Complaints are a routine part of life for directors of Intensive Care units, a surprise and inconvenience for early-career ICU specialists, and a mysterious and fearsome natural occurrence for junior ICU staff, like a solar flare or a locust plague. Judging by the appearance of this topic in Question 22 from the second paper of 2022, it seems the college wants trainees to develop a familiarity with this process long before they are expected to manage it independently. The truth of the matter is that usually even very senior ICU trainees would not be expected to handle a complaint from a patient or their family - this task would often fall to some senior member of the department who is already familiar with the processes and connected to the appropriate political and administrative apparatus. Still, to write the answer, we should look at the steps.
And those steps, to be fair, are not entirely consistent around the world. The college comment to Question 22 was weirdly parochial, noting that none of the candidates mentioned "hospital, LHD, or state guidelines" - suggesting that trainees from across Australia and New Zealand would have been rewarded with more marks if they referred to some idiosyncratic local complaint management process. This implies that an answer that referred to more globally applicable principles (acknowledgement, transparency, timeliness, respect, etc) would have been rewarded with fewer marks than an answer that suggests one needs to start by talking to Judy on the third floor of the Old Admin Building to fill out the appropriate forms. What follows is an attempt to cater for this weird expectation while still respecting the reader's need to know the basic principles.
Universal principles of complaint management
Some of this had come from the local complaint handling guide by the Commonwealth Ombudsman
- 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 safety
It feels weird to tag this critically important topic to the end of the complaint resolution thing, but that is in effect is what happened in Question 4 from the first paper of 2023, where the complaint being resolved happened to be from a traumatised family of an Indigenous patient. A 30% portion of the total mark was attributed to the cultural safety aspect of the response, and this was apparently done very well by some candidates, which is a considerable credit to our specialist discipline. What did they write? It would be impossible to guess, from the vantage point of this thick and insensitive author, but we do have some references to help. This excellent 2019 MJA paper by Paul Secombe et al is one such reference, and Unconscious Bias – Time to Change by Penny Stewart is another (made more important by being linked from the CICM Indigenous Health page).
In summary:
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)
- Bias against Indigenous Australians in healthcare is often unconscious, and needs to be recognised before it can be addressed
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