Transforming Patient Care at Bruyère Health Saint-Vincent Hospital: A Bruyère Rapid Review

Report Authors: Beverley Shea, Vivian Welch, Jason Nickerson

Executive Summary

We conducted a rapid review of the peer reviewed literature to explore hospitals’ complaints systems looking at how the hospitals address complaints about care made by patients and families.

One of the key ways we learn how we are doing is learning from the patient and their families through complaints and from compliments. The latter is always easier to take but the former, if handled well allows us to drastically improve over time.

If standards of care were better and patients felt respected and comfortable communicating concerns to staff, while having their concerns dealt with in a timely fashion--many would not feel the need to issue an official complaint.  Often the patient is vulnerable and in an unequal power relationship. It is incumbent on all caregivers to redress the balance and allow the patient to participate in his/her care.

Too often patients feel uncertain or confused when they feel they have a problem. Some never complain because they feel their complaint is unjustified or because they think staff is too busy to listen to them. Others may lack confidence, feel they will risk their quality of care, or find the complaints process hard to understand or too much inconvenience. It should not be difficult to complain, and patients and families should not bear responsibility for chasing progress once a complaint has been issued.

Hospitals like Bruyère Health need to change the way they deal with complaints. All feedback, including complaints, offer valuable information that can drive continuous improvement. We suggest:

• establishing an Office of Patient Experience (OPE) for patients, caregivers, staff and volunteers
• appointing an Ombudsperson to deal with any complaints that could not be resolved by the Office of Patient Experience

The proposed complaints system will not only constitute a means to measure the patient and family experience at Bruyère Health Saint-Vincent Hospital (SVH), but will also help to address the areas of significant concern identified via the NHS review and the Bruyère Health Research Institute concept mapping sessions. As SVH evolves to deliver high-quality care to an increasingly acute patient population, the nature of patient’s complaints and concerns will evolve in response. This complaints system will identify complaint trends and patterns to accommodate the dynamic concerns of SVH’s population at both individualised and systemic levels.

We propose that most complaints should be resolved within 48-72 hours at the level of the ward and Director of Nursing. If that does not work then either OPE gets involved and after 4 days the Ombudsperson is asked to get involved. It is extremely important that the patient plays a role as things progress in the negotiations as to what a satisfactory outcome and process would look like. The Ombudsperson’s role will be to informally resolve complaints via mediation, negotiation, and subtle diplomacy. They will conduct inquiries and structured investigation to determine if a complaint is founded or identify if complaints are following a trend. Based on the investigations, the Ombudsperson will make recommendations to correct unfair situations of both individualized and systemic nature.

The full report is available for download. 

Table of Contents

• Key messages
• Background: context
• Methods
• Systematic review
• Evidence review
• Suggestions for continuous improvement

Key messages

One of the key ways hospitals learn how they are doing is learning from the patient and their families through complaints and from compliments. All feedback, including complaints, offer valuable information that can drive continuous improvement. We suggest: 

• establishing an Office of Patient Experience (OPE) for patients, caregivers, staff and volunteers.  
• appointing an Ombudsperson to deal with any complaints that could not be resolved by the Office of Patient Experience (OPE). 

The proposed complaints system will not only constitute a means to measure the patient and family experience at Bruyère Health Saint-Vincent Hospital (SVH), but will also help to address the areas of significant concern identified via the NHS review and the Bruyère Health Research Institute concept mapping sessions. It will identify complaint trends and patterns to accommodate the dynamic concerns of SVH’s population at both individualised and systemic levels.

We propose that most complaints should be resolved within 48-72 hours at the level of the ward and Director of Nursing. If that does not work then either OPE gets involved and after four days the Ombudsperson is asked to get involved.

Background: context

Saint Vincent Hospital (SVH), a 336 bed complex continuing care hospital and part of Bruyère Health, is undergoing a major care transformation and revitalization to improve its capacity to provide comprehensive, coordinated, and person-centered care for all patients admitted to the hospital. The project is an 18-month program entitled Transforming the Patient Experience that will propose innovative patient- and family-centered solutions to develop and implement models of care for our challenging and complex patient population.

Bruyère’s vision is to become the champion of continuing care in the Ottawa region, focusing on providing care for complex multi-morbid patients in hospitals and in the community through patient-centered, high-quality, evidence-based practice. The project draws on input from clinicians, staff, patients, and their families to support the implementation of new models of care. Throughout our transformation project, multiple key strategies have been implemented so we would be better prepared to address the needs of an increasingly complex patient population. Essential to our success will be Partnering with Patients and Families and Reaffirming Quality at Bruyère Health.

Methods

To better understand the complex variety of factors that contribute to quality of care at SVH, we conducted concept mapping sessions with patient, family, and staff focus groups. During concept mapping sessions, we asked participants to identify issues they believed had a significant impact on SVH’s clinical environment. These issues constitute person-centred indicators for measuring the quality of care at SVH. Using participant responses, we can develop an instrument to measure the patient and family experience SVH offers, which is a key component of the Transforming the Patient Experience project at SVH.

The concept mapping procedure consisted of the following steps:

• carrying out a literature search
• carrying out concept mapping exercises with patients, patients’ families, leaders, nurses, allied health professionals, and medical staff; group sizes ranged from 3-12 people
• developing concept maps and weights for each of the concepts and themes developed by the groups; over 800 initial concepts were identified

The concepts identified by focus group participants were then distilled into 12 overall themes chosen by the groups, with each of the concepts fitting under the following 12 themes:

Direction toward Sub-Acute Care:

• all focus groups felt SVH needs to clarify its role as a sub-acute care hospital
• the transition requires excellent two-way communication at all organisational levels 

• patients and families were concerned about cleanliness and answering call bells
• staff were concerned about wound care and preventing falls

Equipment and infrastructure:

• patients and families felt equipment should be regularly maintained and fixed before it is rendered unusable or unsafe 

Funding:

• all focus groups agreed funding should be allocated to each unit in proportion to the number and complexity of patients for whom it cares

Person-Centered Care (Quality, Taste of Food):

• all focus groups agreed that explaining rationale for their overall care including therapies, goals and care plans, to patients and keeping them informed is important
• patients and families also wanted higher quality food options 

Coordinated Care (Collaboration and Partnerships):

• staff emphasized the need to establish inter-professional collaborative teams to better deal with patient complexity 

Accountability (Respect (including cultural respect), Professionalism, GRASP, Reporting, and Cultural Safety):

• almost all participants stated all patients and families should be provided with contacts upon admission
• nurses wanted troubleshooting to be added to GRASP
• staff emphasized the importance of reporting incidents and sharing data
• patients felt that staff must speak in the language of the patient when caring for them
• everyone expressed their concerns over a common lack of respect culture

Care at Transitions (Admission, Discharge, and Transfers):

• almost all participants emphasized the need to standardize transition processes both internally and externally but in particular between floors

Best Practices:

• participants emphasized the need to adopt more acute-care pathways, conduct more debriefing with patients during rounds, and standardize and document all rounds procedures

Culture of Learning (Building Capacity, Learning, Mentorship, and Education):

• all focus group prioritized providing accessible education and training opportunities to staff, patients, and families
• families and nurses felt staff should be paid for the time they spend developing their skill sets

Talent Management (Hiring and Managing Talent, Scheduling, Volunteers): 

• all focus groups considered retaining talented staff important
• patients felt volunteers should undergo performance assessments  

Organisational Support (Staff and Support of Caregivers):

• nurses stressed the need to develop a system for dealing with complaints and concerns

Using these concepts and themes, we are deepening our understanding of the key factors shaping the patient and family experience at SVH. The concept mapping sessions yielded information that will guide us in creating an instrument to measure quality of care at the Bruyère Health Saint-Vincent Hospital. We must also strive for continuous improvement–learning from the mistakes we make along the way.

We must build a base that consistently improves through doing it better and innovating how we do it. One of the key ways we learn how we are doing is learning from the patient and their families through complaints and from compliments. The latter is always easier to take but the former, if handled well allows us to drastically improve over time.

Systematic review: developing a system for hearing & addressing complaints

As SVH evolves to address the issues identified via the concept mapping sessions, staff will need a steady inflow of feedback, both good and bad, from patients and families. A system for hearing and addressing complaints will not only constitute a means to measure the effectiveness of newly implemented measures, but also provide a constantly updating picture of areas for improvement.

Patients expect and deserve not just kind, safe care, but an in-hospital experience that is respectful, compassionate, and responsive to their needs. Always remember the individual person behind each patient!

Evidence review

We conducted a rapid review of the peer reviewed literature to explore hospitals’ complaints systems looking at how the hospitals address complaints about care made by patients and families. We searched Medline, Cochrane Library and Google Scholar up to and including 2014. We included grey literature and invited content experts to forward known hospital complaint systems. We found a few relevant studies and websites used to support our recommendations. 

In The National Health Service 2013 review of hospital complaints systems patients expressed concern about lack of information, lack of compassion, lack of dignity and care, poor staff, and insufficient resources. Table 2 (in PDF) presents the similarities between the results of the NHS review and the BRI concept mapping sessions. The column for the results of the BRI concept mapping sessions specifies the type(s) of focus groups that expressed each concern and the theme under which the concern falls.

Many of the concerns expressed by Bruyere’s concept mapping participants are linked directly to the primary issues patients identified during the NHS review. While the concept mapping sessions identified numerous clinical and organisational issues that are not mentioned in this table, the patient and family participants were most often concerned with issues related to the information they were provided, the compassionate care and respect received, the quality of their clinical environments, the attitudes staff adopted toward patients and families, and the clinical and social resources devoted to patients.

Equally importantly patients and their families needed to have a voice and to be able to make known their concerns and complaints. They need clear and simple information about how to express their complaints about issues like these. They may need someone accessible to help them through the process of providing a complaint, and they need their complaints handled as quickly as possible. Furthermore, they should not feel that their complaints will incite hostility and jeopardize their quality of care. Most importantly, patients’ complaints should help improve hospital conditions.

Suggestions for continuous improvement

The following suggestions/recommendations focus on improving the quality of care and improving the way complaints are handled. This latter item includes establishing an office of patient experience and ensuring complaints procedures maintain independence.

The NHS review received 2,500 responses, the majority describing problems with the quality of treatment or care in hospitals. The review panel also heard from people who had not complained because the process was too confusing or who feared jeopardizing their future quality of care. Similar suggestions have recently been made at Bruyère Health and similar recommendations could be adopted.

 
Improving the quality of care:

If standards of care were better and patients felt respected and comfortable communicating concerns to staff, while having their concerns dealt with in a timely fashion--many would not feel the need to issue an official complaint.  Often the patient is vulnerable and in an unequal power relationship. It is incumbent on all caregivers to redress the balance and allow the patient to participate in his/her care. There are the suggestions:

• adequately train, support, and supervise all BCC staff to provide the best possible person-centred care, consistently displaying forms of empathy and respect towards patients, families and their own colleagues. And to better problem solve when faced with complex situations
• conduct annual appraisals focusing on staff communication skills and how staff deal with patients. Communication skills should be a core component of all clinical training programs
• ensure the ward provides enough basic information to patients, such as meal times, visiting hours, and descriptions of staff roles and responsibilities
• provide patients with a way to express concerns at the ward. This includes simple measures, such as placing pen and paper at patients’ bedside and ensuring patients know whom to speak to if they have a concern
• encourage and empower volunteers to support patients. Volunteers can help patients express concerns or complaints. This is particularly important for patients who are vulnerable or alone, for under these circumstances they may find it difficult to express a concern independently. Ensure volunteers are appropriately trained to help patients this way

Improving the way complaints are handled:

Too often patients feel uncertain or confused when they feel they have a problem. Some never complain because they feel their complaint is unjustified or because they think staff is too busy to listen to them. Others may lack confidence, feel they will risk their quality of care, or find the complaints process hard to understand or too much inconvenience. It should not be difficult to complain, and patients and families should not bear responsibility for chasing progress once a complaint has been issued.

Hospitals like Bruyère Health need to change the way they deal with complaints. All feedback, including complaints, offer valuable information that can drive continuous improvement. These are the suggestions:

The above recommendations focus on ways to bring more independence into complaints handling. We suggest establishing an Office of Patient Experience for patients, caregivers, staff and volunteers.  And in addition appoint an Ombudsperson to deal with any complaints that could not be resolved by the Office of Patient Experience. The proposed complaints system (see Appendix 1 and Appendix 2 for complete details of the flowchart and process) will not only constitute a means to measure the patient and family experience at Bruyère Health Saint-Vincent Hospital, but will also help to address the areas of significant concern identified via the NHS review and the BRI concept mapping sessions. As SVH evolves to deliver high-quality care to an increasingly acute patient population, the nature of patient’s complaints and concerns will evolve in response. This complaints system will identify complaint trends and patterns to accommodate the dynamic concerns of SVH’s population at both individualised and systemic levels. 

We propose that most complaints should be resolved within 48-72 hours at the level of the ward and Director of Nursing. If that does not work then either OPE gets involved and after 4 days the Ombudsperson is asked to get involved. It is extremely important that the patient plays a role as things progress in the negotiations as to what a satisfactory outcome and process would look like. The Ombudsperson’s role will be to informally resolve complaints via mediation, negotiation, and subtle diplomacy. They will conduct inquiries and structured investigation to determine if a complaint is founded or identify if complaints are following a trend. Based on the investigations, the Ombudsperson will make recommendations to correct unfair situations of both individualised and systemic nature.