensuring a high level ofconsumer satisfaction. This implies the need for a system which focuses on allaspects of service; from administration to personal staff-consumer relations.

Political will and legislation

Policies concerning the rights of the consumer that are developed at a national levelneed to ultimately reflect those being developed at the local level (WorkingParty.. .1993). A consumer code of rights and codes of practice need to set anddeliver reasonable expectations which benefit the consumer, and provide opportunitiesto the provider for improving service.

Codes of practice for complaint resolution, need to be a part of a contract betweenprovider and purchaser. They need to ensure that specific mechanisms, for reveiw,feedback, following up on the progress of investigations, as well as efforts made toimprove the level of service, are established. The role of the purchaser within thecomplaint resolution process, and the monitoring of such a process, needs to beclearly outlined at the contractual stage.

Management of complaints and accountability

This review has shown that through various kinds of systems, whether there is anindependent complaint unit or not, the success of the system really depends on theoverall policies of the provider, and the agreed contractual methods of evaluation orreview carried out by health authorities.

The management of complaints and their resolution, reflect the level at whichcomplaints are handled by providers, and the type of system in place to do this. Acomplaints resolution process can be measured by the assurance it gives the consumerwithin the documentation and investigation of complaints, and which providescomplete impartiality and independent representation.

Providers need to ensure the consumer that their future access health care will not inany way be denied. Providers need to recognise that consumers do not always lodgecomplaints for their own benefit entirely; it is usually to ensure that the same doesn'thappen to someone else. Every system for resolving complaints needs to provide a

Chapter Eight: Summary and Implications 62

policy for compensation based on the need of the consumer, financial or otherwise. Aconsumer may only wish to have recognition of their suffering and to receive anappology.

Provider based procedures

Research has indicated that when a complaint is handled within it's locality andclosest to it's point of origin then the level of consumer satisfaction is increased. Todo this means that all staff including, professionals (physicians, GPs and nurses) areinvolved in the resolution process from the start. Whether the system for handlingand reporting complaints is situated within an independent unit or at the discretion ofa designated member of staff, the protocol for such a process will be determined bythe polices of the provider.

It was clear through-out the literature that all complaint system's investigations needto be impartial, to ensure equal representation of both parties. This in turn ensuresthat out-comes satisfy both parties as much as possible.

Systems for dealing with complaints can be a combination of formal and informalprocesses, yet they need to be formally publicised for both the consumer and the staff.When implementing new procedures for complaint resolution it is important toidentify barriers within the system for consumers, such as a lack of consumerrepresentation, or interpretive services, to the overall publicity of advocacy andcomplaint resolution services.

It is important that the consumer is given a standardised complaint resolution process;one that deals with complaints promptly and in an efficient manner. All partiesinvolved in the resolution process need to be informed of their rights and progress ofthe complairt investigation at all times.

It was clear through-out the literature that all complaint system's investigations needto be impartial, to ensure equal representation of both parties. This in turn ensuresthat out-comes satisfy both parties as much as possible.

The relationship between the medical staff in hospitals and the consumer influencesthe consumer's decision to complain either formally or informally. Carmel (1990)observed that while informal complaints may actually convey the situation morecorrectly from the consumer's perspective, a formal complaint has a greater impactand results in more satisfactory outcomes.

The relationship between the members of staff and the consumer, was shown to alsoinfluence consumer satisfaction or dissatisfaction with the outcome of the procedure.Patient satisfaction was increased, if the consumer received a polite response fromstaff, even when there was no action taken (Carmel, 1990).


Advocacy

Consumer representation has been emphasised as a crucial part of the resolutionprocess. Advocacy services need to be independent of the provider to ensure theconsumer of true impartiality. Long term advocacy is essential for consumers of longterm care services. In general all consumer representation needs to ensure third partyrepresentation is available, as well as the provision made for lodging complaints ofthird parties.

Providing representation to consumers also calls for the provision of interpreters. Itis important that procedures are publicised to the consumer in as many languagesappropriate to the community served; and that facilities are provided for people whoare deaf, or who have hearing difficulties.

It has been emphasised within the literature that the provision of complaint resolutionprocedures must not be the entire responsibility of the advocate. Complaint resolutionis a responsibility of all involved in the process.

Implications for New Zealand

When implementing a complaint resolution procedure, providers need to consider:

•independent locally based advocacy services;

•provision of advocacy services to both urban rural communities;

•flexibility, within policies to allow the use of problem solving groups, and topromote a working relationship with a variety of consumer representatives;

•cultural awareness, and the;

•requirements within contracts, for providers to demonstrate the proceduresthey have undertaken to resolve complaints.

Differing cultural perceptions of health, for example, the emphasis placed on theholistic elements of a persons health (mind, body, and spirit) need to be acknowledgeby any system that addresses consumer grievances. Such knowledge needs to be thecentral focus of any system for resolving complaints. Providers also need to addressreasons why people of different cultures may not complain and view the system asalien to their needs. It is important that community representatives and elders, areinvolved in the development of policy in this area (Kawa Whakarurhau, 1990).

The policies of Health institutions and the concept of cultural safety are thusinterlinked duties implicit in the Treaty [of Waitangi] itself (KawaWhakaruruhau, 1990).


RHAs could monitor complaint resolution procedures from an analysis of the relevantdocumentation of complaints, ie the types of complaints, frequency of complaintsbeing reported, and the process of resolution and investigation undertaken.

It has been identified that benefits for providers, who have a formally recognisedcomplaint resolution process are:

•less cost and time involved, in resolving complaints;

•identification of areas in need of improvement;

•increased consumer satisfaction;

• one formal system of redress, that can be applied to all degrees of complaints,and from within various types of health care services. Cases of greaterseverity will inevitably undergo a more involved process of investigation butthe underlying principles could remain the same, and the;

• involvement of all parties in the investigative process from the start, will helpelliviate the conflict between staff and advocates. This will also help avoidany further undue process of independent review, which often only increasesthe level of consumer dissatisfaction. -

If there is a visible lack of services for the reporting of complaints and theirinvestigation, then there may well be fewer complaints. This does not imply anygreater quality assurance from the service provider. It does however imply a lack ofstandards set by the provider, and reflects a self-satisfied message from the existingpolicies.

Complaint units or procedures need to befriend the consumer. The primary objectiveof every system which addresses complaints, should be to encourage the consumer toair their concerns. Complaints systems will not work if they are seen to be an afterthought.

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is anyone listening? a literature review of in tern a ......a literature review of in tern a tional...

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