Question 4

College answer

Aim: To explore the theory and process of complaint resolution, a key skill in ICU leadership. Specifically in relation to written complaints and cultural safety.
Key sources include: IC 20- CICM document, Paper 2022.2 Q22. CanMEDS Communicator.
Discussion: Complaint resolution is a repeat topic from last paper 2022.2. and comprised most of the marks. A high level of detail in the complaint resolution process was expected given its importance and its recency in the previous paper. Candidates gained more marks if they addressed concerns AND provided appropriate sensitive follow up in a quality and safety structural format. These candidates did better than candidates who diffused the situation only, without closing the review process in minimal or absent detail.
A list of statements without structure or prioritisation did not address the question as well as a prioritised step wise outline of appropriate investigations and resolution. Some answers escalated the complaint inappropriately suggesting lawyers, police, and hospital administration involvement. The better answers included appropriate referrals through formal or informal channels of resolution and identified the key drivers of change for improvement within the department. The expert answers concluded with methods to monitor and maintain sustainable change for future best practice in this area.
Cultural safety 30% marks – The importance of health equity has been an important topic in health education for many years. No candidate failed this question on cultural safety content. Some candidates went into great depth about specific care and sensitivity to patients with diverse cultural backgrounds they bring to their practice. They were allocated expert pass marks accordingly and are to be commended.
 

Discussion

The CICM document IC-20 (Prevention of Bullying, Discrimination and Harassment in the Workplace) is fifteen pages of dense bleak horror that was published many years ago and that has remained unaltered since 2016. It is therefore unsurprising that such a large number of trainees were able to score so highly on this SAQ. Moreover, as the answer is right there on the college website, there was no excuse for getting it wrong.

As the college answer has pointed out, Question 22 from the second paper of 2022 has already warned people that something like this might be coming, and considering the pass rate has improved (from 40.4% to 66.3%) they clearly paid attention, suggesting there is still some value in doing the past papers.

So: a standard conflict resolution process is produced below, as it would have satisfied the 70% component: 

• Receive the complain - this is usually the part that requires a face-to-face or telephone meeting with the complainant, where empathy is essential
• Identify and log the complaint. This is an essential part of the process, and usually consists of a written notification made to the person who handles such complaints, or a submission into a centralised system that compiles and archives these events for audit (which most large health services will have).
  • Determine whether a response is required: A complaint is often something that requires addressing and following up with a response, whereas feedback from patients and families does not necessarily require follow-up.
• Acknowledge the complaint. This usually requires the complaints manager to
  • contact the complainant (ideally, soon)
  • Make an apology
  • assure them the complaint has been considered
  • indicate a contact person for them to have access to if they have further questions, and 
  • establish a timeframe over which the response should be expected
• Assess the complaint. 
  • This likely requires somebody senior to look at the complaint and determine the level of seriousness, which will then determine the priority and the need for escalation
  • This requires some risk assessment, to determine whether the complaint raises "significant operational, legal, financial or reputational risks" to the organisation.
  • Information needs to be gathered to identify the personnel involved and the issues raised, to help determine the level of risk (but this is not the investigation phase)
• Address the complaint
  • Depending on the type of complaint, possible outcomes include something informal, like an apology and acknowledgement without investigation, or an internal investigation, or even an escalation of the referral 
  • This will depend on what was complained about, and this process should be collaborative,i.e. the complainant's expectations of what needs to happen should be taken into account.
  • The solutions may include some (or all) of the following:
    • Making an apology in some formal sense
    • Providing the complainant with information
    • Meeting with the complainant to have ongoing discussion
    • Escalating the complaint to a regulatory body
    • Investigating the allegations made in the complaint
  • Not all complaints will require an investigation, but where they do, the investigation must be impartial, confidential, and fair.
• Communicate the outcome
  • This may be in the form of a written statement or another meeting
  • Any decisions, as well as the reasons behind them, including remedial actions or preventative measures, would be important here
  • System issues should be fed back to any staff or agencies involved in the complaint or otherwise.
• Finalise the complaint
  • ​​​​​​Determine whether the complainant is satisfied with the outcome
  • Invite them to access review and escalation options
  • Update the record of the complaint to reflect the end of these events

Cultural awareness content for 30% of the marks would likely have been passed by the candidate mentioning that they would make a referral to the Aboriginal Liaison Officer (in Australia) or a corresponding healthcare service position in Aoteroa NZ. However this is really the same thing as reflexively calling for the social worker the moment a family starts crying in your waiting room, and "great depth about specific care and sensitivity to patients with diverse cultural backgrounds" is probably a better standard to aspire to. But how would you demonstrate that standard in three minutes?

The specific main principles of cultural safety (not listed in IC-20) are self-determination, social and restorative justice,  equity, partnership, reciprocity, accountability, sustainability and cultural context. It would have been useful for the candidate to demonstrate that they are aware of these principles; and at the same time it would have been difficult to do so without peppering the answer with stock-sounding phrases like "increased advocacy for, and partnering with, Indigenous communities and health organisations". Some kind of bare minimum answer would probably have consisted of something like this, mainly derived from the excellent 2019 MJA paper by Paul Secombe et al. 

Recognition of the importance of health equity:

• Aboriginal and Torres Strait Islander Australians have:
  • a higher rate of of acute critical care admission, especially sepsis and trauma
  • a higher burden of chronic disease
  • poorer access to healthcare (more come from remote communities)

Practical interventions to improve the healthcare experience of Indigenous Australians requiring ICU:

• Increase the representation of Indigenous people among staff, including CICM fellows and trainees
• Increase access to cultural safety training for frontline staff
• Focus outreach and retrieval services to increase access for rural and remote communities 

Specific interventions in response to the family's complaint

• Establish cultural context by seeking advice from an Indigenous liaison officer or local elder prior to the family meeting
• Encourage self-determination by offering the family a culturally appropriate mechanism for escalating their concerns
• Address social and restorative justice by offering an apology and demonstrating to the family the specific steps being implemented to improve cultural safety in the department
• Partner with the family to decide the best most mutually acceptable resolution to the complaint to help them feel respected and safe