Marie Bismark

Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events

Objectives: To estimate the proportion and characteristics of patients injured by medical care in New Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability Commissioner (“the Commissioner”). Design: The percentage of injured patients who lodge complaints was estimated by linking the Commissioner’s complaints database to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic differences between complainants and non-complainants. Setting: New Zealand public hospitals and the Office of the Commissioner in 1998. Population: Patients who lodged claims with the Commissioner (n = 398) and patients identified by the NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner (n = 847). Main outcome measures: Adverse events, preventable adverse events, and complaints lodged with the Commissioner. Results: Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas (OR 0.3, 95% CI 0.2 to 0.6). Conclusion: Most medical injuries never trigger a complaint to the Commissioner. Among complaints that are brought, severe and preventable injuries are common, offering a potentially valuable “window” on serious threats to patient safety. The relatively low propensity to complain among patients who are elderly, socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation of complaints processes.

Accountability sought by patients following adverse events from medical care: the New Zealand experience

Background: Unlike Canadas medical malpractice system, patients in New Zealand who are dissatisfied with the quality of their care may choose between 2 well-established medicolegal paths: one leads to monetary compensation and the other to nonmonetary forms of accountability. We compared the forms of accountability sought by patients and families in New Zealand who took different types of legal action following a medical injury. This study offers insights into the forms of accountability sought by injured patients and may help to inform tort-reform initiatives. Methods: We reviewed compensation claims submitted to the Accident Compensation Corporation (ACC), New Zealands national no-fault insurer, following injuries associated with admission to a public hospital in 1998 (n = 582). We also reviewed complaint letters (n = 254) submitted to the national Health and Disability Commissioner (HDC) that same year to determine the forms of accountability sought by injured patients. We used univariable and multivariable analyses to compare sociodemographic and socioeconomic characteristics of patients who sought nonmonetary forms of accountability with those of patients who claimed compensation. Results: Of 154 injured patients whose complaints were sufficiently detailed to allow coding, 50% sought corrective action to prevent similar harm to future patients (45% system change, 6% review of involved clinicians competence) and 40% wanted more satisfying communication (34% explanation, 10% apology). The odds that patients would seek compensation were significantly increased if they were in their prime working years (aged between 30 and 64 years) (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.14–2.41) or had a permanent disability as a result of their injury (OR 1.75, 95% CI 1.14–2.70). When injuries resulted in death, the odds of a compensation claim to the ACC were about one-eighth those of a complaint to the HDC (OR 0.13, 95% CI 0.08–0.23). Interpretation: Injured patients who pursue medicolegal action seek various forms of accountability. Compensation is important to some, especially when economic losses are substantial (e.g., with injury during prime working years or severe nonfatal injuries). However, others have purely nonmonetary goals, and ensuring alternative options for redress would be an efficient and effective response to their needs.

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia

Objectives (1) To determine the distribution of formal patient complaints across Australias medical workforce and (2) to identify characteristics of doctors at high risk of incurring recurrent complaints. Methods We assembled a national sample of all 18 907 formal patient complaints filed against doctors with health service ombudsmen (‘Commissions’) in Australia over an 11-year period. We analysed the distribution of complaints among practicing doctors. We then used recurrent-event survival analysis to identify characteristics of doctors at high risk of recurrent complaints, and to estimate each individual doctors risk of incurring future complaints. Results The distribution of complaints among doctors was highly skewed: 3% of Australias medical workforce accounted for 49% of complaints and 1% accounted for a quarter of complaints. Short-term risks of recurrence varied significantly among doctors: there was a strong dose-response relationship with number of previous complaints and significant differences by doctor specialty and sex. At the practitioner level, risks varied widely, from doctors with <10% risk of further complaints within 2 years to doctors with >80% risk. Conclusions A small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.

When informed consent goes poorly: a descriptive study of medical negligence claims and patient complaints.

Objective: To describe the frequency, characteristics, and outcomes of medicolegal disputes over informed consent.

Disclosing Adverse Events to Patients: International Norms and Trends

Objectives There is a growing expectation in health systems around the world that patients will be fully informed when adverse events occur. However, current disclosure practices often fall short of this expectation. Methods We reviewed trends in policy and practice in 5 countries with extensive experience with adverse event disclosure: the United States, the United Kingdom, Canada, New Zealand, and Australia. Results We identified 5 themes that reflect key challenges to disclosure: (1) the challenge of putting policy into large-scale practice, (2) the conflict between patient safety theory and patient expectations, (3) the conflict between legal privilege for quality improvement and open disclosure, (4) the challenge of aligning open disclosure with liability compensation, and (5) the challenge of measurement related to disclosure. Conclusions Potential solutions include health worker education coupled with incentives to embed policy into practice, better communication about approaches beyond the punitive, legislation that allows both disclosure to patients and quality improvement protection for institutions, apology protection for providers, comprehensive disclosure programs that include patient compensation, delinking of patient compensation from regulatory scrutiny of disclosing physicians, legal and contractual requirements for disclosure, and better measurement of its occurrence and quality. A longer-term solution involves educating the public and health care workers about patient safety.

The PRONE score: an algorithm for predicting doctors’ risks of formal patient complaints using routinely collected administrative data

Background Medicolegal agencies—such as malpractice insurers, medical boards and complaints bodies—are mostly passive regulators; they react to episodes of substandard care, rather than intervening to prevent them. At least part of the explanation for this reactive role lies in the widely recognised difficulty of making robust predictions about medicolegal risk at the individual clinician level. We aimed to develop a simple, reliable scoring system for predicting Australian doctors’ risks of becoming the subject of repeated patient complaints. Methods Using routinely collected administrative data, we constructed a national sample of 13 849 formal complaints against 8424 doctors. The complaints were lodged by patients with state health service commissions in Australia over a 12-year period. We used multivariate logistic regression analysis to identify predictors of subsequent complaints, defined as another complaint occurring within 2 years of an index complaint. Model estimates were then used to derive a simple predictive algorithm, designed for application at the doctor level. Results The PRONE (Predicted Risk Of New Event) score is a 22-point scoring system that indicates a doctors future complaint risk based on four variables: a doctors specialty and sex, the number of previous complaints and the time since the last complaint. The PRONE score performed well in predicting subsequent complaints, exhibiting strong validity and reliability and reasonable goodness of fit (c-statistic=0.70). Conclusions The PRONE score appears to be a valid method for assessing individual doctors’ risks of attracting recurrent complaints. Regulators could harness such information to target quality improvement interventions, and prevent substandard care and patient dissatisfaction. The approach we describe should be replicable in other agencies that handle large numbers of patient complaints or malpractice claims.

Motivations for medico-legal action. Lessons from New Zealand.

A tangle of motives lies behind a patient or family’s decision to take legal action following medical injury, and money is only one of them. These motives, which all can be considered to represent a demand for some form of “accountability,” generally fit into four themes: restoration, including financial compensation or some other intervention to “make the patient whole again”; correction, such as a system change or competence review to protect future patients; communication, which may include an explanation, expression of responsibility, or apology; and sanction, including professional discipline or some other form of punitive action. Previous studies exploring patients’ reasons for filing a malpractice suit have identified a similar spectrum of needs. In the United States, factors that have prompted claims among families of children with severe perinatal injuries have been studied. Even though these families presumably faced significant

Reasons and remedies for under-representation of women in medical leadership roles: a qualitative study from Australia

Objective To elicit medical leaders’ views on reasons and remedies for the under-representation of women in medical leadership roles. Design Qualitative study using semistructured interviews with medical practitioners who work in medical leadership roles. Interviews were transcribed verbatim and transcripts were analysed using thematic analysis. Setting Public hospitals, private healthcare providers, professional colleges and associations and government organisations in Australia. Participants 30 medical practitioners who hold formal medical leadership roles. Results Despite dramatic increases in the entry of women into medicine in Australia, there remains a gross under-representation of women in formal, high-level medical leadership positions. The male-dominated nature of medical leadership in Australia was widely recognised by interviewees. A small number of interviewees viewed gender disparities in leadership roles as a ‘natural’ result of womens childrearing responsibilities. However, most interviewees believed that preventable gender-related barriers were impeding womens ability to achieve and thrive in medical leadership roles. Interviewees identified a range of potential barriers across three broad domains—perceptions of capability, capacity and credibility. As a counter to these, interviewees pointed to a range of benefits of women adopting these roles, and proposed a range of interventions that would support more women entering formal medical leadership roles. Conclusions While women make up more than half of medical graduates in Australia today, significant barriers restrict their entry into formal medical leadership roles. These constraints have internalised, interpersonal and structural elements that can be addressed through a range of strategies for advancing the role of women in medical leadership. These findings have implications for individual medical practitioners and health services, as well as professional colleges and associations.

Governance of quality of care: a qualitative study of health service boards in Victoria, Australia

Objectives To describe the engagement of health service boards with quality-of-care issues and to identify factors that influence boards’ activities in this area. Methods We conducted semistructured interviews with 35 board members and executives from 13 public health services in Victoria, Australia. Interviews focused on the role currently played by boards in overseeing quality of care. We also elicited interviewees’ perceptions of factors that have influenced their current approach to governance in this area. Thematic analysis was used to identify key themes from interview transcripts. Results Virtually all interviewees believed boards had substantial opportunities to influence the quality of care delivered within the service, chiefly through setting priorities, monitoring progress, holding staff to account and shaping culture. Perceived barriers to leveraging this influence included insufficient resources, gaps in skills and experience among board members, inadequate information on performance and regulatory requirements that miss the mark. Interviewees converged on four enablers of more effective quality governance: stronger regional collaborations; more tailored board training on quality issues; smarter use of reporting and accreditation requirements; and better access to data that was reliable, longitudinal and allowed for benchmarking against peer organisations. Conclusions Although health service boards are eager to establish quality of care as a governance priority, several obstacles are blocking progress. The result is a gap between the rhetoric of quality governance and the reality of month-to-month activities at the board level. The imperative for effective board-level engagement in this area cannot be met until these barriers are addressed.

Mandatory reports of concerns about the health, performance and conduct of health practitioners.

Objective: To describe the frequency and characteristics of mandatory reports about the health, competence and conduct of registered health practitioners in Australia.