Handling complaints: research and developments Professor Johan Legemaate Vrije Universiteit Amsterdam EPSO, Tallinn, 21 May 2010

A complaint  Expression of dissatisfaction with the healthcare delivered to the patient  A complaint has to be distinguished from: signal, report, incident, adverse event etc

The right to complain  Is a key feature of the patients’ bill of rights  To enforce your substantive rights or to clarify issues that are not yet regulated

Health professionals: strong feelings  They fear ‘a culture of complaints and claims’  “A complaint is a free advice”  Handling complaints: the ‘aftersales’ of healthcare delivery

Council of Europe, 2006  Council of Europe recommendation (2006)7 on the management of patient safety and prevention of adverse events in health care.  “a fair and open complaints system, a just and adequate compensation system and an efficient and reliable supervisory system.”

Handling complaints: aims  To justify the (legal) needs of individual patients  To improve the quality of care on the basis of individual complaints  To detect structural quality problems in health care (complaint used as a signal)  Related but yet different perspectives > different solutions, safeguards and requirements

Handling complaints as a right of patients (individual dimension) (1)  What does the patient want to achieve: * explanation, recognition, being taken serious, apology * feeling that ‘justice is done’ * feeling that ‘justice is done’ * to prevent the situation from happening again * the compensation of damages * ‘punishment’

Handling complaints as a right of patients (individual dimension) (2)  How does the patient want to achieve this: * Disclosure of the relevant facts and information * Informal procedures, close to where the complaint originated * Preferably not: lengthy and distressing formal legal procedures

The Netherlands: the complaints pyramid Legal procedures (civil, criminal or disciplinary) Complaints committee for care providers Informal handling of complaints (complaints officer, patient advocate etc)

Complaint systems for patients  The health professional or service concerned  Complaints officers and/or complaint committees (local, regional or national)  Ombudsman (local, regional or national)  Health commissioner (national)  Professional bodies or organisations (regional, national)  Medical or disciplinary tribunals (regional, national)  Civil courts  Medical or Health Councils (regional, national)  Inspectorates (first instance and/or appeal)

Complaint systems for patients: Netherlands (♫)  The health professional or service concerned (♫)  Complaints officers and/or complaint committees (local, regional) (♫)  Ombudsman (local, regional or national)  Health commissioner (national)  Professional bodies or organisations (regional, national)  Medical or disciplinary tribunals (regional) (♫)  Civil courts (♫)  Medical or Health Councils (regional, national)  Inspectorates (first instance and/or appeal)

Relationship between the complaints committee and the Inspectorate (Netherlands)  (Since 2005) If a serious complaint is filed with the complaints committee and the care provider does not solve the situation the complaint is about, the complaints committee is obliged by law to report the complaint to the Inspectorate  This obligation is hardly ever practised

Handling complaints by Inspectorates (public interest) (1)  Why does the Inspectorate handle complaints?: -(a) to satisfy the needs of individual patients -(b) to detect structural quality problems in health care  If (a): is the Inspectorate the most suitable body to address the needs of individual patients?  If (a) and (b): is the Inspectorate able to perform both activities, and to prevent that one activity (b) outshines the other (a)  In other words: are both activities compatible?

Handling complaints by Inspectorates (public interest) (2)  Points of discussion: -Whose responsibility is it to handle complaints (care provider, inspectorate)? -Is the Inspectorate the right body to deal with complaints from the perspective of the ‘individual dimension’ -Is there an alternative option? -To what extent do complaints provide a full view of what might be wrong? -What is the prevailing culture in your country (emphasis on individual rights, emphasis on public interest)?

Inspectorates: serving the public interest  Complaints are not the only input the Inspectorate receives  Lost of others sources: Investigation at the initiative of the Inspectorate (‘fueled’ or not by information from other sources) Investigation at the initiative of the Inspectorate (‘fueled’ or not by information from other sources) Various performance indicators Various performance indicators Signals Signals Voluntary reporting systems (blame free reporting) at local or national level Voluntary reporting systems (blame free reporting) at local or national level Mandatory reporting systems (serious incidents) Mandatory reporting systems (serious incidents) Reports in de media (newspapers, tv, internet) Reports in de media (newspapers, tv, internet)  Complaints as such handled by the Inspectorates… ?  … or used only to detect structural problems (and referred to other bodies to deal with the ‘individual dimension’) > the complaint is seen as a signal

Specific issue (1): care providers and patients crossing borders  An increasing number of care providers and patients is crossing borders: -does one country inform the other about complaints, pending procedures, convictions etc? -is there a need to ‘harmonize’ supervisory systems?

Specific issue (2): the Inspectorate as complainant  The Inspectorate acts as a complainant (e.g. procedures before a medical or a discplinary tribunal or medical council)  If the Inspectorate does have this authority: in which cases is it used?

Final remarks  Handling complaints: there is both a relationship and a tension between the ‘individual dimension’ and the ‘public interest’  Patients who voice a complaint have specific wishes and goals: the complaints system should recognize that  We should have both “a fair and open complaints system” and “an efficient and reliably supervisory system” (Council of Europe 2006)  Mixing these systems is possible, but raises questions and requires careful consideration