Quality improvement measures made across the health sector as a result of complaints made to the Health and Disability Commissioner are evidence that investigating systemic failures in care, and recommending improvements, is making a positive difference in New Zealand.
There is a growing international interest in using patient complaints to address problems with quality in healthcare. In New Zealand, the complaint mechanisms under the Health and Disability Commissioner Act 1994 have become the primary vehicle for dealing with complaints about the quality of healthcare and disability services.
The complaints system
New Zealand has had a health and disability service complaint system in place for over a decade. This complaints system is headed by the Health and Disability Commissioner, who has the role of promoting and protecting the rights of health and disability consumers, and facilitating the resolution of complaints. The Commissioner’s specific complaints investigation role relates to alleged breaches of the statutory Code of Health and Disability Services Consumers’ Rights (the Code)1.
Consumers of health and disability services have ten rights under the Code, which cover basic principles such as the right to respect, the right to an appropriate standard of care and the right to full information and to give informed consent, and places duties on providers regarding complaint procedures. Consumers in both the private and public sector are covered, and the duties apply to health professionals, unregistered healthcare providers and institutional providers such as hospitals and rest homes.
The Health and Disability Commissioner complaints process ensures that the rights set out in the Code are enforced. One of the primary objectives of the Health and Disability Commissioner is to “secure the fair, simple, speedy and efficient resolution of complaints” 2. The complaints system ensures a degree of accountability for healthcare providers3, but also allows consumers to express their concerns, facilitates the resolution of complaints, triggers an investigation in appropriate cases, and ensures action is taken to reduce the risk of harm to other patients.
Anyone can make a complaint to the Commissioner alleging that any action of a healthcare or disability services provider appears to be in breach of the Code4. Essentially, this means complaints may be made about anything related to the quality of services (including the way in which they were provided, and the handling of a complaint about them). The Commissioner may also undertake investigations on his or her own initiative, without waiting for a complaint to be made5, allowing the Commissioner to fulfil a “consumer watchdog” role and to ensure public safety.
The Commissioner’s investigation is an impartial and independent process to which the rules of natural justice apply.
Investigations often involve liaison with the other bodies with an interest in the subject matter of the complaint. Where the quality of care is in issue, the Commissioner will obtain independent expert advice from a peer of the provider with knowledge of, and experience in the matters under investigation. After an investigation, the Commissioner forms an opinion as to whether the provider has breached the Code.
Improvements in quality of care
There is growing evidence that investigating systemic failures in care, and recommending improvements, is making a positive difference in the health and disability sectors. Landmark research has recently been published on the relationship between complaints and quality of care in New Zealand6. Dr Marie Bismark compared 398 complaints to the Commissioner relating to public hospital admission in 1998 with a nationally representative sample of non-complainants who suffered adverse events in the same year. Bismark concluded that “complaints offer a valuable portal for observing serious threats to patient safety and may facilitate efforts to improve quality”.
The following Commissioner’s reports are illustrative of the way in which complaints can be influential in bringing about quality improvements in healthcare.
Medication mix-up
A report released in November 2005 highlighted the systemic issues regarding medication safety in public hospitals. The Commissioner received a complaint from Mrs Anderson’s daughter about the care her mother received at a hospital. 91 year old Mrs Anderson presented to the hospital’s Emergency Department with a suspected lower respiratory tract infection. At some time during the course of her clinical assessment or admission, a computer-generated patient identification label was affixed to the top of a completed drug chart intended for another patient. Due to this error, Mrs Anderson received incorrect medications (and did not receive her own regular medications) for a period of four days.
While the error was perpetuated by a number of individuals in the medical and nursing teams, the critical issue identified in the investigation was that various organisational and system factors outside of the individual providers’ control ultimately conspired to create a dangerous situation for Mrs Anderson. Accordingly, the hospital was held to have breached Right 4 of the Code. A copy of the report was sent to the Minister of Health, the Director-General of Health, the Medical Council, the Nursing Council, the Royal Australasian College of Physicians, the Accident Compensation Corporation, the Coroner, and the national Quality Use of Medicines Group. The report was also posted on the Commissioner’s website, www.hdc.org.nz. Following the report, the Commissioner visited the hospital to follow up on his recommendations that the report be circulated for orientation and training purposes, and that a number of changes be made to the policies and practices in place.
This report has been widely used for teaching purposes in the health sector, and prompted one metropolitan DHB to write: “This DHB has taken the key messages from your review very seriously indeed. The measures we have put in place since receiving your report include: redesigning the drug chart so that the patient’s name is handwritten; assigning a common area for patient records and drug charts in all wards; keeping the patient labels with the drug charts; and deploying a ‘10 rules of safe prescribing’ document to all medical officers and senior nurses.” The report has prompted medication safety audits and improvements in hospitals throughout New Zealand.
Graseby pump
In another case, the Commissioner’s recommended changes regarding the use and manufacture of a medical device are being adopted nationally. A complaint was received from the Police on behalf of the family of a woman who died while receiving palliative care at home for end-stage lung cancer. The woman’s death followed the administration of an overdose of morphine by a palliative care nurse. The morphine was administered subcutaneously, using a Graseby pump. The Commissioner found that the nurse had inadvertently set the pump to deliver 20mm of diluted medication per hour instead of 2mm per hour. Accordingly, the nurse was found in breach of the Code. A factor contributing to the error was confusion about the operation of two different types of Graseby pump—a “green” one, which delivered medication at millimetres per 24 hours and a “blue” pump set at millimetres per hour.
The Commissioner’s report recommended that to reduce the risk of error, where practicable, palliative care services move towards using one type of pump for the administration of subcutaneous medication. The recommendation was sent to all DHBs, Hospice New Zealand, and the Society of Palliative Medicine. They were subsequently contacted to see what follow-up action they had taken. Only six of the 21 DHBs reported that they were still using two types of pump (and they were either phasing out one model, or had responded to the recommendation by instituting tighter protocols, new labels, or training to reduce the potential for error). All DHBs indicated that they had carefully considered the concerns raised by the Commissioner, and had drawn them to the attention of appropriate staff. The Society of Palliative Medicine supported the Commissioner’s recommendation and Hospice New Zealand advised its members of the risks involved in holding and using different types of the pump. It asked the manufacturer to consider developing a standard pump with a single scale setting. The company, Graseby International, replied that this would be considered as part of its product development process.
Pharmacy error
Another recent complaint has resulted in widespread changes in the systems in place at pharmacies to reduce the risk of errors. In March 2005 the Commissioner received a complaint from the mother of a 10 year old girl who had been dispensed the incorrect strength of medication on two separate occasions at her local pharmacy. An investigation revealed that there had been a failure to check the medications before they were dispensed. Staff also failed to accurately record who was responsible for those checks, so it was not possible to establish the identity of the responsible pharmacist. The Commissioner’s report found the pharmacists and the pharmacy in breach of the Code for failing to have adequate systems in place to prevent such mistakes. The report was sent to the Pharmacy Council, the Pharmaceutical Society, the Pharmacy Guild, and Medsafe (New Zealand Medicines and Medical Devices Safety Authority). The Commissioner also made a recommendation that Roche and Jansen-Cilag Pty Ltd review labelling of medication to assist pharmacists to clearly identify different strengths of medication. The report was also published on the Commissioner’s website.
In addition to systems changes implemented at the individual pharmacy, the Pharmacy Council of NZ reported that it is “actively addressing” the issues raised, including standardisation of dispensing procedures and mechanisms for sharing procedural changes made as a result of errors. In a recent survey, 83% of pharmacists said that the media attention to this case had prompted action in their pharmacy (Pharmacy Today, Sept 2006).
Conclusion
These cases are part of a body of evidence on the use of complaints to improve the quality of healthcare. The Health and Disability Commissioner complaints system plays a key role in linking dispute resolution with improvements in patient safety and quality of healthcare. The Commissioner’s reports are widely reported in the media and are used for educational purposes throughout the health sector. The complaints system is linked to other strategies for improving the quality of care, such as continuing professional development, audit, risk management, and critical incident reporting, which promotes learning from complaints and the implementation of quality improvement measures. Leading safety experts Alan Merry and Mary Seddon recently commended the New Zealand Health and Disability Commissioner on “a world-leading focus on addressing aspects of the system which contribute to patient harm, rather than only seeking to identify individual scapegoats when things go wrong”7. This focus on investigating systemic failures in care, learning from complaints, and recommending quality improvements, is making a positive difference to the quality of health care in New Zealand.
References
1. The Code came into force in July 1996 as a regulation under the Act. The Act created the Office of the Commissioner together with a national network of independent consumer advocates (under the Director of Advocacy), and an independent prosecutor (the Director of Proceedings).
2. Health and Disability Commissioner Act 1994, s 6.
3. The safety and quality of health services in New Zealand is also regulated by the Health Practitioners Competence Assurance Act 2003, which provides mechanisms to ensure that health practitioners are competent and fit to practise their professions; and the Health and Disability Services (Safety) Act 2001, which provides for service standards and the certification and audit of providers of health or disability services.
4. Health and Disability Commissioner Act 1994, s 31(2).
5. Health and Disability Commissioner Act 1994, s 40(3). For example, as occurred in relation to Gisborne Hospital (Gisborne Hospital 1999–2000: A Report by the Health and Disability Commissioner, Auckland, Health and Disability Commissioner, 2001) and Southland Hospital (Southland District Health Board Mental Health Services February–March 2001: A Report by the Health and Disability Commissioner, Auckland, Health and Disability Commissioner, 2002). These reports are available on the Commissioner’s website at www.hdc.org.nz/publications/other-reports.
6. Dr Marie Bismark, Troy Brennan, David Studdert, Peter Davis and Ron Paterson, “Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events”, Qual Saf Health Care (2006) 15:17–22.
7. Alan Merry and Mary Seddon, “Quality improvement in healthcare in New Zealand. Part 2: are our patients safe — and what are we doing about it?” NZMJ Vol 119 No 1238 (21 July 2006).
