Mismanagement of Client and Family Complaints

Clients and families provide feedback to healthcare organizations for a variety of reasons. They may be seeking information about a negative experience or clinical outcome or may want reassurance that necessary steps will be taken to ensure that what happened to them does not occur again. Adoption of a clear and transparent process for clients and families to initiate a complaint is essential in all care settings.

Expected Outcomes

Adopt a formal best practice and legislation compliant client relations process / program that is accessible to all persons.

Implement formal strategies to publicize the organization’s patient relations process / program and codes of conduct internally and externally.

Adopt standardized quality indicators for patient relations, quality and client safety, and workplace violence and harassment.

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• Healthcare organizations – organizations engaged in providing, financing, improving, supervising, evaluating, or other activity related to health care
• Patient relations process / program – “A patient relations process offers patients, their families and the public with a mechanism to confidentiality voice compliments and concerns about their experience or the care they received and provide feedback that can help hospitals track the quality of patient experiences and identify opportunities for quality improvement.” (Ontario Hospital Association, n.d.). Also known as patient complaints and patient experience in other jurisdictions 
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician

Common Claims Themes and Contributing Factors

Organizational

• Inadequate and / or outdated processes and practices related to:
  • Patient relations;
  • Incident and complaint investigation;
  • Disclosure of client safety incidents.
• Systemic delays in:
  • Acknowledging, investigating, and following up on complaints;
  • Disclosing harm and / or unintended outcomes to clients and families.
• Lack of interdisciplinary team training and education focused on:
  • Effective communications with clients and families;
  • Disclosure of harm and / or unintended outcomes;;
  • Managing clients’ and families’ expectations, complaints, and abusive behaviour.

Client and Family Concerns

• Perceived or actual lack of compliance with professional standards of practice and / or compliance with the organization’s clinical practice guidelines. 
• A desire to protect other clients from an “incompetent” provider / team or having a similar negative experience.

Communication 

• Perceived or actual breakdown in the therapeutic relationship / trust between the client or family, and the team, MRP, and / or healthcare organization.
• Ineffective communications with clients regarding:
  • Planned and unexpected service limits or service closures; 
  • Inter- and intra-facility transfers;
  • Transfers of care to another team / MRP and ending therapeutic relationships.
• Inadequate or ineffective communication and complaint management skills at the point of care.
• Inadequately and / or inappropriately drafted response letters / emails to client and family complaints and safety incidents e.g., lack of or insincere apology where indicated or shifting the fault or blame onto the client or family.
• Ineffective processes to address threatening or abusive behaviour by clients and families.
• Inadequate and / or inconsistent practices to manage unrealistic client and family expectations.

Documentation

• Inadequate documentation surrounding the receipt and management of client complaints.

Mitigation Strategies

Patient Relations Process

• Implement a formal best practice and legislation compliant patient relations process / program for accepting and responding to complaints from clients and families; if not in place, develop a strategy to engage clients and families regarding the organization’s patient relations process / program (Health Quality Ontario, 2015b) (Ontario Hospital Association, 2015) (Health Quality Ontario, 2015a) (Bill No. 294 Patient Safety Act, 2023) (Patient Concerns Resolution Process Regulation, n.d.) (Patient Ombudsman, n.d.) (Ombudsperson British Columbia, 2020).
• Implement formal strategies to ensure the patient relations progress / program:
  • Is accessible to all persons (e.g., those without access to computers or whose first language is not English or French) (Health Quality Ontario, 2015b);
  • Aligns with / embeds the organization’s strategies and commitment to anti-racism, diversity, equity, inclusion, and belonging.
• Adopt an evidence-based and legislation compliant (where applicable) protocol and / or practice for:
  • Incident investigation (Incident Analysis Collaborating Parties, 2012) (HIROC, 2015);
  • Disclosure of harm events and unintended outcomes (Disclosure Working Group, 2011).

Safety Culture

• Implement formal evidence-based strategies to support psychological health and safety in the work environment (Mental Health Commission of Canada & HealthCareCan, 2019) (Canadian Patient Safety Institute, 2020).
• Implement a formal:
  • Code of conduct for clients and families;
  • Code of ethical and professional conduct (or behaviour) for employees, credentialed members of staff, learners, and volunteers.

Communication

• Implement formal strategies to publicize the organization’s patient relations process / program and codes of conduct (for clients / families and for staff) both internally and externally (Association of Ontario Midwives, n.d.).
• Adopt best practice for drafting written response to a complaint (where requested or indicated) (HIROC, 2017) (ECRI, 2016).

Team Training and Education

• Implement formal strategies to support and enhance the teams’ knowledge, skills (technical and non-technical) and practical experience surrounding (but not limited to):
  • Effective provider – client communication, including active listing, managing client / family expectations, threatening or violent behaviours, de-escalation, and conflict management and prevention (Canadian Medical Protective Association, 2021) (Canadian Medical Association, n.d.) (Registered Nurses’ Association of Ontario, 2009);
  • Anti-racism, diversity, equity, inclusion and belonging;
  • The organization’s patient relations process;
  • How to obtain support or to reroute a client or family issue that is beyond the team member’s / team’s ability to resolve;
  • Incident review and investigation; 
  • Disclosure of harm and unintended outcomes (Disclosure Working Group, 2011) (Patients for Patient Safety Canada & Canadian Patient Safety Institute);
  • Codes of conduct for clients / families and staff.
• Ensure the team training and education strategies consider or involve: 
  • Scheduled interprofessional and cross-department skill drills and simulations;
  • Knowledge, skills, and practical experience required for the given care setting (e.g., home, community health centre, high workload environments);
  • Unregulated care provider, locums, travel, agency, contracted care providers in addition to regulated health professionals.

Documentation

• Implement formal strategies to support the timely and comprehensive documentation of all findings and actions taken in response to complaints (ECRI, 2016) (HIROC, 2015).
• Adopt best practices for the retention, storage, and destruction of client complaint related records (Ontario Hospital Association, 2022).

Monitoring and Measurement

• Adopt standardized quality indicators for (but not limited to):
  • Patient relations (Health Quality Ontario, 2017);
  • Quality and client safety (e.g., people centred care, safe care, accessible care, appropriate care, integrated care);
  • Workplace violence and harassment (Association of Ontario Midwives, n.d.) (Health Quality Ontario, 2019).
• Incorporate learning from local, provincial, and national learnings from client complaints and data (e.g., client and family feedback, surveys, audit of patient relations records, incident reports, team debriefs, critical incident and quality of care committee reviews, ombudsman and coroner’s reports and recommendations, human right tribunal findings, and medical legal claims) into local protocols as well as staff and client education and training.

References

• Association of Ontario Midwives. (n.d.). Workplace violence and harassment. Retrieved from https://www.ontariomidwives.ca/violence-and-harassment
• Bill No. 294 Patient Safety Act. (2023). Retrieved from Nova Scotia Legislature: https://nslegislature.ca/legc/bills/64th_1st/1st_read/b294.htm
• Canadian Medical Association. (n.d.). Conflict management and prevention. Retrieved from https://www.cma.ca/popular-topics/conflict-management-and-prevention
• Canadian Medical Protective Association. (2021). Challenging patient encounters: How to safely manage and de-escalate. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/challenging-patient-encounters-how-to-safely-manage-and-de-escalate
• Canadian Patient Safety Institute. (2020). Creating a safe space: Strategies to address the psychological safety of healthcare workers. 
• College of Physicians & Surgeons of Alberta. (2021). Managing threatening and violent patient behaviour. Retrieved from https://cpsa.ca/news/managing-threatening-and-violent-patient-behaviour/
• Disclosure Working Group. (2011). Canadian disclosure guidelines: being open and honest with patients and families. Canadian Patient Safety Institute: Edmonton, AB.
• ECRI. (2016). Managing complaints and grievances. Retrieved from Health System Risk Management - Self-assessment: https://www.ecri.org/components/HRC/pages/SAQ37.aspx
• Health Quality Ontario. (2015a). Engaging with patients and caregivers about patient relations: a guide for hospitals. Toronto, ON: Queen’s Printer for Ontario.
• Health Quality Ontario. (2015b). Striving for excellence in patient relations processes in ontario’s hospitals. Toronto, ON: Queen’s Printer for Ontario.
• Health Quality Ontario. (2017). Patient relations indicator specifications v1.0. Toronto, ON .
• Health Quality Ontario. (2019). Number of workplace violence incidents (overall). Retrieved from Indicatory Library: http://indicatorlibrary.hqontario.ca/Indicator/Summary/Workplace-violence-incidents/EN
• HIROC. (2015). Critical incidents & multi-patient events. Retrieved from https://www.hiroc.com/system/files/resource/files/2018-10/HIROC-Management-of-Critical-Incidents-April-2015.pdf
• HIROC. (2017). Responding to complaints and concerns. Retrieved from https://www.hiroc.com/system/files/resource/files/2020-01/Letter%20Writing%20Guide.pdf
• Incident Analysis Collaborating Parties. (2012). Canadian incident analysis framework. Edmonton, AB: Canadian Patient Safety Institute.
• Mental Health Commission of Canada & HealthCareCan. (2019). Caring for healthcare: A toolkit for psychological health and safety in healthcare workplaces. 
• Ombudsperson British Columbia. (2020). Complaint handling guide: Setting up effective complaint resolution systems in public organizations. Victoria, BC .
• Ontario Hospital Association. (2015). OHA backgrounder ECFAA regulation 188/15 on patient relations proces. Toronto, ON.
• Ontario Hospital Association. (2022). Records retention toolkit a guide to the maintenance and disposal of hospital records. Toronto, ON.
• Ontario Hospital Association. (n.d.). Patient Relations. Retrieved from https://www.oha.com/quality-safety-and-patient-and-family-centred-care/patient-relations
• Patient Concerns Resolution Process Regulation. (n.d.). Alta Reg 124/2006. Retrieved 05 08, 2023, from https://canlii.ca/t/52pdc
• Patient Ombudsman. (n.d.). Information for Respondents. Retrieved from https://patientombudsman.ca/Health-Sector-Organizations/Information-for-Respondents
• Patients for Patient Safety Canada & Canadian Patient Safety Institute. (n.d.). Principles for disclosing harm. 
• Registered Nurses’Association of Ontario. (2009). Preventing and managing violencein the workplace. Toronto, ON.