Canadian Association of Radiologists Journal 65 (2014) 310e314 www.carjonline.org

Health Policy and Practice / Sante : politique et pratique medicale

Looking Back, Moving Forward: An Analysis of Complaints Submitted to a Canadian Tertiary Care Radiology Department and Lessons Learned Jason A. Robins, MDa,b,*, Najla Fasih, MBBS, FRCRa,b, Mark E. Schweitzer, MDa,b a

Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada b Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada

Abstract Purpose: We present an analysis of various types and strata of complaints received in a geographically isolated tertiary care center over a 2.5-year period. Methods: Research ethics board approval was obtained. The institution described is a closed system with formalized procedures for submitting complaints. All complaints submitted between November 2010 and March 2013 were collected retrospectively. The following data were extracted: type of complainant, nature of the complaint, site or modality of concern, dates in question, and the response. The data were analysed in multiple subgroups and compared with patient and study volume data. Results: The frequency of complaints equalled 0.01% (100/1,050,000). The largest group of those who submitted complaints were patients (69% [69/100]), followed by referring physicians (16%). Examination scheduling and interpersonal conflicts were equally of greatest frequency of concern (21% [21/100]), followed by issues with study reporting (16%). The average time interval between complaint submission and formal address was 15 days. Conclusions: We present a low frequency of complaints, with the majority of these complaints submitted by patients; scheduling and personal interactions were most often involved. Effective communication, both with patients and referring physicians, was identified as a particular focus for improving satisfaction. Resume Objectif : Nous avons analyse les plaintes qui ont ete adressees a un centre de soins tertiaires situe dans une region isolee au cours d’une periode de 2,5 ans, en nous penchant sur les divers types et domaines de plainte. Methodes : Le projet a ete approuve par le comite d’ethique de la recherche. L’etablissement en question constitue un systeme ferme dote de procedures officielles visant la soumission des plaintes. De fac¸on retrospective, nous avons reuni toutes les plaintes rec¸ues entre novembre 2010 et mars 2013. Nous en avons ensuite extrait les donnees suivantes : type de plaignant, nature de la plainte, partie du corps ou modalite visee par la plainte, dates et mesures prises a l’egard de la plainte. Enfin, nous avons analyse les donnees en les repartissant en de nombreux sous-groupes et en les comparant aux donnees sur les patients et les volumes d’examens. Resultats : La frequence des plaintes a ete etablie a 0,01 % (100/1 050 000). Les patients ont ete les plus nombreux a deposer une plainte (69 % [69/100]), suivi des medecins traitants (16 %). Dans une proportion egale (21% [21/100]), la planification des examens et les conflits interpersonnels se sont averes les motifs de plainte les plus souvent invoques, suivis des problemes lies aux rapports d’examens (16 %). Le delai moyen entre le dep^ot de la plainte et la prise de mesures officielles etait par ailleurs de 15 jours. Conclusion : Nous avons releve une frequence de plaintes peu elevee. Dans la majorite des cas, les plaintes ont ete deposees par des patients, le plus souvent pour des questions de planification des examens et d’interactions entre personnes. Nous avons determine qu’il y avait moyen d’ameliorer la satisfaction en mettant l’accent sur une communication efficace avec les patients et les medecins traitants. Ó 2014 Canadian Association of Radiologists. All rights reserved. Key Words: Quality assurance; Patient-centered care; Communication; Education

* Address for correspondence: Jason A. Robins, MD, Department of Medical Imaging, The Ottawa Hospital - Civic Campus, 1053 Carling Ave, Room C159, Ottawa, Ontario K1Y 4E9, Canada.

E-mail address: [email protected] (J. A. Robins).

0846-5371/$ - see front matter Ó 2014 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2014.02.003

Complaints in Canadian tertiary care radiology / Canadian Association of Radiologists Journal 65 (2014) 310e314

Although radiology departments strive to provide excellent patient care and service to referring physicians, instances do occur in which members of these groups are dissatisfied with their encounters. Complaints submitted as a result of these interactions warrant consideration, both in terms of addressing concerns in a timely and appropriate manner as well as of representing a resource in the assessment of quality. With the shifting focus towards more patientcentered care, there is a need to understand what issues arise in terms of service. Through investigation of the nature of these complaints, one may establish the best areas to target to improve. We present a unique experience in a closed-loop system in which all individuals in a geographic area use a single institution and where there are specific, wellrecognized legal avenues for each stakeholder to express concerns. What follows is an analysis of various types and strata of complaints received over a 2.5-year period. Materials and Methods Research ethics board approval was obtained. In our system, all tertiary care and most secondary care occur in 1 single institution that serves a geographic region of slightly more than 1 million individuals. In addition, there is a formal structure mandated to receive complaints. Complaints submitted by patients are directed through the hospital’s Department of Patient Advocacy. This department is advertised at various locations within the hospital, including information desks and is readily identified on the institution’s public Web site; contact can be made by telephone, fax, e-mail, or post. It is recommended to patients that they first discuss their concerns with the involved care team and/or member; if they are not satisfied or if they are uncomfortable doing this, a patient advocacy specialist will be involved to further investigate. Complaints from referring physicians and other employees are addressed directly to the radiology department chair or are funneled through the administrative director; both have their names, telephone numbers, and e-mail addresses listed within the hospital directory, and on the department Web site. This information is publicly available as well for patients who choose to contact them directly. Methodology was informed by our local experience as well as the UK Royal College of Radiology’s audit template collection [1]. All complaints submitted within the time period of November 2010 through March 2013 were collected retrospectively, as well as any correspondence related to these, before anonymization of patient information. The investigators then extracted from each submission the following data: the type of complainant, the nature of the complaint, the site or modality of concern (if specified), and the dates of the interaction in question and of the formal complaint submission. In addition, for those cases in which a response was documented, the nature and timing of this response was assessed as well. After extraction, the data were analysed in reference to volume and referring clinician data, in multiple subgroups, to best identify relative importance, trends, and, consequently, areas on which to focus for greatest quality improvement.

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Figure 1. Distribution of complainant type.

This included but was not limited to relative proportions of roles of those who submitted complaints, the frequency of different natures of complaints, and the intervals between initial submission and the complaint being addressed. Results A total of 106 complaint submissions were available for initial evaluation. Four of these entries lacked sufficient information regarding complainant type and the nature of the complaint; 2 entries reflected duplication between databases. After exclusion of these entries, the final sample included 100 complaint submissions, the earliest from January 13, 2011, and the latest from March 14, 2013. Approximately 1,050,000 radiologic examinations were performed at the involved institution during the period of review; the frequency of complaint, therefore, was 0.01% (100/1,050,000). Complainant Type Complainant types are listed in Figure 1. The largest group of those submitting complaints were patients themselves, which represented 69% of entries (69/100); 62 of these were submitted through the Department of Patient Advocacy, 5 directly to the radiology department, 1 through a clinical manager, and 1 through an investigator (in the case of a serious adverse event). This group was followed by individual referring physicians (16%), radiologists from within the department (7%), referring departments (5%), technologists (2%), and, finally, 1 nurse (1%). Nature of Complaint The nature of complaints are listed in Figure 2. Examination scheduling and interpersonal conflicts were equally of greatest frequency of concern (21% of entries [21/100]). Subgroup analysis demonstrated that the largest proportion of complaints submitted by patients were related to interpersonal conflicts (27% [19/69]), whereas interpretation errors were the focus of those submitted by physicians (31% [5/16]). Further details on these categories follow, with demonstrative examples.

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Patient Safety This category reflected 13% of entries. CTs were most frequently involved (31% [4/13]). One such examination came to light after the administration of oral contrast that was not requested by the referring physician; the patient had aspirated and was subsequently admitted to the intensive care unit. The patient’s swallowing difficulties were not known to the radiologist who had chosen the protocol for the study.

Figure 2. Distribution of the natures of complaints.

Examination Scheduling This category accounted for 21% of entries; 76% of the documented issues (16/21) were related to booking magnetic resonance imaging.

Image Interpretation Concerns regarding errors in image interpretation or lack of medical expertise were among the fewest reported, at 9% of entries. Miscellaneous Of the submissions, 3% were related to technical considerations, voiced primarily by radiologists and technologists. Finally, 2% of entries were in actuality letters of praise. Time Frame for Resolution

Interpersonal Conflicts Interpersonal conflicts were implicated in 21% of submitted complaints (21/100). These most often occurred during ultrasound examinations (43% [9/21]), followed by magnetic resonance imaging appointments (33% [7/21]). One incident had a patient’s mother express concern that her daughter was treated in an insensitive manner as she underwent an ultrasound examination that revealed a miscarriage. The involved radiologist was surprised by this perception and extended a written apology to both family members. Reporting These incidents accounted for 16% of entries. This particular category included failure to relay radiologic findings urgently, transmitting results to an inappropriate party, or marked delay in the availability of the report. In 1 example, a complaint was submitted by a patient who had visited the emergency department (ED) 2 years earlier after a fall. Radiographs at that time demonstrated no fractures but revealed an incidental lung nodule for which further investigation with computed tomography (CT) was suggested in the report. However, the patient was not made aware of the finding, and no CT was ultimately scheduled. Upon returning to the ED at the time of complaint, a radiograph showed worrisome interval growth. An investigation was undertaken by the hospital’s vice president of medical affairs, and the patient’s diagnostic and therapeutic care was expedited. Inappropriate Examinations A total of 15% of incidents were related to examinations that were different than those requested or that should not have been performed (ie, duplicate). Multiple similar examples occurred in which patients complained that they were scheduled for CT examinations instead of the magnetic resonance imaging requested by their general practitioner. The department manager or radiologist contacted the individual to explain the rationale for the change.

For complaints in which responses were documented, the average time interval between complaint submission and formal address was 15 days; the median interval was 3 days. The majority of complaints were responded to immediately; the longest interval recorded measured 248 days (a complex case after discord between the initial imaging report and the results of a later resultant surgery). Discussion Radiology departments today represent the diagnostic point of care in many hospitals and are rapidly expanding. This study demonstrates that complaints regarding their service are uncommon, despite the potential that arises from the great number of encounters. However, when they do occur, they originate from a variety of sources and involve interactions that are diverse both in their content and setting. Although radiology department complaints are infrequent, analysis of their content provides a valuable assessment of quality and suggests avenues for improvement; effective communication, both with patients and referring physicians, was identified as a particular focus to enhance satisfaction. It is implicated in the majority of the most-frequent categories of complaint. Although a significant proportion of the incidents can be attributed to errors on the part of the radiology department and/or the individual radiologist, many complaints materialized as a result of misconceptions rather than actual mistakes. Exploration of these examples provided important insight. The majority of entries that concerned scheduling were the result of inappropriate delays in obtaining studies. In several incidents, this indeed was the case, which potentially limited timely surgical and oncologic therapies for patients in need. However, many perceived ‘‘delays’’ were found to be due to inadequate information provided on the requisitions or those marked as high priority and/or urgent when in

Complaints in Canadian tertiary care radiology / Canadian Association of Radiologists Journal 65 (2014) 310e314

fact the examinations were not truly indicated for the time frame requested; waiting for nonurgent imaging is quite common in our system. Likewise, the majority of ‘‘inappropriate’’ examinations originated from radiologists switching modalities of a study to the one that was appropriately indicated for answering the clinical question or further workup. In our system, a requisition is a request for a consultation; a radiologist is able to, and is encouraged to, change the requested modality to another that is of lower cost or wider availability. Similarly, investigation of several incidents in which results were allegedly not relayed in a timely manner revealed that the radiologist had, in fact, communicated his or her findings to the requesting physician listed on the requisition, separate from the one who ultimately complained. Previous research into this topic has been limited. Salazar et al [2] recently published their analysis regarding the radiology department at Massachusetts General Hospital and reported a frequency of complaints of 0.238 per 10,000 encounters. The majority of the submissions reflected a failure to provide patient-centered care, and the investigators similarly identified interpersonal interactions as a focus for improvement. However, several of their points of concern are less applicable in the Canadian medical environment or elsewhere with socialized health care; these include issues with, for example, billing and reimbursement. In addition, their investigation was limited only to patients’ complaints; in our study, 31% of submissions came from other sources, including referring physicians. The information provided by the latter must be equally considered of value in optimizing the operation of a department within a multidisciplinary institution. Comparable studies have been performed in other medical specialties. An audit performed within a university hospital surgical department examined complaints submitted over a 1-year period; these were most frequently related to clinical care (31%), followed by delays in progression and/or discharge (30%), and communication issues (19%). The frequency of complaints in their particular setting was approximately 1 per 400 encounters, far greater than we found. The investigators documented poor communication as a common underlying cause and noted that the majority of the complaints were satisfactorily addressed by a single letter or telephone explanation, which suggests that they ‘‘may have been preventable by better communication and explanation at the time of the health-care episode’’ [3]. Several investigations have been performed in the emergency setting. A systematic review of ED ‘‘customer satisfaction’’ noted reported rates of complaints of 1.65-5 per 1000 patients [4], also far higher than we found. In another study, an analysis of ED complaints concluded that patients were often negatively affected by staff attitude and behavior [5]. Interpersonal issues appear to be a common concern in medical care. A further study of ED complaints focused solely on those submitted by health care providers and found that the nature of their concerns often differed from those of patients; the

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investigators noted that this group is ‘‘uniquely positioned to provide detailed follow up, to present pointed inquiry, and to give informed opinions about care’’ [6]. Quality assurance has become an essential component of service industries outside of medicine and perhaps the most thoroughly examined has been aviation. In 1987, in responding to growing consumer dissatisfaction, the U.S. Department of Transportation established both a formalized method for passengers to voice complaints and a requirement of all major airlines to report metrics of performance (eg, mishandled baggage). The information from these sources was used to form the U.S. Department of Transportation Air Travel Consumer Report, widely available to the public. In late 1989, complaint rates ranged from 0.726.5 per 100,000 passengers. It is interesting to note that the 5 airlines with the highest frequency of complaints either filed for bankruptcy within the following 2 years or ceased to operate entirely [7]. The Air Travel Consumer Report is still published monthly to this day; the most recent available at the time of this writing reported an overall rate of complaint of 0.97 per 100,000 enplanements (passengers) (0.001%) [8]. Several limitations were identified in this study. Due to its retrospective nature, there was a lack of uniformity among the information recorded for each incident; as a result, some cases were missing details that could have provided further insight. In particular, for those entries in which a response was documented, few included whether this was considered satisfactory by the complainant involved. This factor is of paramount importance beyond just the timeliness of addressing one’s concern. The facts presented in this article reflect a snapshot in time and may not necessarily be applicable beyond the time period studied; however, it is believed that the findings remain realistic and informative. Our findings may be more demonstrative because we have a closed-loop system in which all patients within a geographic region come to a single institution for advanced care; the results of such an investigation will vary among institutions, as will the feasible solutions to the problems discovered. This study was designed and performed in an effort to identify areas of concern so that these may ultimately be addressed to improve patient and referring service satisfaction. In several cases, procedural changes have already come into effect to further prevent incidents from occurring. Additional solutions have also become evident as a result of this research. This work has helped identify numerous opportunities for quality improvement as well as for education both within and outside our department; it is recommended that similar projects be undertaken locally to determine one’s own path to assuring best patient care and referring physician satisfaction. Acknowledgements We thank Melanie Henderson, manager, and Samantha Soubliere, triage coordinator, of The Ottawa Hospital

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Department of Patient Advocacy, for their significant contributions to this project as well as their ongoing dedication to patient care. References [1] Duncan K, Warwick R. Audit of complaints. Royal College of Radiologists: Academic radiology and audit. February 15, 2008. Available at: http://www.rcr.ac.uk/audittemplate.aspx?PageID¼1020&AuditTemplate ID¼64. Accessed January 4, 2013. [2] Salazar G, Quencer K, Aran S, et al. Patient satisfaction in radiology: qualitative analysis of written complaints generated over a 10-year period in an academic medical center. J Am Coll Radiol 2013;10: 513e7.

[3] Mann CD, Howes JA, Buchanan A, et al. One-year audit of complaints made against a university hospital surgery department. ANZ J Surg 2012;82:671e4. [4] Vukmir RB. Customer satisfaction. Int J Health Care Qual Assur 2006; 19(1):8e31. [5] Mace SE. An analysis of patient complaints in an observation unit. J Qual Clin Pract 1998;18:151e8. [6] Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument. Qual Saf Health Care 2006;15:344e6. [7] Lapre MA, Scudder GD. Performance improvement paths in the US airline industry: linking trade-offs to asset frontiers. Production and Operations Management 2004; 2004;13(2):123e34. [8] U.S. Department of Transportation. DOT Air Travel Consumer Report July 2013. Available at http://www.dot.gov/sites/dot.dev/files/docs/ 2013JulyATCR.pdf. Accessed July 18, 2013.

Looking back, moving forward: an analysis of complaints submitted to a Canadian tertiary care radiology department and lessons learned.

We present an analysis of various types and strata of complaints received in a geographically isolated tertiary care center over a 2.5-year period...
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