Service Recovery Making it Right Rebuilding Confidence Learning from our Patients and Reducing Malpractice Risk Gerald B. Hickson, M.D. Associate Dean for Clinical Affairs gerald.hickson@vanderbilt.edu Welcome – This is the management training program for Service Recovery. Any manager - clinical research, diagnostic services, clinics, ED, and hospital managers are all required to complete this training. I’m Jodi Gumucio, [title] In the next hour, you will hear explanation of the Service recovery policy, protocol and resources and the role you & your staff play in service recovery. This same presentation is one you can use with your own staff as you explain & implement the program before ________.

Case: Never on Wednesday Daughter reported: “the resident my mom was to see entered the continuity clinic acting agitated… talked down to girl at desk: “Answer my questions immediately with a yes or no…don’t need any extra conversation…I’m here to see one of my patients.” Receptionist replied “no,” and said, “but there’s the consult we called about.” Res became even more upset…

The story continues: “Sensing that the doctor was in a hurry, I said that my mom was ready to be seen. Res. whirled toward me, made a “T” sign with his hands and barked, ‘Time out! It’s not your turn to talk!’ Turning back to the receptionist, he demanded, ‘Who consulted me?...’”

The doctor walks out “Res yelled so the whole area could hear, ‘You didn’t do anything wrong. The staff did!...You need to go where they know what they are doing…I don’t do consults on Weds… months before I can book you an appt.’” “Then he turned and left me standing there. I don’t think that was very professional.” What might you do if you witnessed this event?

Service Recovery …To promote exemplary patient care… when dissatisfaction occurs… “making right what went wrong”

So aren’t we always going to make some patients unhappy? Yes … but …

Tip of the Iceberg Consumer and medical literature indicate voiced complaints represent only a small fraction For every pt/fm that complains there are many more … Annandale. Accounts of disagreements with doctors. Soc Sci Med 1998. Carroll. Characteristics of Families that Complain Following Pediatric Emergency Visits. Ambulatory Pediatrics. 2005. "Consumer Complaint Handling in America: An Updated Study for the U.S. Office of Consumer Affairs," 1986.

Spectrum of Patient Dissatisfaction Lawsuits Voiced Complaints (tip of the iceberg) -Some patients that are unhappy may say or do nothing, some may not adhere to recommendations or drop out of the health care system. -And a minority of patients may be so unhappy that they choose to file a complaint with an institutional authority or at the tip of the iceberg of patient dissatisfaction, file a lawsuit in the event of an adverse outcome. Errors Drop out Non adherence ©CPPA 2007

Capturing complaints also allows us to be proactive

Patient Observations The patient was offended by Dr. _____’s attitude and comment “get both thundering thighs into the paper shorts for an exam.” Pt. states “MD sent frustrated e-mail to his secretary…must have inadvertently hit ‘Reply to All’…e-mail stated… ‘Can you get this crazy woman’s chart?’”

Do these complaints represent some sort of pattern Do these complaints represent some sort of pattern? And what else can we learn?

9% of MDs Accounted for 50% of Complaints (6-year study period) % of Physicians Hickson GB, et al. JAMA 2002;287:1583-1587.

Predictors of Risk Outcomes (logistic regression) Gender Physician specialty Volume of service Unsolicited patient complaints Predictive concordance of risk models ranges from 81-92% Hickson GB, et al. JAMA 2002;287:1583-1587.

Incurred $s By Risk Category This document is confidential and privileged pursuant to the provisions under State peer review statutes. DO NOT DISSEMINATE WITHOUT PERMISSION. Incurred $s By Risk Category Pred Risk Category # (%) MDs Mean $ Paid* % of Tot. $ Mean # Cmplts 1 (low) 318 (49) 1 4% 2 147 (23) 6 13% 3 76 (12) 4 10 52 (8) 42 29% 16 5 (hi) 51 (8) 73 50% Total 644 (100) 100% * In multiples of lowest risk group

Disruptive Behavior Pyramid Level 3 "Disciplinary" Intervention No ∆ Pattern persists Level 2 "Authority" Intervention Apparent pattern Level 1 "Awareness" Intervention Single “unprofessional" incidents (merit?) "Informal" Intervention Mandated Issues Vast majority of doctors—no issues

PARSsm Level 1 Intervention* Peers (mostly) agree to share the info Make high complaint MDs aware of data via correspondence and personal visit Use graphic displays, peer-based data comparisons and all complaint reports Encourage creative systems thinking Continue ongoing assessments to promote accountability *VUMC Policy, Pt Complaint Monitoring Committee

Top 10 Surgeons* Means for surgeons *Complaint Index is a function of the number of reports filed with the Office of Patient Relations and the number of specific complaints embedded within those reports over the previous four year period. Recent reports count more heavily than those more than a year old. This document is confidential and privileged pursuant to the provisions of O.C.G.A. Sections 31-7-131,133.

Interim Observations Over ~800 interventions completed No one killed (yet) <2% responded with hostility Professional: Asked PAO to shadow, give ideas Went to Chief: Asked for resources Reorganized the unit Level 2 Interventions Follow-ups ongoing

Teamwork When patients are angry or upset, they see each of us as representatives of the entire Medical Center. Ultimately it is up to each of us to help create satisfied and loyal customers- Story of Liz Jazwiek- How can I ask my team to do One more thing? Amazed to find that people responded to insincere concern- she thought you had to mean it- then she began to see improvement in morale and people really meaning it.

Special Skills Studies show that more than half of all efforts to respond to customer complaints actually reinforce negative reactions to service. Hart, CWL. Service breakthroughs: changing the rules of the game, 1990.

H-E-A-R-T Protocol Hear the patient Empathize Apologize* Respond to the problem Thank the patient/family member for sharing their concerns * Really acknowledge and sometimes apologize

Summary Service recovery is about doing the right thing For every expression of dissatisfaction, there are numerous unexpressed dissatisfactions… Responding appropriately requires thoughtfulness and certain skills (H - E - A – R – T) May reduce your time in court

Thank you for your dedication to continuous improvement Service Recovery empowers YOU to act as an advocate for your patients & their families Thank you for your dedication to continuous improvement

Gerald.Hickson@Vanderbilt.edu Jim.Pichert@Vanderbilt.edu Questions now or later? www.mc.vanderbilt.edu/cppa Gerald.Hickson@Vanderbilt.edu Jim.Pichert@Vanderbilt.edu