Concerns Management TOOLKIT

Concerns Management

TOOLKIT

May 2006

Revised 2011

Department of Patient Advocacy

Concerns Management Toolkit

Content:

Introduction ...3

Purpose of Concerns Management...4

Concerns Management Process ...5

Compliments ...7

Key Points and Tips ...7

Concerns Management Flowchart ...8

Tips for Avoiding Complaints...9

Tips for Dealing with “difficult” patients...11

Improving Your Communication Skills...14

Frequently Asked Questions ...17

References & Links ...20

Appendices ...20 Appendix A: Concerns Management Policy

Appendix B: Concerns Management PowerPoint Presentation

CONCERNS MANAGEMENT TOOLKIT

Introduction:

This Toolkit is designed and intended to provide guidance on the principles, rationale, and necessity of an excellent concerns management process from a risk management perspective. It provides information on the purpose and essential elements of concerns management with key points and tips on risk reduction strategies with effective

management. The Toolkit includes the purpose, the process, some relevant articles, and a section on Frequently Asked Questions, links and references.

The resource materials provided in this Toolkit are for general information purposes only and should be adapted to each situation.

Effective concerns management is a fundamental process that supports our patient care and reflects the standards and values of The Ottawa Hospital. Effective concerns

management answers both to the Mission and Vision of TOH using compassion, commitment to quality, teamwork and respect while working to resolve concerns. Effective concerns management is an important component in improving patient satisfaction and managing risk for the hospital.

A safer system is one that “places consumers at the centre of the system and

harnesses the experiences of patients and their caregivers to drive improvements.” Concerns are a unique source of information for the hospital on how and why negative events, both perceived and real, occur and how to prevent them. As well as reducing future harm to patients, excellent concerns management restores trust and reduces the risk of litigation, through open communication and a commitment to learn from the problem and prevent its recurrence.

Purposes of Effective Concerns Management Are to:

 Improve Patient Satisfaction  Decrease Risk

 Manage Risk

 Ensure Accountability  Ensure Transparency  Reestablish Trust

 Identify Opportunities for Quality Improvement and Patient Safety  Contribute to the Goal of Achieving Excellence

Concerns Management Process

The Ottawa Hospital has a corporate Concerns Management Policy titled Patient Concerns Management that can be found under the Administrative Policies & Procedures Manual, policy # ADM VIII 310 (See Appendix A).

All concerns are handled without prejudice or assumptions. The emphasis is on resolving the problem.

Everyone benefits when one takes the time to work with the patient/family to identify the source or cause of the frustration, and then to resolve it (Osborne).

All complainants are treated with respect, sensitivity and confidentiality.

Our department has an SLA (service level agreement) to respond within 24 hrs upon initial receipt of a concern.

Identify:

 Serious

- an adverse medical outcome - a human rights issue

- reputation damage to hospital  All Others

Investigation:

 Sources of information:

o Events as by complainant

o Health Record/vOacis/SMS

o Any and all documentation

o History of event by manager and/or physician

o History of events by any care team members involved

o Policies and Procedures

Resolution:

 Identify interests of involved individuals

 Identify realistically based options for resolution

 Potential options are assessed and evaluated against objective criteria  Negotiate a fair and equitable resolution in an attempt for closure  Consider core values demonstrated in resolution

 If necessary, meetings can be arranged

 Deal with complaints in a manner that is complete, fair to all parties and provides just outcomes

 Accept that some issues simply cannot be resolved, even with best attempts The process of resolving the problem will include:

 An expression of regret for any harm suffered

 An explanation or information about what is known, without speculating or blaming

 Considering the problem and the outcome complainant seeking and proposing reasonable solution

 Confirming that complainant is satisfied with the process

 Response should be provided in the same manner in which it was received:

o Phone call response via return phone call

o E-mail: response via e-mail or phone call

o Written concern received:

 Send an acknowledgement letter (under signature of receiver)  Communication and resolution via phone

 Followed up with closure letter (In some cases, issues can be adequately resolved in a letter alone).

Documentation:

 Documentation should include:  A summary of the concern

 The action taken during the investigation  The outcome of the investigation

The documented resolution is to be maintained by the manager and/or the Specialist, Patient Advocacy as appropriate. Safekeeping of documentation is to follow Privacy guidelines.

 All complaints via Patient Advocacy are recorded to enable review of

individual cases, to identify trends and risks, and to report on how concerns have led to improvements

 The process in the Patient Advocacy Department is documented in the PSLS Concerns Database and kept for 2 years, unless it proceeds to or is a

Compliments

 Compliments are an extremely positive feedback

 Written compliments should be acknowledged by a written response.  A copy of the compliment will be sent to the Manager and other applicable

individuals. They may wish to put a copy of the compliment letter into the employee’s file.

 All people mentioned in the compliment will receive a copy of the communication.  Compliments that are received via Patient Advocacy are entered into the PSLS

Database to allow for tracking.

Key Points & Tips

The RULES

Guiding Principles Process

o Patients and families are treated with respect, compassion and understanding

o There is no absolute right single way to respond to complaints (Osborne)

o The concerns manager must remain impartial and respect confidentiality at all times

o Patients and/or families are kept informed at appropriate intervals as to the progress of the investigation of their concern. This shows that TOH takes concerns seriously.

o The process must be equitable for the complainant, the staff and the physicians

o Investigations must be timely and thorough

o Information must be managed in a fair manner so that relevant facts and decisions are openly communicated while

confidentiality and privacy are protected

o The majority of concerns are managed at Point of Care (at unit level)

o The Patient Advocacy Specialist can be contacted for support, guidance and/or if concerns have not been resolved.

o All communication with the complainant will be in the Official Language chosen by the

Consumer Feedback Loop

practice (if any) Improved health care service for all

Acknowledge Receipt of feedback Clarify issues raised by consumer Advise consumer of outcome of investigation Advise consumer of changes (if any)

in administrative practice Resolution and Recommendations Acknowledge Complaint

Incident Clarify Investigate

Adapted from: Complaints Management Handbook for Health Care Services

Australian Council For Safety and Quality in Health Care July 2005

College of Nurses of Ontario

Taken from the Communiqué/March 2002

Tips for Avoiding

Complaints

Here are a few steps that anyone at POC (point of care) can take to manage situations professionally and decrease the chance of a complaint.

1. ACKNOWLEDGE: Acknowledge the situation. People are less likely to remain angry when you agree something went wrong and explain what happened.

2. APOLOGIZE: Apologize for what happened. It shows a caring attitude toward someone’s feelings and experience. Often this alone is enough to diffuse the situation.

3. ACT: Attempt to defuse by reflecting from patients’ perspective and immediately offering a corrective measure.

4. COMMUNICATE ONCE: Talk to the patients. By explaining directly what happened, trust can begin to be rebuilt and can help defuse anger.

5. COMMUNICATE TWICE: Talk about what happened and what you did to fix it.

6. COMMUNICATE AGAIN: Discuss in a professional manner with appropriate colleagues in health care team what happened and what you are doing to resolve the situation. Don’t wait for a patient/family to tell them. Your team and colleagues can help diffuse the situation and reassure the patient and family.

7. DOCUMENT: Document only factual patient information.

8. DEBRIEF: By talking with colleagues or the unit manager, while respecting privacy and confidentiality, one can reflect on what happened, what was done to deal with the situation and what could be done differently if it happens again. Talking also allows for an opportunity to reflect upon ways to avoid repeating the incident.

9. PLAN: Have an action plan. It is inevitable that misunderstandings, emergencies and disappointments will happen. To ensure that they are handled professionally and

consistently, every unit should have an action plan to deal with problem situations. If your unit doesn’t, advocate for one. The plan should include steps to alleviate the tension, correct the problem, and notify the appropriate staff of the situation.

10. PERCEPTION: Negative perceptions sometimes lead to complaints regardless of the quality of care. If the patient and or family feel ignored, then it does not matter why or how the situation occurred. Change the patient/family perception by showing

concern, communicating and taking action.

These 10 suggestions can help handle difficult situations, regain trust and defuse anger. Even if the patient/family still complains, being able to show that the situation was

Taken from College of Nurses of Ontario Communiqué June 2003 pages 8 & 37

Getting off on the right foot

Tips for dealing with “difficult” patients

Here are 10 tips that can help all health care providers to build relationships with patients who are perceived as difficult or challenging.

1. Introduce yourself to patients: State your name and position and indicate any

identification you may be wearing. This informs patients of who you are and what care you will be providing (within the organization). The patient will begin to understand your role and feel more comfortable.

2. Treat patients as individuals: Try to know patients as people. Asking questions

and forming therapeutic relationships with patients show that you are interested and respect them.

3. Listen to patients: Stop by periodically to see patients rather than waiting for

them to ring for something. This shows that you’re thinking about them. When you actively listen, patients will open up and tell you what’s bothering them.

4. Assess: Do a thorough assessment of patients. The data you obtain may help in

understanding the meaning behind their behavior.

5. Demonstrate patience: If you show frustration or annoyance while providing care,

some patients may react by becoming difficult – in effect, mirroring your behavior. Reflecting on the situation will help you understand your own reaction to certain patients and situations.

6. Monitor verbal/body language: Good communication is important. Speak calmly,

in a friendly tone, and watch your body language. Avoid technical language that patients may not understand.

7. Be sensitive to your patients’ situations: Remember that patients are sick and

may not be acting like themselves. Their behavior may stem from fear, frustration or pain. Put yourself in your patient’s situation and think about what your needs would be and how you would react.

8. Tell patients your plan: Patients will understand that you’re busy, and that you

will return as soon as possible. Patients feel more neglected when they don’t know what’s going on.

9. Give patients a sense of control: Do not control patients by imposing your will on

them, being harsh or punishing them for being difficult. As well, maintaining rigid rules and schedules may increase problems and possibly escalate situations. Instead, allow patients to determine their goals and expectations and have input into their care plan.

10. Keep informed: Keep up-to-date on new ways and suggestions for building relationships with patients by reading journals, books and by speaking to fellow colleagues who have good skills in establishing therapeutic care provider-patient relationships. By incorporating some of these suggestions into your daily

practice, you may find that patients you perceive as “difficult” aren’t so difficult after all.

JCAHO

Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) reported that the root cause of

more than 65% of sentinel events was directly attributable

to a problem with

communication.

It’s not what you say,

but what is heard.

It’s not what you show,

but what is seen.

It’s not what you mean,

but what is understood.

Perception is reality.

- author unknown

A correlation between the quality of communication and

improved patient outcomes suggests that engaging

patients in discussion is a key clinical method

.

Taken from College of Nurses of Ontario Communiqué June 2003 pages 6-7

Improving your Communication

Skills

Brenda is coming to the end of a difficult 12-hour shift. She has been caring for eight patients, the majority of whom are acutely ill. In addition, one of the

patients, Mrs. Cooper, has been particularly challenging, ringing the call bell for what Brenda considers trivial concerns. Mrs. Cooper complains that she hasn’t received any attention, although Brenda feels she has taken up most of her time. At one point, Brenda and a nursing colleague are changing Mrs. Cooper’s bed and turning her. Both Brenda and her colleague recently learned Spanish and occasionally converse with each other in Spanish for practice. Brenda asked her colleague, in Spanish, whether she would mind finishing up with Mrs. Cooper, as Brenda hadn’t started her documentation and needed to leave work on time. Mrs. Cooper was offended that the nurses’ spoke in a language she couldn’t understand. She accused them of making derogatory remarks about her. Frustrated with Mrs. Cooper’s ongoing complaints, Brenda responded that she was doing her best with limited resources and that if Mrs. Cooper wasn’t satisfied, she could take it up with her Member of Parliament. Brenda realized shortly afterwards that she handled the situation badly by letting her emotions take over.

The following day, Mrs. Cooper lodged a complaint with the unit manager. In response, the manager spoke with Brenda and Mrs. Cooper to find out what happened. The manager learned that Mrs. Cooper’s husband had recently died in the same hospital. Mrs. Cooper was terrified nurses would not come if she needed them in an emergency. The manager assured Mrs. Cooper that the nurses would always answer the call bell, and showed her where the emergency bell was if the situation was critical.

To address Mrs. Cooper’s concerns, the manager asked if she’d prefer a room closer to the nurses’ station, and suggested that a bereavement counselor help her cope with the loss of her husband. Mrs. Cooper agreed with the manager’s suggestions.

Investing some time

By reflecting on this incident, Brenda recognized that she might have used some of her manager’s strategies to get at the root of Mrs. Cooper’s behavior. She could have invested some time early in the shift communicating with Mrs. Cooper, assessing her concerns and assuring her that the nurses would not forget about her. Brenda also recognized that speaking another language with a colleague could easily alienate patients. Using medical jargon without an explanation has the same effect, creating situations in which patients may feel afraid to ask for explanations.

Managing difficult situations

When nurses don’t know how to manage a difficult situation, they may end up avoiding patients, making a bad situation worse. Early intervention is the key to preventing a tense situation from escalating. When the situation is too difficult to handle alone, nurses should consult with their managers or supervisors. In many instances, patients behaviour may stem from their frustration with their illness, the care they have received or the health care system in general. Pain, grief, fear and confusion can contribute to difficult behaviours.

Nurses can identify the root cause of behaviours that they perceive as demanding and often resolve issues by using expert communication skills to establish a therapeutic relationship with the patient.

Surveys confirm that nurses are among the most trusted professionals and therefore are at an advantage when establishing therapeutic relationships. Here are therapeutic communication strategies that strengthen nurse-patient relationships:

 Introduce yourself by name and designation;

 Know and use patients’ preferred names, whether they are first names or family names;

 Make eye contact when culturally appropriate and use friendly and open body language – crossed arms often convey frustration or anger;

 Ask open-ended questions that encourage patients to express themselves;  Listen actively and show interest in patients;

 Explore unusual comments, attitudes or behaviours;  Identify patients goals and wishes in the care plans;

 Provide sufficient information that allows patients to make choices and have realistic expectations;

 Collaborate with patients to find best possible solutions;

 Maintain commitments to patients or explain if there are going to be changes to routines/schedules;

 Be aware of how you are being perceived by patients; and

 Think about how you would want a nurse to treat a close relative.

Steps to improve skills

Many complaints received by CNO involve breakdowns in communication. Nurses can take a variety of steps to improve their communication skills as part of their learning plan. Articles, books and learning resources about therapeutic communication are available. For example, CNO’s One is One Too Many abuse prevention program contains learning modules for developing therapeutic nurse-patient relationships and avoiding situations that result in inappropriate behaviour. The nurse’s workbook

component is a self-directed learning tool containing excellent exercises and scenarios to help nurses understand that good practice begins with an awareness of the dynamics of the nurse-patient relationship. This program is available by contacting CNO.

In addition, there are courses at universities or as part of in-service education. In-service programs may target specific client populations, like pediatrics, geriatrics or communicating with patients of different cultures. Nurses may also develop mentoring relationships with colleagues who have strong communication and conflict resolution skills.

Nurses often feel that they have more work than time. When this happens

communicating with patients loses priority, and the nurses’ attention shifts to meeting only patients’ physical needs. It’s critical to take the time to inform patients about what is going on and listen to their concerns. Time invested in communication is time invested in building relationships of trust and respect.

Concerns Management Toolkit

Frequently Asked Questions (FAQs)

What is the purpose of concerns management?

o To improve patient satisfaction and manage risk to the hospital, the staff and physicians

o To restore trust and confidence in the hospital

o To identify potential areas for quality and safety improvement How are concerns resolved?

o In a timely manner, without bias, in the most effective way possible.

Who and where do we refer patients and/or families to when they have a concern?

o If they are currently inpatients, first refer to the Clinical Manager of the Unit

o The Manager will contact Patient Advocacy for Consultation if needed

o If the patient and/or family are in the community, they can be referred to (613) 798-5555 ext 13377 or to [email protected] What is the impact of not taking concerns seriously?

o If concerns are not taken seriously, they may escalate to the point where patients and/or their families feel a need to involve a regulatory body, notify the media or initiate the litigation process.

o Delays and frustrations may worsen the situation. Historically, what are most concerns about?

o Communication issues

o Misperceptions and miscommunications.

o Not feeling heard.

o Wanting to make sure situation does not repeat itself. Which policies at TOH refer to Concerns Management?

What happens if a concern/s cannot be resolved?

o There may be situations where the hospital has taken appropriate and reasonable actions on the patient’s behalf in order to resolve the patient’s concern, and the patient and/or representative remain dissatisfied with the hospital’s actions.

o In these situations the hospital may consider the concern process closed for the purposes of these requirements. The hospital must maintain

documentation of its efforts.

What are the essentials steps of managing concerns?

o Listen, clarify, investigate, resolve, and record

o Provide potential recommendations for improvement. What can we learn from patient concerns?

o Concerns are an excellent source of quality issues

o They provide “vital red flags” (ref. 1, p. 6)

What should I do if a patient or family has a concern about parking?

o Depending on which campus, please refer the patient or family to the following: Riverside 82104, General 72003 and Civic 14888.

How are concerns about hospital invoices such as preferred accommodation, ambulances, etc managed?

o The complainant should be referred to the Accounts Receivable Department of Finance at 14444

My patient is complaining about their TV or telephone service. Who should these complaints be referred to?

o Please refer the patients to the following number: 1-800-253-5011 extension 152092 or they can send an e-mail to [email protected]

Does the Hospital have any courses on how to “Manage Concerns”?

o Please refer to page 8 of the Learning and Development Calendar for the course calendar:

What other tools are available to help educate our staff regarding our Concerns Management Process?

o Please refer to Appendix B for a PowerPoint Presentation highlighting relevant concepts. You are welcome to contact our department if you feel further education and training are required.

References

Osborne, L. (2004). Resolving patient complaints. Sudbury: Jones and Bartlett.

Concerns Management Policies

See Appendix A - Concerns Management Policy (in DRAFT – will be available soon)

Self directed learning tool – Concerns Management