Wanted: Complaints
Turn Complaints into Assets with a Physicians' Complaint System
by Dr. Ross DiBernardo, M.D. and James Shaw, MBA

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A hospital's admitting, or attending, physicians are in a unique position to know how well a hospital is working. They are customers of many hospital transactions, receiving x-rays and laboratory tests, for example. They can apply professional expertise in evaluating the outputs they receive, and they know how different activities fit in with the overall goal of delivering quality care. They are also customers of the organization as a whole, bringing patients to the hospital and retaining responsibility for patients after discharge. They see first-hand the quality of care their patients have received, and they know how to judge it.

At the same time, physicians are also suppliers/partners with a vested interest in improving performance. Both hospital and physician are in the business of delivering the highest quality of care possible. Improvements in a hospital's performance boost physician productivity, too. These were some of the reasons the St. John's Performance Improvement Council decided to establish a Manage Physicians' Complaint Process as part of our overall development effort. We suspected that our physicians were a rich, unused source of useful knowledge and that a complaint system would be the best way to tap into it.

Avoiding Pitfalls
We included physician input from the outset by inviting two physicians to join the design team. One of the first questions put to them was: How should complaints be entered into the process?

The physicians were quick to reject a paper system. Filling out a complaint form was the kind of task likely to be postponed and forgotten, they said. After some discussion, the team came up with the idea of a hotline, a voice mailbox where physicians could phone in a complaint and be done with it.

The "no paper" requirement was confirmed when we contacted colleagues who had tried physician complaint systems and failed. Just as our own physicians predicted, filling out complaint forms had proved to be a major stumbling block.

We also learned a second reason for failure. Our colleagues reported that complaints were not always resolved in a timely or satisfactory manner, which undermined the effort and hampered success. Answering complaints was frequently low on the priority list of busy staff. Often physicians didn't bother to document complaints, suspecting that it would do no good.

These preliminary findings provided us with two key goals as we prepared to design our system.
We decided: ·
-to implement an easy-to-use input device available 24 hours a day, 7 days a week, 365 days a year-the hotline our improvement team physicians had suggested. ·
-to build accountability into the process to assure timely and satisfactory responses to complaints.

Developing the Blueprint
To conceptualize the key elements of a physician's complaint process, the team used Shaw Resources' Process Advisor™ software to create a Process Profile® graphic , a display tool that defines the elements of a process. A Process

Figure 1

Profile graphic displays a process's purpose, its customers and suppliers, inputs and outputs, quality measures, and the process's start and end point in a single, easy-to-read format (see Figure 1). Coming to consensus on these elements requires a good deal of discussion and exploration that pay off in the long run. Everyone on the team becomes a stakeholder in the success of the process, and everyone on the team has a shared vision of what the process should be. The Process Profile^® graphic is a good tool for communicating the basic elements of a process to others in the organization, too.

After hammering out a process purpose statement, the team went on to identify physicians as our new process's primary customer-and also its primary supplier. Physicians would be providing the process's most important input-complaints-and they would also be receiving its most important output-the resolution (and prevention of recurrence) of the complaint. With these important elements established, the team went on to identify an additional customer (management) and output (reports), as well as the start and end points of the process. Next came the vital question of measurements. How would we measure the performance of our new process? Using the Shaw methodology, we began with the customer's expectations regarding the outputs received. For example, the physicians would expect the resolution of a complaint to be satisfactory and timely. The team then learned how to express these expectations as measurements. For example, "timely" could be quantified as a cycle time: the time it takes to resolve a complaint. The number of "unsatisfactory" ratings gathered in a follow-up survey could quantify "satisfactory." (Generally, expectations can be quantified in either of these two ways, as a cycle time or as an adverse indicator.) Considerable discussion accompanied the development of the measures, and during the pilot period, the team made a number of adjustments. The timeframe for resolving complaints, for instance, underwent several changes. We found that the physicians' complaints tended to require systemic changes that could not be made in a day or two. We tried out different time periods and finally settled on three weeks. We followed the same procedure to determine the performance measurements for the process's inputs. For example, the incoming complaints needed to contain accurate information. Two measures quantifying this "expectation" were the number of complaints with incomplete information and the number of follow-up phone calls needed to gather additional data. By the time we completed our Process Profile^® graphic, we had developed a clear, detailed picture of a Manage Physician's Complaint Process. All process elements were displayed in one place. It was an iterative display that the team could update and adjust as necessary, and it continues to guide us as we work to improve process performance.

                                                                           Figure 2

Establishing the Process Steps
The team next created a deployment flow chart to establish the steps of the process, the responsible parties, and the location of each step (see Figure 2). The format we used helped us to see places where we could build in accountability and establish control measures to spur performance.

When a physician encounters an unsatisfactory situation (Step 1), complaints can be entered into the process via our hotline, as an oral communication to an employee, or in a traditional complaint form (Step 2). Medical Staff Services captures, logs, triages, and forwards the complaints to the appropriate managers (Step 3). Since complaints can enter the process in three different ways, we developed a standard complaint form, including a control number for each complaint, in order to minimize variations and make it easier to triage the complaints. Medical Staff Services also sends an acknowledgment to the physician that the complaint had been received (Step 4). This was our first opportunity to set a time limit, and we settled on two days as a reasonable response time.

As mentioned, the manager has three weeks after receiving a complaint to investigate, resolve, and take action to prevent it from recurring (Step 5). The manager is responsible for creating and sending a report of actions taken to the physician, with a copy to Medical Staff Services (Step 6). When a complaint cannot be resolved in this timeframe, the manager's report must explain why, along with actions in progress or proposed. If a report is not received in the Medical Staff office on time, a notice is sent to the appropriate vice president or director.

To evaluate our Manage Physicians' Complaint Process we send a brief (three-question) survey to the participating physician (Step 7). Any doctor who expresses dissatisfaction with the complaint resolution process receives a personal phone call from the Vice President of Medical Affairs in an effort to find out what could have been done better. At this point the resolution of the complaint is complete.

Quarterly, the Process Improvement Team analyzes and trends the data, presenting the results to medical and managerial staffs (Step 8). This step is key to making permanent changes to our processes that improve organizational performance. Annually, the team evaluates and makes improvements to our Manage Physicians' Complaint Process (Step 9), an important step in our continuous improvement cycle.

Deployment
We launched our new Physicians' Complaint Process quietly to give ourselves time to work out the kinks. Once we were satisfied that the process was robust and our response times acceptable, we posted signs with the complaint hotline number in each unit where the physicians do their paper work. We also put stickers with the phone number on the phones they were likely to use. We put up storyboards in the doctors' lounge, reminding them of the new system.

Our Physicians' Complaint System drew from a pool of 285 physicians on active status: 182 specialists and 103 primary care physicians. Between February 1996 and June 31, 1999 we received 890 complaints, and 860 of them were resolved successfully, a 96.6% success rate.

Sometimes a complaint could not be resolved. When this happened, it was forwarded to the Vice President of Medical Affairs, who called the physician entering the complaint to explain the realities of the situation and why it was impractical or impossible to resolve the complaint. Usually the doctor understood our position and was satisfied by the explanation, but sometimes we simply had to agree to disagree and make the best of the situation.

Monitoring
Ongoing monitoring is important to prevent performance degradation. We track cycle times and resolution rates, trending the data every quarter so that we can analyze our performance over time.

Twice a year we aggregate the data into categories, compiling reports that we send to the Physicians' Executive Committee, as well as the Process Improvement Council. We find that the physicians are very interested in these reports. Categorizing the complaints often reveals issues that may have escaped notice, prompting questions from the physicians. We investigate and report back our findings, sometimes making improvements to a process in the light of what we have discovered, even though there has been no specific complaint. Consequently, the physicians are beginning to see our Physicians' Complaint System as their means of input to the administration.

Overcoming Obstacles
Patience and persistence were essential to the success of our Physician's Complaint Process. We met with some resistance at first, partly because people have a natural aversion to hearing complaints about themselves and partly because of a suspicion that the complaints might be used to criticize performance. We had to turn these perceptions around. We emphasized that complaints were a valuable source of information on how to improve our processes. We made no negative judgments on the number of complaints. In fact, we stressed the opposite: more complaints meant more good information and more opportunities to improve. A lack of complaints was not necessarily a sign of good performance either. It could mean that physicians were too frustrated to report them.

There was also initial reluctance on the part of some physicians to participate in our complaint process. We emphasized the power of numbers, explaining that when we receive a complaint from only one physician on an issue, rather than from the four or five with the same concern, we cannot know that the issue is a significant one. A conspicuous number of complaints would assure an issue's resolution.

Writing a good response report turned out to be a skill that had to be learned and practiced. At first, there was a tendency to make excuses. After about a year, though, the managers were writing objective, professional documents.

To encourage good performance, we set up a reward system that has proven effective. When a manager has met the three-week deadline and received a highly satisfactory rating for complaint resolution from the doctor, we put the manager's name in a hat for a quarterly drawing. The winner receives a dinner for two at one of our local restaurants, and all of the managers in the drawing receive a congratulatory letter from the president that goes into their personnel file.

Benefits
Our Manage Physicians' Complaints Process has gone a long way toward improving physician/hospital relations. Our physicians are impressed that we are willing to expend so much effort to elicit and address their concerns, and many have written letters to tell us so. We have even received letters from physicians associated with other hospitals. One example is a physician who complained to us that our Medical Records Department had not transferred a patient's records to him in a timely manner. When the manager of Medical Records wrote to the physician apologizing for the delay and explaining how the improvement team had changed the process to prevent it from happening again, he not only wrote us a complimentary letter, thanking us for our response, he also sent a letter to his own administrators suggesting that they implement a complaint process similar to ours.

The benefits go beyond physician/hospital relations, too. Our physicians provide vital information for improvements via our complaint system. We now have numerous, improved supply items, thanks to our physicians' suggestions. They tell us when a supply item is not the right kind or if there is something better available. For example, our surgeons tipped us off to a surgical drape that was better and less expensive than the one we had been ordering.

Part of our purpose in resolving a complaint is to make a permanent change that eliminates the problem altogether and prevents it from recurring. In one instance, our physicians alerted us to an insufficient number of intravenous pain medication pumps, which caused a delay in getting them on patients when they needed them. A process improvement team investigated and found that many pumps were out of operation because they were old or broken. The team also discovered that there were many different types of pumps, which was confusing for the nurses, who often were responding under time pressures and the demands of other duties. The team did a cost analysis and bought new pumps, all the same kind, thus standardizing the equipment. The result of this permanent improvement was an increase in the availability of the pumps and a decrease in the time it takes to put them on patients.

In another instance, an air vacuum suction machine failed during pediatric surgery, and no replacement was immediately at hand. Our practice had been to include the air vacuum suction machine on the emergency cart, but we had not provided redundant equipment. To prevent future occurrences of this problem, we installed an air vacuum suction machine on a permanent fixture in the pediatric surgery unit. We still include one on the emergency cart but as a backup now.

Examples like these speak for the long-term benefits of our Manage Physicians' Complaints Process. It is an emblem of our changing culture at St. John's, as we work to systematically improve our performance in order to become a more competitive provider of first-rate healthcare.

About the Authors
Dr. Ross DiBernardo was formerly Vice President of Medical Affairs for St. John's Hospitals in Ventura County, CA.. Prior to his administrative position, he practiced cardiology at St. John's for 21 years. He received his medical degree from UC San Francisco and served his internship and residency at Wadsworth VA/UCLA.. In addition, Dr. DiBernardo was a member of Malcolm Baldrige National Quality Award Board of Examiners in 1997-1998. He may be contacted via email at diber@gte.net or via telephone at 805-985-1727. 

James G. Shaw, M.B.A., is President of Shaw Resources. He spent four years on the Board of Examiners for the Baldrige Award where his service included being a senior examiner. Currently, he is a member of the Awards Councils for both the California Governor's Award and the California Council for Quality and Service. He may be contacted via www.ShawResources.com, via telephone at 888-ShawRes (888-742-9737), or via e-mail at Jim@ShawResources.com.