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Study of people lodging complaints with the Victorian Health Services
Commissioner
Final report
June 2013
Department of Health
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Contents Table of tables 5
Glossary and acronyms 6
Executive summary 7Introduction 7
About the Victoria’s Health Services Commissioner 16The Commissioner’s core functions 16
Presentation and discussion of principal findings 19Report on the data 19
About the respondents and their complaints 19Who was complained about and why? 22
Other complainant and complaint information 24
Complainant expectations 31
Outcomes 39
Explaining complainant (dis)satisfaction 46
Outcome and (dis)satisfaction: a direct relationship? 55
Positive aspects of the Commissioner’s service 60
Appendix A: Methodology 66Research method 66
Ethics approval 69
Limitations of the study 69
Appendix B: Scan of the relevant literature 70Key themes 70
Appendix C 80Technical report 80
Appendix D 84Survey tool 84
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Table of figures Figure 1. Age range of respondents by gender....................................................................................20
Figure 2. Respondent residence by stage of case closure.................................................................20
Figure 3. Health service provider complained about...........................................................................22
Figure 4. Complaints by public or private provider type.....................................................................23
Figure 5. Proportion of public or private provider by provider type...................................................23
Figure 6. Reason for complaint lodgement..........................................................................................24
Figure 7. Medium for finding about the Commissioner’s service.......................................................25
Figure 8. Age range of those accessing information about the Commissioner by internet.............25
Figure 9. Approach the health service provider prior to contact with the Commissioner...............27
Figure 10. Reason problem wasn’t resolved where it occurred............................................................28
Figure 11. Commissioner initial advice to complainant about who to contact about complaint.......29
Figure 12. Seriousness rating of complaint............................................................................................30
Figure 13. Public and private provider type by complaint seriousness rating....................................30
Figure 14. Respondent understandings/expectations of the Commissioner’s role............................32
Figure 15. Actions expected of the Commissioner ...............................................................................34
Figure 16. Desired outcome(s).................................................................................................................36
Figure 17. First-mentioned desired outcome per complainant.............................................................36
Figure 18. Conciliation respondents first mentioned desired outcome at the conciliation stage.....39
Figure 19. Conciliation respondents’ first mentioned desired outcome at first contact....................39
Figure 20. Conciliation and assessment respondents perceptions of their outcome........................40
Figure 21. Proportion of respondents seeking and achieving reimbursement or compensation by age 43
Figure 22. Cross tabulation of respondent expectations with the outcome achieved........................44
Figure 23. Complainant satisfaction with outcome................................................................................44
Figure 24. Reason for complainants stated level of satisfaction with outcome..................................45
Figure 25. Conciliation officer impartiality..............................................................................................48
Figure 26. Assessment respondents’ perceptions about their dealings with the Commissioner.....49
Figure 27. Conciliation respondents’ perceptions about their dealings with the Commissioner......50
Figure 28. Respondent perceptions of a fair outcome..........................................................................51
Figure 29. The expected outcome: conciliation and assessment respondents..................................51
Figure 30. Was the complaint resolved to your satisfaction?...............................................................52
Figure 31. Participant feelings about the Commissioner’s process by stage.....................................53
Figure 32. Satisfaction with Commissioner’s handling of the case.....................................................54
Figure 33. Responses per respondent to three satisfaction questions...............................................56
Figure 34. Satisfaction across three questions and the relationship to the achieved outcome........57
Figure 35. Advice about who else could be contacted about the complaint.......................................58
Figure 36. Satisfaction with outcome by Yes or No to recommend the Commissioner’s service.....60
Figure 37. Respondent assessment of what the Commissioner did well............................................61
Figure 38. Areas for improvement: first-mentioned recommendation.................................................62
Figure 39. First-mentioned recommendations for improvement of conciliation process..................63
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Figure 40. Definition of justice elements and associated research (reproduction)....................................75
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Table of tablesTable 1. Respondent highest completed level of education 21
Table 2. Language spoken at home by respondents and the Victorian population 21
Table 4. Number of complaints ever made to the Commissioner 26
Table 3. Numbers of complaints by public or private provider by provider type.............................24
Table 5. Year of first and most recent contact regarding most recent complaint 26
Table 6. Reasons for case closure at the enquiry stage 31
Table 7. Commissioner advice regarding desired outcomes and explanatory comments 37
Table 8. Reported final outcome for assessment and conciliation respondents 41
Table 9. Perceived fairness and bias of the Commissioner’s officers - the assessment group 47
Table 10. Perceived fairness and bias of the Commissioner’s officers - the conciliation group 48
Table 11. Type of action taken after the Commissioner closed complaint only those who took action 58
Table 12. Reason for recommending or not recommending the Commissioner’s service 59
Table 13. Particularly good aspects of complaint handling 61
Table 14. Areas for improvement 62
Table 15. Sampling frame 66
Table 16. Final achieved surveys 67
Table 17. Achieved sample stratification 67
Table 18. Key project statistics 80
Table 19. Overview of questionnaire design 81
Table 20. Number of calls per completed interview 82
Table 21. Analysis of call outcomes 82
Table 22. Participation rate 83
Table 23. Reason for refusal 83
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Glossary and acronyms
AHPRA Australian Health Practitioner Regulation Agency
Commissioner Victorian Health Services Commissioner
Doctor A medical practitioner. It includes medical practitioners who are employees of hospitals and health services
GP A medical practitioner with post-graduate training in general practice. GPs are commonly located in community settings.
HSP Health service provider: the organisation or individual practitioner involved in a complaint. The organisation could be a hospital, a health service, a pathology service or any other organisation providing health services that are within the jurisdiction of the Commissioner.
Hospital or health service Both are types of health service organisations and are health service providers
Specialist A medical practitioner with extensive post-graduate training in a specialist field of medicine.
The Act Health Services (Conciliation and Review) Act 1987
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Executive summary
Introduction
The purpose of this paper is to present the key findings and associated data that report the perceptions of respondents (the study population) who have lodged complaints with Victoria’s Health Services Commissioner (the Commissioner). The Commissioner has undertaken the research as part of the statutory functions of the role to review and improve the operation of the office and the complaints process. The study has been conducted in the context of the review of the Health Services (Conciliation and Review) Act 1987 (the Act) which was undertaken during 2012 by an independent Expert Panel appointed by the Minister for Health.
Rationale for the Commissioner’s complainant studyIn Victoria, the levels of satisfaction with outcomes with the Commissioner’s complaints service are reported in the annual report. Feedback is gathered from complainants and providers who send back an evaluation form to the Commissioner following a recently closed case. Over time, there has been a consistent and large gap between provider and complainant satisfaction with the outcome of complaints. Similarly, there is a consistent gap between provider and complainant judgement about how well the case was handled, but the gap is smaller.
Reported in the Commissioner’s 2012 annual report1 are the evaluation responses from complainants and providers. Two hundred and thirty-three (233) complainants voluntarily returned an evaluation form and 257 providers did so. There are notable differences in satisfaction levels between providers and complainants with 58 per cent of complainants (134 of 233) and 90 per cent of providers (232 of 257) reporting that they were satisfied with the outcome of the case. The gap between the two ratings was wider in the previous year, being 54 per cent complainants to 94 per cent providers.2
Researchers investigating health complaints services advise that, where large differences in satisfaction between parties exist, further inquiry is worthy of consideration.3 In the context of the review of the Act, a de-cision was made to collect more robust data from complainants about their experience of the Commis-sioner’s complaint process, with the aim of improving the quality of the service.
Research focusThe high complainant dissatisfaction level with the Commissioner’s service is consistent with like services examined in other studies.4 Previous research has identified a gap between complainant expectations of what might be achieved by lodging a complaint and what is actually achieved. Further inquiry has sought to map the gap between expectations and outcome to explain complainant dissatisfaction. It has been suggested that better management of complainants’ expectations could result in more realistic expectations and higher levels of satisfaction.5
1 Office of the Health Services Commissioner (2012) Annual report 2012, Melbourne, pp. 40-41. 2 Office of the Health Services Commissioner (2011) Annual report 2011, Melbourne, pp. 40-41.3 Friele, R. D. and Sluijs, E. M. (2006). Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health
Services Research 6, pp. 101-109.4 Daniel, A., E. Burn, R. J., and Horarik, S. (1999) Patients’ complaints about medical practice. MJA, 170. June, pp. 598-602.
Friele et al, (2006).Resolution Resource Network and Health Issues Centre (2004). Bringing in the consumer perspective. Final Report. Consumer experiences of complaints processes in Victorian Health Practitioner Registration Boards. Department of Human Services.
5 Bismark, M., Spittal, M., Gogos, A., Gruen, R and Studdert, D. (2011) Remedies sought and obtained in healthcare complaints. BMJ Qual Saf, 20: 806-810.Daniel et al, (1999).
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This study sought to identify a gap between complainants’ expectations of the outcome and the actual outcome6 and any causal association between that gap (if identified) and complainant dissatisfaction. The study also sought to establish if complainants have unrealistic expectations of the Commissioner’s role as well as identify any other causes of satisfaction or dissatisfaction.
The specific research questions that guided this inquiry were:
is there a gap between complainants’ expectations of what would be achieved by lodging a complaint and their perception of the actual outcome achieved? if identified, does this gap explain complainant satisfaction?
do complainants have unrealistic expectations of the Commissioner’s complaint service?
Summary of study methodologyThe study surveyed Victorians over 18 years of age who had lodged complaints with the Commissioner and had them closed during the last three financial years (2009-10, 2010-11 and 2011-12). Complainants were sampled from three of the four stages7 of the Commissioner’s complaint process: enquiry (n=53), assessment (n=228) and conciliation (n=155) with a total study population of 436.
Respondents from the assessment and conciliation groups were randomly selected to achieve a broadly representative sample from a total population, while the enquiry group respondents were randomly selected from a convenience sample.
Computer assisted telephone interviews using a prepared survey approved by the Department of Health Human Research Ethics Committee (DH HREC) were undertaken in October 2012. The achieved response rate, as a proportion of interviews plus refusals, was 72.7 per cent. Analysis employed both quantitative and qualitative techniques.
Key conclusion from the studyComplainants have high levels of dissatisfaction with the Commissioner’s complaint service. This is not generally a result of unrealistic expectations about the service the Commissioner provides. A majority of complainants perceive that they have not achieved an outcome, or that the outcome achieved is of poor quality, that it is unfair and does not resolve the complaint for the service user.
6 First identified in the Victorian context by Bismark et al (2011).7 Throughout this report, complainants are categorised by the stage of their case closure and are often referred to as part of
that group. There are four stages: enquiry, assessment, conciliation and investigation.
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The study population is broadly representative of the Commissioner’s usual complainant profile with regard to gender, age and residence. Similarly, the type of complaint, who it concerned including public/private provider and seriousness rating were consistent with complaints usually received. The majority of respondents had made ever only one complaint to the Commissioner and had attempted to resolve the complaint at the local level prior to doing so. Reasons why the complaint was not resolved locally were that the health service provider:o did not take responsibility for what had occurredo did not admit a mistakeo ignored the complainto did not take the complaint seriously.
Overview of findingsThe findings below report the analysis of the study population’s perceptions of the Commissioner’s service.
The study population and their complaints
The study population is similar to that in other studies with regard to complainant profile, reason for lodging a complaint, service provider complained about and the complainant’s desired outcomes:
women lodge more complaints than men the majority of complaints concern clinical matters most complaints concern medical practitioners (including specialists and surgeons)
the majority of complainants want system or practice change as outcomes, ‘so that it doesn’t happen to someone else’, and/or an apology.
The gender profile of the complainant population reported by the Commissioner in 2012 was 3:2 female to male complainant ratio.8 In this study the ratio is 2:1 female to male ratio. Two thirds of the respondent population reside in metropolitan Melbourne with one third in rural Victoria which is the same ratio as the Commissioner’s complainant profile in a given year. The study respondents are more highly educated than the Victorian population and a large majority are first-time complainants, consistent with the Commissioner’s usual complainant population. The majority of respondents is between 40-60 years and the proportion of people from cultural and linguistic diverse communities is very slightly lower than the general Victorian population. Participation of Aboriginal complainants was consistent with the proportion using the Commissioner’s service, which is slightly higher than the state population – but the numbers are very small.
Issues and health service providers complained about by the study population are broadly consistent with those reported by the population using the Commissioner’s service – clinical treatment is the main source of complaint (53 per cent) followed by interpersonal behaviour and communication with clinical staff (26 per cent). Complaints about costs accounted for another 11 per cent. The majority of complaints concerned medical doctors (40 per cent) with 34 per cent of the complaints being about hospitals or health services. The seriousness rating of the complaints examined is similar to that reported in the Commissioner’s 2012 annual report with most complaints being of medium seriousness (56 per cent). Of the health service providers complained about, approximately half (49 per cent) were public providers and 42 per cent were private providers, with 7 per cent of complaints involving both public and private providers. The seriousness rating of cases was spread evenly across public and private services and providers.
8 Office of the Health Services Commissioner (2012) Annual report 2012, Melbourne, p. 13.
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Overall, the majority of respondents had reasonably accurate expectations of the Commissioner. A minority of respondents did not accurately understand the role of the Commissioner or what the Commissioner could do to assist them resolve the complaint. Respondents expect that the Commissioner will actively engage with the complaint: to do something to help sort out or resolve the problem. Respondents have a variety of expectations about what active engagement means. Most commonly it means: impartial complaint resolution, assistance, ‘looking into the complaint’, influencing the health service provider to progress resolution of the issue, protecting the public.
Expectations of the Commissioner
The majority of respondents (86 per cent)9 had reasonably accurate understandings of the Commissioner’s role which most commonly included provision of an impartial complaint resolution service, assisting the complainant resolve the complaint and ‘looking into’ the complaint. Commonly, respondents think that the Commissioner has a role in ‘protecting the public’ or acting in the public interest.
The 12 per cent of respondents whose understandings of the Commissioner’s role were less accurate included those who thought the Commissioner has regulatory powers with regard to the practice of health professionals and activities of health service providers, and that the Commissioner could make determinative judgements and impose sanctions or penalties.
With regard to what actions respondents expect of the Commissioner, they most commonly expect that the Commissioner will make an assessment of the complaint, which is what is meant by the term ‘looking into’ or investigating the complaint, and that the Commissioner will assist in the resolution of the complaint and achieve an outcome. Apart from ‘looking into the complaint’ respondents most commonly expect that the Commissioner will be able to engage with the health service provider in a way that the individual complainant cannot. That is, respondents believe that health service providers will listen, take note of, or respond to the Commissioner in a way that they will not engage with the complainant.
A minority of respondents (13 per cent) had less accurate expectations of Commissioner action including, warn or discipline the health service provider and make determinative judgements. These inaccurate understandings and expectations of a minority of respondents is similarly reflected in the hoped-for outcome. Eleven per cent wanted the health service provider disciplined although it was the first-mentioned, hoped-for outcome for only 4 per cent of respondents.
9 Two per cent of respondents did not answer the question about role and 5 per cent did not answer the question about expected Commissioner action.
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Respondent expectations of what might be achieved by lodging the complaint (the outcome) were broadly consistent with what has been reported in other studies:
o the majority hoped to achieve institutional or practice change.o an apology and then compensation were the next most commonly hoped-for outcomes.
A minority of respondents appear to have unrealistic or unreasonable expectations about the outcome of lodging a complaint which was often associated with a poor understanding of the Commissioner’s role and powers. The majority of the assessment and conciliation respondents - 61 per cent - reported a negative outcome which was commonly perceived as not having achieved any outcome. Thirty-one percent reported a positive outcome and 7 per cent, a partial outcome: 38 per cent in total reporting some form of positive outcome. Comparison with outcomes achieved reported by the Commissioner’s associated annual reports suggests that what constitutes an outcome or how an outcome is perceived by complainants can be different from what is officially recorded.
Outcome of complaint lodgement
Forty-four per cent of respondents named institutional and practice change as one of their hoped-for outcomes. For 22 per cent it was the first mentioned hoped-for outcome. Twenty-one per cent of respondents wanted an apology and 19 per cent wanted compensation.
When asked about what outcome was achieved, the majority of the assessment and conciliation respondents perceived that they had not achieved an outcome: they were either told that the Commissioner’s office could not help them further, they were referred elsewhere or they ‘gave up’. There is a marked difference between respondents’ perceptions of outcomes achieved and the outcomes recorded at case closure and reported by the Commissioner in the associated annual reports.
There may be a number of explanations for this variance. One may be that the respondent does not remember the outcome, or that the outcome recorded on their file does not have any meaning for the respondent and is therefore not perceived nor remembered as an outcome. As reported in the 2011-12 annual report just under half the cases at the assessment stage are declined (633 of 1328 complaints). Just over half the cases declined in 2011-12 were for reasons such as, ‘does not warrant investigation’, ‘reasonable steps were not taken’, ‘the complaint was not confirmed in writing’, ‘the complaint contains insufficient detail’. It is unclear from the analysis of the verbatim10 comments that respondents fully understand the reasons why their cases are closed, resulting in, what is for the respondents, an unresolved situation with no apparent outcome. It is also unknown how many of the assessment group respondents who reported a perceived negative outcome were classified as ‘declined’ at the assessment stage.
10 The term ‘verbatim’ is used throughout this document to refer to the exact ‘word-by-word’ answers provided by respondents to questions that prompted responses ‘in their own words’. The exact response was directly transcribed into a database during the telephone interview and has been used for thematic and content analysis, per question and per respondent, across a set of responses.
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Satisfaction with the outcome was very low across the study population at 22 per cent. Sixty-five per cent of the study population were dissatisfied and 11 per cent were ambivalent. The majority of the enquiry respondents were dissatisfied with the outcome of their contact with Commissioner’s service (64 per cent). The conciliation respondents were a little less dissatisfied than the assessment respondents (61 per cent and 68 per cent respectively). For 56 per cent of assessment and conciliation respondents there is a direct relationship between the outcome achieved and the satisfaction with the outcome rating. For 42 per cent, the explanation for the dissatisfaction with outcome rating is more complex with other factors such as process or interaction and communication issues being influential.
Principal reasons for dissatisfaction provided by assessment and conciliation respondents were:
o lack of resolution/lack of closure often associated with a perceived lack of outcomeo commissioner’s lack of power to effect system or practice changeo lack of interest, assistance or support provided by the commissionero lack of an outcome, or an unsatisfactory outcome, and case closure processes appear to contribute in a major way to dissatisfaction with outcome.
Enquiry respondents identify poor process and interaction issues, lack of closure and lack of support as reasons for their dissatisfaction.
Satisfaction with outcome
The large majority of respondents are dissatisfied with the outcome of their complaint with high levels of dissatisfaction consistent over a range of questions. There is some minor fluctuation across the three groups of respondents as classified by their stage of case closure: enquiry, assessment and conciliation with the conciliation group respondents consistently slightly more satisfied than the enquiry and assessment group respondents.11
Cross tabulation of responses about the outcome, the dissatisfaction rating and the reason given for the dissatisfaction rating reveals an apparent direct relationship between the outcome and satisfaction with outcome for a small majority of respondents. For a substantial minority, ‘the outcome’ appears to be perceived as a composite because many respondents explained their dissatisfaction as being due to other process or interaction/communication factors as well as the outcome achieved or not achieved.
Reasons for dissatisfaction
Reasons given by respondents for their satisfaction with outcome rating highlight problems principally with perceived unachieved outcomes and problems at the beginning and end of the complaint process. Lack of resolution and poor closure processes were reported by 30 per cent of the study population. For the enquiry respondents whose contact with the office is minimal, the contact for the majority was not satisfactory.
Forty-four per cent of respondents wanted institutional or practice change, they ‘didn’t want the same thing happening to someone else’. Seven per cent of respondents reported achieving this outcome. It may be that for the remaining 37 per cent there were no grounds for change but it is not clear from the respondent comments that they received full information about why their hoped-for outcome was not achieved. However, a proportion of respondents became aware of the lack of power of the Commissioner in relation to health
11 In 2012, 891 complainants had their cases closed at the enquiry stage, 1,328 were closed at the assessment stage and 235 at the conciliation stage.
13
The study provides evidence of a gap between complainants’ hoped-for outcome and the outcome achieved. This finding is consistent with findings from other studies. However, as the study provides evidence of what appear to be mostly reasonable expectations about the outcome and fairly accurate understandings of the Commissioner’s role, the hypothesis that the gap is explained by complainants’ unreasonable or unrealistic expectations is not supported.
In response to three separate questions about the outcome of the complaint, the majority of the assessment and conciliation respondents answered that the outcome was:
o unfair (70 per cent).o not what was expected (67 per cent).o resulted in the complaint being unresolved or not resolved to the respondent’s satisfaction (71 per cent).
The perceived lack of fairness of the outcome and the lack or poor quality of the outcome appear to be major explanatory factors for the high respondent dissatisfaction.
service providers and strengthening of the Commissioner’s powers was an improvement recommended by respondents.
Understanding dissatisfaction with outcome
The role and operation of social norms such as fairness is considered in the complaint handling research literature where expectations of fairness are considered normative.12 The perception of the respondents in this study was that the outcome achieved was unfair and in being perceived as unfair did not meet their expectations. The outcome may also have been not what they wanted (expected).
Other factors that appear to influence satisfaction relate to resolution of the case. Respondents expect that the Commissioner will assist them resolve the complaint and achieve an outcome that is meaningful to them. Resolution appears to be a valued aspect of the outcome for complainants. That is, lodging a complaint is not only about getting what you want but also about resolving a problem.
Providing respondents with assistance is another common expectation. Threaded throughout the verbatim responses from respondents are statements such as ‘it is not a level playing field’. Some are wanting assistance to ‘even up’ the disparity between the health service provider and the complainant, others want assistance with the complex tasks involved in the complaint process during a time in their lives when they are unwell or carrying extra responsibilities or stress because of family illness or incapacity.
Gap between expectation and outcome
Some of the discussion in the literature about the high levels of complainant dissatisfaction focuses on complainant expectations and proposes that if complainant expectations are unrealistic, dissatisfaction is likely. To remedy that problem, effort should focus on modifying complainant expectations by ‘coach(ing) them from an early stage through the range of feasible outcomes’.13 There is evidence from the literature and from this study that increased effort and engagement on the part of the complaints body is highly valued by complainants.14 However, complainants’ expectations are also influenced by societal norms of fairness – of
12 Dasu, S. and Rao, J. (1999). Nature and determinants of customer expectations of service recovery in health care. Quality Management in Health Care, 7(4), pp. 32-50.
13 Bismark et al, (2011) p. 810.14 McColl-Kennedy, J. and Sparks, B. (2003). Application of fairness theory to service failures and service recovery. Journal of
Service Research, 5(3), Feb, pp. 251-266.
14
The respondents’ satisfaction ratings about how the case was handled are more positive: a larger proportion (46 per cent) reported that they were satisfied or very satisfied, 42 per cent reported that they were dissatisfied or very dissatisfied, 10 per cent were ambivalent and 2 per cent said they ‘didn’t know’. Satisfaction with the handling of the case was significantly more likely with complaints associated with private providers.
The study provides evidence of the mostly positive interaction and good practice of the Commissioner’s officers in their dealings with assessment and conciliation respondents. In particular, the impartiality of the Commissioner’s officers was affirmed by the majority of respondents. However, assessment respondents were more likely to say that they did not think the Commissioner’s process was fair to all parties and that the Commissioner did not put enough effort into resolving the complaint. The conciliation respondents provided a slightly less favourable response about the timeliness of the service.
A majority of respondents (51 per cent) reported feeling negatively about the complaint process overall with 43 per cent having positive feelings, 3 per cent being ambivalent and 3 per cent saying they ‘didn’t know’. Fifty-nine per cent of the total study population gave consistent responses (either all positive or all negative) to three satisfaction questions (satisfaction with outcome, how the case was handled and feelings about the process overall). Of the 59 per cent:
o thirty-five per cent were negative responses with no perceived outcomeo nineteen per cent were positive responses with a perceived outcomeo five per cent provided contradictory responses in the context of the perceived outcome achieved or not achieved.
This finding suggests a direct relationship between the outcome and satisfaction more generally for the majority of respondents: 54 per cent. However, for a substantial minority of respondents – 41 per cent – satisfaction is more complex and is influenced by process and interaction issues as well as by the perceived outcome. Sixty-six per cent of all respondents said they would recommend the Commissioner’s service to others because the service is an important institution, or because of a positive personal experience.
fair dealing – so coaching/expectation management could have its limitations if other factors including the process, interaction with the Commissioner and/or providers or the outcome itself are considered or perceived by complainants to be unfair.
Process and interaction (including communication) with the Commissioner’s officers
The assessment and conciliation group respondents provided consistently positive responses to a range of statements about the complaint process and interaction and communication with staff. However, the set of statements did not include a specific question about the lodgement process nor the case closure process and these are the two areas of the process that respondents highlighted as problematic in their explanations for their satisfaction with outcome rating.
Importantly, the impartiality of the Commissioner’s officers was affirmed by the majority of these respondents. However, there was a marked difference between the two groups of respondents. Although the majority of respondents in the conciliation group agreed that officers were not biased and did not take sides (69 per cent), the proportion of assessment group respondents was noticeably lower at 52 per cent. And although the majority of conciliation respondents, unlike the assessment group respondents, did think the process was fair to all parties it was a slim majority at 52 per cent. Timeliness was more of an issue for the conciliation respondents, some of whom had their cases conciliated because the matter had not been attended to within the timeline required at the assessment stage. For a small number of conciliation respondents, they were engaged in the process for one, two and up to three years.
Other areas of satisfaction15
15 The meaning of ‘all positive or all negative’ responses in this section is, positive = satisfied/very satisfied and negative = dissatisfied/very dissatisfied.
15
Areas for improvement recommended by respondents included:o frequency and quality of communicationo better/clearer explanations and more effective listening and understanding
o a faster process and increased power to act in the public interest.
Although 46 per cent of respondents were satisfied with the handling of the case, there is a larger proportion who were either not satisfied or who were ambivalent (42 per cent and 10 per cent respectively). There is also a similarly sized group who feel negatively, (51 per cent) or who are ambivalent about the complaint process, (three per cent).
Responses to the three questions probing respondent satisfaction with the complaint service were analysed to gauge the effect of the outcome (achieved or not) on overall satisfaction. An apparent direct relationship between the outcome and satisfaction was discerned for 54 per cent of the study population but for 41 per cent this was not the case. Process and interaction including communication issues affect both satisfaction with the outcome and satisfaction overall.
In the context of low satisfaction levels across the study population, the finding that the majority of respondents would recommend the Commissioner’s service is notable and the reasons provided for this response indicate that the respondents value the service even when ‘it didn’t work for me’.
Areas for improvement
Interaction and communication are important for complainants. Although the respondents, for the most part, valued and appreciated the contact they had with the Commissioner’s officers, there remain areas for improvement in the complaint process and the form, type and quality of interaction and communication between complainants and the Commissioner’s officers. The respondents want to be heard, they want clear information and they want the public interest more actively protected.
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About the Victoria’s Health Services Commissioner Under the Health Services (Conciliation and Review) Act 1987 (the Act) the Health Services Commissioner (the Commissioner) deals with complaints about health services delivered by public and private healthcare providers. Until 1988, health complaints mechanisms in Victoria were fragmented. Complaints were generally handled by registration boards, the state branch of the Australian Medical Association or the Department of Health. Legal proceedings for negligence were the main option for people who experienced an adverse health event. This led to dissatisfaction and frustration, with complexity, cost, inefficiency and inaccessibility hindering the resolution of complaints. These problems were identified in a 1986 inquiry conducted by the Social Development Committee of the Victorian Parliament. It recommended the establishment of a central ‘health ombudsman’. In 1987, the Act became law with bipartisan support. At the time, the importance of using consumer complaints to improve service quality was a significant reform.
Although the Commissioner has a specific mandate concerning health service complaints, there is a range of other complaints resolution options operating within health and related fields. Complaints may not necessarily find their way to the Commissioner. Many are resolved locally, while others may be more appropriately handled by regulatory bodies such as the Australian Health Practitioner Regulation Agency (AHPRA) and related boards, commissioners in related sectors such as the Disability Services Commissioner, consumer protection bodies or litigation.
The Commissioner undertakes quality improvement activities as one of a range of agencies with responsibilities in this area. Service quality changes are driven by healthcare providers as well as agencies charged with policy development, standards setting, and education and training – such as the Department of Health, the Australian Commission on Safety and Quality in Health Care, accreditation agencies and tertiary education providers.
The Commissioner’s core functions
The Commissioner’s core functions are to:
conciliate between users and providers where a complaint has been made investigate complaints relating to health services.16
The Commissioner can deal with complaints about all health services, including those provided by public and private hospitals, individual registered health practitioners and unregistered providers, such as naturopaths and speech pathologists.17 A complaint may be lodged by a ‘user’ or recipient of a health service or, if they are unable to complain, by a relative, friend, health service provider or someone else with sufficient interest (such as the Public Advocate).18 Complainants and providers can be represented. Often providers receive advice from their insurers.
The Commissioner, in assisting complainants and health service providers to resolve disputes, operates a conciliation model of complaints resolution – recognised as an alternative dispute resolution (ADR) process. ADR is an umbrella term for processes, other than judicial determination, in which an impartial person assists parties to resolve a dispute. The Commissioner does not adjudicate complaints and cannot make binding decisions. The main functions of the Commissioner that do not relate directly to complaints resolution are:
Collection and use of complaints information to improve the quality of healthcare While receiving and resolving complaints, the Commissioner may identify ways to address an underlying issue that led to a group of complaints. Such problems can then be tackled collaboratively with
16 Health Services (Conciliation and Review) Act 1987, s. 9.17 Ibid. s. 3.18 Ibid. ss. 3 and 15.
17
other organisations, such as hospitals, the Department of Health, medical colleges, registration authorities and professional associations, to make improvements in health service delivery.19
Broader inquiries and investigations The Commissioner can conduct inquiries by: referral from the Minister, either House of Parliament, or a committee of a House; referral from the Health Services Review Council and, subject to ministerial approval, initiating an inquiry into broader healthcare issues arising out of complaints received.20
Education, training and guidance about the prevention or resolution of complaints A number of training and education functions are set out in the Act.21 The Commissioner’s educative role
plays an important part in the prevention or early resolution of complaints.
The Commissioner’s complaints handling process Complaints to the Commissioner are handled in four stages:
enquiry: complaint lodgement by the complainant assessment: seeking a direct response from the health service provider, assessing the provider’s response and determining whether further action is required or if referral to conciliation is necessary conciliation
investigation.
These stages need not be sequential. The complaint process, the associated staff activity and type of interaction with complainants are outlined in more detail in the diagram below.
Referral
Where appropriate, a complaint may be referred to a specialist body such as the State Coroner, the Victorian Civil and Administrative Appeals Tribunal (for guardianship and Health Records Act 2001 matters), the Chief Psychiatrist, the Ombudsman, the Privacy Commissioner, the Australian Aged Care Commissioner or aged care complaints scheme, the Victorian Equal Opportunity and Human Rights Commission, the Victorian Assisted Reproductive Treatment Authority, the Australian Private Health Insurance Ombudsman or Victoria Police.
If the provider is a registered health practitioner, the Commissioner must notify and consult with AHPRA. Both parties agree on how the matter is to be handled and by whom. Where it is decided that the complaint will be dealt with by a registered practitioner board, the Commissioner refers the case. National boards are responsible for dealing with issues concerning the conduct and competence of registered health practitioners.
19 Quality-related functions are incorporated in the Preamble’s guiding principles, the objectives (section 4), provisions outlining the functions (section 9) and powers (section 10) of the Commissioner; and sections relating to collecting, analysing and publishing information about health complaints data. In collecting, analysing and disseminating information about complaints data, the Commissioner is required to record all complaints received, maintain a central register of all complaints and publish information about complaints (section 9). ibid.
20 ibid. s. 9.21 Under section 9 of the Act, the Commissioner’s functions include: taking steps to bring to the notice of users and providers
details of complaints procedures under the Act; developing programs for the training of health complaints officers and others in the handling of complaints; suggesting ways in which providers may follow the guiding principles; providing education and information to users, and training and education to providers, about the prevention and resolution of complaints relating to health services. The OHSC provides training to a wide range of health service users, providers and organisations holding health information. A cooperative working relationship exists between the OHSC and health complaints officers in hospitals and with many other health service providers in Victoria. Consultation with consumer organisations occurs directly or through ‘umbrella’ organisations like the Health Issues Centre.
18
Complaint closed after investigation
Victorian Health Services Commissioner’s complaint activity by stages
AssessmentComplaint must be made in writing within 12 months
of the incident occurring (discretionary extension is available).
Provider is sent the complaint and must respond within 14 days (discretionary extension is available).
Assessment must conclude within 84 days – if not resolved, Commissioner must recommend closing the case, refer it to conciliation or investigate it.
Victorian Health Services Commissioner’s complaint activity by stages
Complaint closed after assessment
Investigation A small number of matters are referred for investigation when conciliation or referral is not appropriate. Commissioner must propose remedies if matter is
found to be justified.Written notice of decision is provided to parties within
14 days.Provider must report to Commissioner within 45 days
what action has been taken – complainant receives a copy of provider’s report.
Matter may be referred for conciliation.
Enquiry An assessment officer will provide initial information, advice and assistance including:recommending that the complainant try to resolve the
problem with the health service provider providing complainant with a lodgement form or advise
you of how to access the form from the website referring the complainant elsewhere if the complaint is
not within jurisdiction.
AssessmentAn assessment officer will work with both parties to achieve resolution of the complaint including:encouraging conciliatory communication managing correspondence, negotiating timelines for
responses, and following-up sameassessing documents to recommend closure,
conciliation, investigation or referral to another agency
assisting the complainant to identify outstanding issues or to accept they may have nothing further to achieve
discussing complaints about registered providers with AHPRA when appropriate
advising parties of a decision to close the case.
Conciliation The conciliation officer will work with both parties to achieve resolution of the complaint including:contacting parties to discuss the conciliation process,
and arranging an introductory meeting, if desiredarranging a conciliation meeting, if suggestedaccessing and assessing the necessary documents obtaining expert opinion/assessment, if requiredconducting the conciliation meeting and following up
with closure if complaint resolvedmanaging the administrative processes associated with
more complex casesconducting a settlement meeting when requiredcommunicating case outcomes.
Process
Investigation An investigation officer will identify the issues and evidence required and will:notify relevant parties interview parties and explain the process obtain initial provider responseobtain expert advice opinionscollate evidenceform recommendationswrite report for the Commissioner’s signature.
Complaint closed after conciliation
Complaint closed after enquiry
Interaction with staff and staff activity
Conciliation Commissioner writes to both parties within 14 days of
referral for conciliation.Proceedings are confidential and privileged – nothing
said or disclosed in conciliation can be used in court or disclosed to another person or body
It is a voluntary process. Conciliators are impartial and cannot direct either party
how to proceed.Conciliator can request medical records, reports,
independent expert opinion and assessments.Outcomes sought are usually: explanation, apology,
quality change and/or financial settlement.
Enquiry Complaints to the Commissioner can come by
phone, letter, email or in person.
19
Presentation and discussion of principal findings
Report on the data
IntroductionWhen reviewing the tables and charts note that they address either the number of respondents or the number of issues that a number of respondents have reported (where the respondent could make multiple responses). Detailed below are the different formats for presentation of the data:
To the questions about gender, age and residence, the information per respondent is reported. In many other cases the number of issues or reasons is reported. In this case a respondent may have provided more than one issue or reason so the total number of issues will be greater than the total number of respondents answering the question. For example, there may be two or more aspects to a complaint. It may have been about clinical treatment but also about amenities.
There are questions where each respondent is asked to respond to a set of individual statements. In these cases, the percentage shown in the table or figure is the proportion who responded positively, who agreed, who did not agree or who were ambivalent eg Table 9 and 10, Figure 25.
A number of figures present data related to the respondents’ first-mentioned response where some respondents may have made multiple comments. On occasions this data is compared with the full dataset of responses.
For the majority of survey questions, an explanation of the data is presented.22
There are a number of question types included in the survey tool.23 Some provided a set of statements where respondents could choose their level of agreement or disagreement with the statement. Other questions provided respondents with a rating scale or a list of options from which to choose while others required that respondents answered ‘in their own words’.24 Initially, verbatim data were analysed and ‘back-coded’ using a coding frame influenced by relevant research and further informed by the analysis. During second and subsequent rounds of analysis the coding frames were modified to ensure a close fit with the intent of respondents’ comments.
About the respondents and their complaints
GenderThe proportion of female respondents in the study population was slightly higher than the total population of complainants using the Commissioner’s service. In total, there were 293 females and 143 males. The high proportion of female complainants lodging complaints is consistent with the profile of complainants reported elsewhere and is perhaps explained by the greater engagement of women with health services during their reproductive years and the larger social responsibility carried by women for the health and care of others.
AgeComplainants in the sample ranged in age from 18 to over 80 with the largest numbers of complainants aged 50-59, followed by those aged 40-49. There were fewer men in all age groups other than the 80 plus group,
22 Survey question – E2 – has not been reported because of the poor response to the question.23 Please refer to the survey tool at Appendix D.24 Coding names, rating scale variables, statement sets and options where relevant to the question, are presented in the figures
and tables in this section.
20
where numbers were equal. The age range is consistent with the total population accessing the Commissioner’s service.
Figure 1. Age range of respondents by gender
0
10
20
30
40
50
60
70
80
90
Num
ber
MaleFemale
Residential location: rural or metropolitanThree hundred and twenty-three (323) participants provided a metropolitan Melbourne postcode and 104 a Victorian rural postcode. Four respondents provided an interstate postcode and five were unknown. This ratio matches the Victorian population and is consistent with the ratio of rural and metropolitan Victorians using the Commissioner’s service. There were proportionally slightly fewer respondents living in rural Victoria who had cases closed at the conciliation and assessment stage.
Figure 2. Respondent residence by stage of case closure
Residence by stage of case closure n=436
0
10
20
30
40
50
60
70
80
90
% Metropolitan % Rural %Unknow n/interstate
Conciliation Assessment Enquiry
21
Educational levelRespondents had, on average, higher levels of education than the Victorian population. This finding is consistent with the profile of complainants documented elsewhere in Australia and internationally.25 Complainants were most likely to have a postgraduate level of education (19 per cent), followed by a bachelor degree (17 per cent) and year 10 or below (16 per cent). When compared with the Victorian population, they were more than twice as likely to have a postgraduate degree and around 50 per cent less likely to have a trade or certificate as their highest level of education. The complainant sample was also slightly less likely to have no non-school qualification.
Table 1. Respondent highest completed level of education n=436
Educational level Complainants % Victoria* %
Year 10 or below 15.8
Year 11 8.3
Year 12 13
No non-school qualification (37) 42
Trade / Certificate 14 21
Diploma 11 10
Bachelor Degree 17 19
Post-Graduate Degree 19 8
* 6227.0 - Education and Work, Australia, May 2011
Language other than English spoken at homeTwenty-two (22) percent of the sample reported speaking a language other than English at home, most commonly Italian (4 per cent) and Greek (2 per cent). The proportion of people that reported speaking a language other than English at home was very slightly lower than that reported for Victoria in the 2011 Australian Bureau of Statistics (ABS) Census (23 per cent). 26 Although the numbers are small, data showed a higher proportion of Italian and Hindi speakers than in the Victorian population, and a lower proportion of speakers of Chinese languages.
Table 2. Language spoken at home by respondents and the Victorian population n=436
Language Complainants % Victoria %English Only 77.8 72
Other than English 22.2 23.1
Italian 4.1 2.3
Greek 2.3 2.2
Hindi 1.6 0.6
Chinese languages* 1.4 3.6
Unstated 4.6
* Cantonese, Mandarin, Chinese language
25 Daniel et al, (1999); Taylor et al, (2004).26 2011 Census of Population and Housing, Basic Community Profile, Cat. No. 2001.
22
Participation in the Commissioner’s complaints process by Aboriginal peopleFive of the 436 complainants that participated in the survey identified as being Aboriginal or Torres Strait Islander. As 1 per cent of the sample, this was higher than the proportion of Aboriginal people in the Victorian population, 0.7 per cent (2011 ABS Census), but consistent with the number of Aboriginal people lodging complaints with the Commissioner.
Who was complained about and why?
Health service provider complained aboutMedical practitioners were the most common focus of participants’ complaints with a combined total of 40 per cent. This group consisted of general medical practitioners (GP) or doctors (for example, hospital interns or registrars) were identified by 19 per cent of complainants with specialists and surgeons complained about by 11 per cent and 10 per cent respectively. A hospital or health service was the next most common cause for complaint (34 per cent of cases). Dentists accounted for nine per cent of complaints, allied health practitioners eight per cent and nurses seven per cent. Eighty-nine participants identified more than one party being complained about, most commonly, for 21 participants, a GP/doctor and a hospital or health service.
Figure 3. Health service provider complained about n=537 number of providers by 436 respondents
Health service provider complained about n=537
0% 5% 10% 15% 20% 25% 30% 35% 40%
Other
Nurse or nursing staff
Allied health professional
Dentist
Surgeon
Specialist
GP or Doctor
Hospital or health service
Percentage
Public versus private providersAlmost half of the complaints made to the Commissioner (49 per cent) were about public providers, with 42 per cent about private providers and 7 per cent about both public and private providers. Hospital or health service complaints and those about a nurse or nursing staff were most likely to relate to a public provider, whereas complaints about a dentist or surgeon were most likely to involve a private provider.
Rural respondents made more complaints about public services (59 per cent) and fewer about private services (30 per cent) than metropolitan complainants, for whom the percentages are 47 per cent public and 45 per cent private. This finding is unsurprising. In 2010–11 in rural Victoria, there were 23 private hospitals providing 24 per cent of total rural separations (105,755 separations) while there were 97 public hospitals or health services providing 76 per cent (440,435 separations). At the same time in Melbourne, private hospitals numbered 144 and provided 41 per cent of total metropolitan separations (770,344 separations) while there were 51 public hospitals providing 49 per cent (1,087,006 separations).27 The ratio of GPs is 1:3
27 Department of Health Victorian Admitted Episode Dataset, 2011.
23
(rural/metropolitan) and dentists (excluding specialists) 1:4 in favour of the metropolitan area (DH regional profile data, 2011).28
Figure 4. Complaints by public or private provider type
Complaint by provider type n=436
49%
42%
7% 2%
Public Private Both Don't know
In the figure below comparative proportions of public or private provider type by who was complained about ordered by total number of complaints (descending) are presented. Perhaps not surprisingly more hospitals and health services, medical practitioners and nurses working in the public sector are complained about, whereas more specialists, surgeons, dentists and allied health professionals complained about are private providers. To complement the figure below, Table 3 which follows provides the numbers of complaints per provider type.
Figure 5. Proportion of public or private provider by provider type
Public/private provider by provider type by no. of complaints n=537 providers by 436 respondents
0% 20% 40% 60% 80% 100%
OtherNurse or nursing staff
Allied health profDentist
SurgeonSpecialist
GP or DoctorHospital or health svs
Public Private Both (Don't know )
Table 3. Numbers of complaints by public or private provider by provider type n=537
Other Nurse Alliedhealth
Dentist Surgeon Specialist GPDoctor
Hospitalhealth service
28 Department of Health regional profile data, 2011.
24
Public 7 26 16 11 18 19 59 121Private 7 8 22 33 32 32 31 46
Both 1 2 3 2 2 7 7 15(Don't know) 2 1 1 0 0 0 3 3
Total 17 37 42 46 52 58 100 185
Reason for complaintThe most common reason for complaints being lodged with the Commissioner was clinical treatment (59 per cent). This was followed by interpersonal communication and behaviour by clinical staff (26 per cent) and costs (11 per cent). Fifty-one people identified more than one reason for their complaint, with more than half of these identifying clinical treatment and poor interpersonal treatment by clinical staff. These results are similar to those reported in other studies.29 Across different classification systems applied to the types of complaints, clinical treatment and communication and conduct are usually, the first and second reasons for complaint, respectively. In Victoria, the Commissioner reports access issues as the second most common reason for complaint.30 This question elicited a verbatim response from respondents and the categories employed by the Commissioner did not provide the best fit for the information provided by the respondents.
Figure 6. Reason for complaint lodgement n=489 number of reasons given by 436 respondents
Reason for complaint lodgement n=489 number of reasons given by 436 respondents
0% 10% 20% 30% 40% 50% 60%
Amenities
Other
Poor qualityproduct
Comm/behaviour from other staff
Costs
Comm/behaviour from clinical staff
Clinical treatment
Other complainant and complaint information
The most common method of finding out about the Commissioner’s complaints service, reported by approximately 25 per cent of complainants, was via a general internet search. This was followed by friend/family/colleague (16 per cent) and the health service (16 per cent). A larger group reported ‘other’ methods (22 per cent), with the dominant source in this group being a lawyer, followed by Consumer Affairs Victoria, Medicare and local politicians. A low proportion of people (3 per cent) found out about the process from advertising (brochure or poster). These findings remain consistent when the data are examined applying a public/private and, separately, a rural/metropolitan lens. However, for rural complainants the medical practitioner is an important source of information, and for respondents making complaints about
29 Cowan, J. and Anthony, S. (2008). Problems with complaint handling: expectations and outcomes. Clinical Governance: An International Journal, 13(2), pp. 164-168.Daniel et al, (1999).
30 Annual report 2012, Office of the Health Services Commissioner, p. 25.
25
private providers, the health service is not quite as important a source of information as for respondents making complaints related to public services.
Figure 7. Medium for finding about the Commissioner’s service n=436 respondents
Communication medium for finding out about the Commissioner's service n=436
0% 5% 10% 15% 20% 25% 30%
Advertising**
Can't remember
Medical Practitioner
Health service*
Friend/family/colleague
Other
General internet search
* for example, complaints or liaison officer at hospital; ** brochure/poster
Further investigation of which respondents are using the internet for information reveals a preponderance of younger to middle aged people, highlighting the importance of e-communication. However, it is important to note that older age groups need to be communicated with and have access to other communication mediums.
Figure 8. Age range of those accessing information about the Commissioner by internet
Internet search by age n= 105
0%
10%
20%
30%
40%
15-24 25-34 35-44 45-54 55-64 65-74 75+
Internet
Number of complaints made by respondents to the Commissioner
A total of 521 complaints had ever been made by complainants in the sample. As shown in the table below, including the current closed complaint, a single complaint had been made by 387 complainants. Thirty-three (33) complainants had made two complaints and 16 had made more than two complaints.
Table 4. Number of complaints ever made to the Commissioner n=512 made by 436 respondents
Complaints Frequency1 387
26
2 333 84 46 2
10 2
Year of first and most recent contact with the Commissioner’s service n=432 respondents
Of the 432 respondents who answered this question, 29 per cent had lodged their most recent complaint in 2010, followed by 24 per cent in 2011 and 13 per cent in 2009. Only 8 per cent of complainants had lodged their most recent complaint in 2012. For a small group of respondents the most recent complaint lodged with the Commissioner was more than five years ago, which may suggest that there has been some misunderstanding of the question. For 28 per cent of complainants, the most recent contact with the Commissioner was in 2012 and for another large group (26 per cent) it was 2011. There appears to be a small group of respondents who lodged a complaint prior to 2009 for whom it appears that that the complaint process has been lengthy.31 Verbatim responses from complainants provide support for regular delays in the process and the protracted length of some cases:
- It was the time it took. I put my letter in to the service provider in November 2010 and it was about June 2012 when I got the last bit of correspondence from the Commissioner with the letter attached from the service provider so that’s actually more than 18 months. So it was the time, the person I dealt with there, she was very good but if you can’t adhere to your own processes in terms of time then the Commissioner has a serious problem. (R82/c) 32
- At that point, 2 years later I’d ceased to care, it’s not cost or time effective to complain but then I am reasonably assured the same problem won’t reoccur to someone else but it was an uphill battle and I don’t feel it achieved much. (R330/c)
- The Commissioner should have assurance and power. What is the point if they don’t have any power to make decisions? Why did I waste three years of my life? (R260/c)
Table 5. Year of first and most recent contact regarding most recent complaint
First contact with Commissioner (n=432)Most recent (last) contact with Commissioner (n=432)
Year Number Percentage Year Number Percentage2012 34 8 2012 119 282011 102 24 2011 113 262010 127 29 2010 71 162009 58 13 2009 21 52008 30 7 2008 11 3
2007 or earlier 25 6 2007 4 1Unknown 56 13 Unknown 93 21
Attempt at local resolution n=436 respondents
The majority of complainants (79 per cent) had approached the health service provider prior to making contact with the Commissioner, 20 per cent had not approached the provider and 1 per cent answered, ‘don’t know’.33
31 There may have been some misinterpretation of the question for the 15 respondents who said their most recent contact was outside the period of the research as only those with cases closed between 2009 and 2012 have been included in the study.
32 The ‘R’ before the number in brackets following a quote represents the word, ‘respondent’, and the letter following the respondent number indicates the respondent group: a = assessment, c = conciliation and e = enquiry
33 In usual circumstances, before the Commissioner will accept a complaint, the complainant needs to have attempted to resolve the problem with the health service provider concerned.
27
Figure 9. Approach the health service provider prior to contact with the Commissioner
Attempt at local resolution prior to contacting the Commissioner by stage of case closure n=436
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Enquiry Assessment Conciliation
Yes No (Don't know )
These results are quite positive in that it would appear that the large majority of people do attempt to resolve the issue where it occurred.
Reasons why local resolution was not attempted
Principal reasons for the complaint not being resolved at the local level were that the provider did not take responsibility for the problem or admit a mistake or it was ignored or not taken seriously. Of the 86 respondents who did not attempt to resolve the complaint with the health service provider, 45 respondents (52 per cent) said that they did not feel comfortable or were too upset:
- I felt I needed someone to act on my behalf. (R588)- I didn’t want to contact them as I was very angry and I would not have dealt with them very well. (R965)- I just didn’t want to speak with them due to how sick I was. I didn’t want to deal with them directly. (R217)- I didn’t have the right words. (R378)
- He didn’t care about me. (R995)
A smaller number of people were unsure about what to do (6) or wanted to better know their rights before contacting the health service directly (6) and 3 didn’t provide a reason.
Another 26 respondents provided other reasons with the most commonly stated reasons being that complainants did not have faith that the provider would do anything about the problem (10) and that they had already received a negative response from the provider (9): ‘The doctor refused to talk to me’. (R950) ‘They were too busy to listen to me’. (R503)
Reason why attempts at local resolution failed
Of the 436 who responded eighty-nine (89) respondents provided multiple reasons. The most commonly identified issue was that the provider did not take responsibility for the problem, (23 per cent). Between 15-16 per cent of respondents reported for each of the following: the provider did not admit a mistake had been made, the complaint was ignored or the complaint was not taken seriously.
28
Fifty-two (52) complainants (13 per cent) gave ‘other’ reasons why local resolution failed. Themes emerging from the ‘other’ category were that the provider intimidated or refused to see the complaint, was no longer practising at the service or the complainant had no faith that anything would be done about the complaint.
Figure 10. Reason problem wasn’t resolved where it occurred n=619 reasons provided by 436 respondents
Reasons for local resolution failure (no. of reasons n=619)
0% 5% 10% 15% 20% 25%
I wanted an apology.
The apology was not enough
The HSP wouldn't pay compensation
I wanted it to go to a higher level
The HSP did not provide a clear explanation
The HSP took too long
I couldn't approach the HSP
I wanted the HSP disciplined
Other
The complaint wasn't taken seriously
The complaint was ignored
The HSP would not admit that the mistake
The HSP did not take responsibility
A sample of representative comments is provided:
- They told me that I should pay for it because Medicare doesn’t. They threatened me with a debt collector. (R463)- My specialist at the time told me I had the right to do it but that I wouldn’t cope as I have anxiety and depression and I "wouldn’t win". (R378)- The health provider specifically wouldn’t see complainant. (R687)- He pretty much kicked us out of the building. (R157)- I didn’t see the hospital do anything to prevent it happening again even though they did acknowledge there was a problem. (R611)- I was not confident that it wouldn’t happen to anyone else. (R128)- I was not confident in the professionalism of the GP. (R956)
- Because the people involved into the hospital complaint area, have no power to change anything. (R179)
These results further suggest the need for improvement of complaints handling at the local level including both provider education and skill development and strengthening of complaint processes.
- I hope that if changes come through that the end result is better for the patients so the hospitals will have better ‘PR’ skills. (R548)
29
When a public/private lens is applied to the reasons provided there is very little difference between whether the complaint concerned a public or private service. Complaints about public services/providers were slightly more likely to ‘not be taken seriously or ignored’, 32 per cent, to private providers, 28 per cent., There was a slightly greater likelihood of the private provider not taking responsibility for the problem or admitting a mistake’ (40 per cent) compared to public providers (37 per cent).
Commissioner early advice to respondents
Only 108 respondents (24 per cent) said that the Commissioner had advised them of who else they might want to contact about their complaint, and those most commonly mentioned were: a lawyer or legal service, AHPRA, the Victorian Ombudsman and the health service provider. In the ‘other’ category, the police, professional associations, government bodies and politicians were mentioned amongst others.
Figure 11. Commissioner initial advice to complainant about who to contact about complaint
Advice to respondents about who else to contact n=108
0 5 10 15 20 25 30 35 40 45
Health service provider
Ombudsman
AHPRA
Other
Lawyer
No. of respondents
Seriousness rating of respondents’ complaints
The seriousness rating of the complaints made in the sample is broadly consistent with those reported by the Commissioner. In the Commissioner’s 2012 annual report,34 the majority of complaints are of medium seriousness, followed by low and then high seriousness. The proportion of cases rated medium to high seriousness is higher in the conciliation group and the greater proportion of low seriousness cases is found in complaints at the enquiry stage.
34 Annual Report 2012, Office of the Health Services Commissioner.
30
Figure 12. Seriousness rating of complaint n=436 respondents
Distribution of seriousness rating across stages n=436
0%
10%
20%
30%
40%
50%
60%
70%
Low Medium High Very high
% Enquiry % Assessment % Conciliation
As reported above, there are more complaints associated with public providers than private providers, 49 to 42 per cent respectively but when the distribution of the seriousness rating is considered as a proportion of either public or private, the similarity is striking as shown in the figure below.
Figure 13. Public and private provider type by complaint seriousness rating
Distribution of complaint seriousness rating by provider type n=399
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Low
Medium
High
Very high
Public Private
*There were 30 complaints that involved both public and private providers and seven complaints where the service provider type was not identified accounting for the 37 complaints not represented in the figure above.
Respondents who lodged a submission to the public consultation process
Forty-six respondents made a submission to the review of the Health Services [Conciliation and Review] Act 1987 comprising 10.5 per cent of the total study population.
Enquiry group only
Complainant case closed at enquiry
All 53 respondents, who according to the Commissioner’s records had had their case closed at enquiry, responded to this question. Forty-eight respondents said ‘yes’, but three said ‘no’ and two said they didn’t know. It is hard to account for the three who said ‘no’. It may be that they had another understanding about the Commissioner’s terminology where the ‘enquiry stage’ is one stage in the complaint process, not just a
31
casual contact, and the complainant may accurately have considered that they made more than just an ‘enquiry’. Five people said they couldn’t remember the reason why the case was closed at the enquiry stage.
Table 6. Reasons for case closure at the enquiry stage
Reason n=48 Complainant comments - exemplars
Lack of support 7 I couldn’t fill in the paperwork. I’m suffering form anxiety and don’t know how to start or how to go about it. (R939)
Referred on/or to local level/resolved at local level
6 The Commissioner told me to go back to the hospital. (R141)
Nothing the Commissioner could do
6 They told me that because the doctor involved kept getting insured he would always be hired and there was nothing they could do. (R922)
Disillusioned/What’s the point? 6 Because during the initial enquiry I looked into the timelines and I found out there were no strict timelines and I could be waiting for months or a year for a response. Which I thought was embarrassing because what’s the point in me being here when I can’t get a timely response? … I had no confidence that the matter would be resolved or that the Commissioner had any power or that they would refer it to any other body, that’s how I felt, the lady was lovely to speak to but I felt I nothing was going to be done. (R211.
Ill health 5 I got frustrated because they just gave me paperwork to fill out. I had a shoulder injury and couldn’t fill in a lot of paperwork. (R906)
Too hard 5 The paperwork was too difficult and I’d say the paperwork just got too much … It was just too difficult essentially. (R739)
The Commissioner didn’t follow up
5 I have no idea. They never contacted me again after I first made the call, they said they’d send me some forms but they never did and when I asked them to send them to remind them I never heard back. (R760)
Can’t remember/don’t know 5 I have no idea. Life goes on. It’s full of elderly people. We die off. (R864)
Provider intimidation/denial 3 The bullying from [named provider] & I did not think it would make much difference. (R786)
Changed doctors/moved on 2 I got files from the GP and thought I would move on as I was not planning to visit that GP again. (R829)
Provider opted out 1 The technician wouldn’t send me the information I needed to pass on to the Commissioner. (R1025)
Powerless 1 I felt small. I am just a person. Doctors have a guild. I felt I needed legal help. I was a long time patient of that clinic. It was hard to change the relationship. I mean, who was I? I was a patient, I was complaining. Who was I? (R915)
Complainant expectations
Expectations and understanding of the Commissioner’s roleComplainants were most likely to understand the Commissioner’s role as being to provide an impartial complaints resolution service. ‘Looking into’ the complaint and assisting the complainant resolve the complaint were the second and third most common understandings of the Commissioner’s role.
In the figure below all responses to the question about the complainant understanding of the Commissioner’s role are presented. Nine respondents did not provide a response and 63 provided more than one response.
Figure 14. Respondent understandings/expectations of the Commissioner’s role
32
Understanding of Commissioner role n=514 comments made by n=427 respondents
0% 5% 10% 15% 20% 25% 30%
Refused
Act on behalf of complainants
Don't know
Regulate/monitor health service providers (HSP)
Resolve the complaint
Make decisions/sanction or discipline HSP
Get an outcome
Protect the public interest
Assist the complainant resolve the complaint
'Look into' (investigate) the complaint
Provide impartial assisted complaint resolution
Twenty-seven per cent of comments from respondents described the Commissioner’s role as impartial complaint resolution which included 80 individual respondents (19 per cent) who specifically referred to the mediating role of Commissioner.
- To mediate, to basically, not necessarily support a particular side but to find some middle ground for everyone. (R544)
- Mediator between the public and health professionals. (R112)
Seventeen per cent of comments received from respondents indicated that the second most common expectation of the Commissioner was that the complaint would be ‘looked into’, investigated35 which for the majority of complainants meant active engagement and inquiry into the complaint:
- to look into it, the way I was treated in the hospital. (R391) - that they would look into it and help me out, instead of going through a solicitor. That they would look through all relevant documents and see if it was worth fighting for. (R40)
- From the bullet points on the website, I thought they would investigate the matter. (R207)
Some respondents wanted to know if the Commissioner thought they ‘had a case’, others wanted some accountability from the provider, which at the simplest level included provider engagement. Respondents want the provider to recognise their issue and respond appropriately, most commonly by providing an explanation or an apology or changing practice. Respondents expect that the Commissioner will be more influential in securing a provider response than they have been:
- If an individual couldn’t get their point across I was hoping a government organisation could. (R244)
- They were a body that would be able to take my questions and get some answers and some accountability. (R620)
Thirteen per cent of respondent comments related to expectations about the role of the Commissioner providing assistance to the complainant to help them resolve the complaint.
35 The term investigate when used by complainants is a more casual use of the term than that included in the Act and which constitute the fourth stage of the Commissioner’s process.
33
- To help me as best they could. (R100)- I thought they would have helped me understand my rights. (R199)
- I just thought they were there to give me some advice and give me some help. (R226)
Another 10 per cent of comments related to the role of the Commissioner in protecting the public interest:
- They were there to protect the public interest. (R646)- Someone who could see what was going on and make sure it didn’t happen to anyone else. (R263)
The categories ‘get an outcome’ and ‘solve the complaint’ reveal a slightly different emphasis for respondents where approximately 7 per cent of responses refer to the Commissioner’s role in achieving desired outcomes, and 5 per cent of responses that reveal expectations related to the Commissioner’s role in resolving the issue.
Another set of comments (six per cent) reveals a less accurate understanding of the Commissioner’s role including ‘making a determination’ about the complaint, attributing culpability and possibly disciplining or sanctioning the practitioner:
- I thought that they would look into it and tell us whose fault it really was. (R394) - Something like an Ombudsman who would determine whether an injustice has been done. (R379)
- To put a stop to this doctor so he doesn’t harm anyone else. (R373)
Five per cent believe that the Commissioner has regulatory authority in the sector:
- That they could sanction doctors at their practice like a watchdog. (R950) - I assumed they monitored misdiagnosis and that they would reprimand those who misdiagnosed. (R878)
- An authority who would check on the medical practice. A standard checking body like an Ombudsman. (R396)
Four per cent expect that the Commissioner will advocate for them. There is a mixture of responses in the ‘advocate for the complainants’ code where only seven respondents used the term ‘advocate’ when describing their understanding of the Commissioner’s role. However, some other respondents said they expected the Commissioner to act on their behalf, for example,
- I thought they would act on my behalf to get an answer and improve the processes at the hospital. (R401).
- I didn’t know actually. I wanted someone to stand up for me and tell the company, this is a human being, a customer. You can’t treat people like this. (R420)
When respondent comments are examined per respondent rather than as themed sets of comments the order changes little but the percentages increase slightly in favour of the first four expectations:
Provide impartial assisted complaint resolution Assist the complainant resolve the complaint 'Look into' (investigate) the complaint Protect the public interest Get an outcome Resolve the complaint Act on behalf of complainants Make decisions about the case/sanction or discipline health service providers (HSPs)
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Regulate/monitor HSP Don't know
Expectations of Commissioner actionWhat respondents expected the Commissioner to do to assist them achieve their desired outcome is presented in the figure below. Twenty respondents said that they ‘didn’t know’ in response to this question. Eighteen per cent or 75 complainants had multiple expectations about how the Commissioner would assist them achieve their desired outcome.
Figure 15. Actions expected of the Commissioner n=491 expectations provided by 416 respondents
Anticipated Commissioner actions: n= 491 comments made by n=416 respondents
0% 2% 4% 6% 8% 10% 12% 14%
Conciliate
Don't know
Make decisions about the case
Refused
Act on my behalf
Contact the provider
Other
Warn or discipline HSP
Ensure institutional and or practice change
Mediate
Provide assistance, support or advice to resolve issue
Engage & influence HSP to progress resolution
'Look into'(investigate) the complaint
Resolve the complaint/achieve an outcome
A major theme emerging from the respondents’ verbatim comments was that the complaint would be resolved and an outcome achieved by engaging the Commissioner’s assistance (13 per cent). The outcome might be an apology, an explanation, compensation or just ‘fixing it up’ (R255), or ‘talk to all parties and come to a conclusion’ (R237). When verbatim comments are examined per respondent it is of interest that only 28 respondents (7 per cent) expected the Commissioner to help them secure reimbursement or compensation, yet 157 respondents hoped for such an outcome.36 The difference may suggest that complainants are unsure about exactly what the Commissioner will do to assist them, unsure about the process or about what may emerge from the process.
Commonly there was an expectation the Commissioner would look into, assess and investigate the complaint (13 per cent) and that the Commissioner would influence providers to resolve the complaint (12 per cent). Just over 10 per cent of comments related to respondent expectations that the Commissioner would assist the complainant and nearly 8 per cent that the Commissioner could (and would) act to protect and assure the public interest by ensuring practice or system change. Just under 10 per cent of comments related to mediating action by the Commissioner which is a much smaller theme set than the responses to the earlier question where 19 per cent of individual respondents understood mediation to be part of the Commissioner’s role.
36 In total, 157 respondents (36%) wanted compensation or reimbursement amongst other things when asked at first contact with the Commissioner’s office, what they hoped to achieve, yet only 28 respondents of that group mentioned it with regard to what they expected the Commissioner would do to assist them achieve their outcome.
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Smaller sets of themed responses revealed more inaccurate expectations of Commissioner action, namely to warn or discipline the provider (five per cent), advocate on my behalf (four per cent) and make decisions about the complaint, (four per cent) some of which were associated with making determinative decisions.
When respondent comments are examined per respondent rather than as themed sets of comments the order changes little but the percentages increase slightly in favour of the first two expectations:
'Look into' (Investigate) the complaint Resolve the complaint/achieve an outcome Engage and influence HSP to progress resolution Mediate Provide assistance, support or advice to resolve issue Ensure institutional and or practice change Other Warn or discipline HSP Act on my behalf Contact the provider Make decisions about the case Don't know
Conciliate
Complainants commonly express sentiments to the effect that the Commissioner will ‘do something’ to help sort out the problem. As Dasu and Rao, and Tax et al observe, responsiveness and effort on the part of those helping to resolve the complaint, matter.37 Individuals lodging complaints with the Commissioner may have had an incomplete or unsatisfactory experience with the provider at the local level so their expectations about what the Commissioner ‘should’ do to assist them in terms of responsiveness and effort may be heightened.
Expectations of outcome
Complainant desired outcome
The most common outcome mentioned by respondents was institutional and/or practice change, 27 per cent of complainants. This is a common finding in other studies in this field.38 An apology (13 per cent), compensation (12 per cent) and reimbursement (11 per cent) were the next most commonly desired outcomes. Just under half of all respondents (202) provided more than one outcome they were hoping for, most commonly an apology or a clear explanation and institutional/practice change. The proportion of those wanting compensation and/or reimbursement is higher than reported in some other studies. A possible explanation for this finding is that there could be a proportion of complainants availing themselves of the Commissioner’s services who prior to the introduction of the Wrongs and Other Acts (Law of Negligence) Act 200339 might have pursued litigation.
There was a range of hoped-for outcomes regardless of whether the complaint involved a public or private provider. However, where reimbursement or compensation were the hoped-for outcome, they were more likely to be associated with complaints about private providers (34 per cent) rather than public providers (14 per cent). System or practice change was more likely to be associated with complaints about public providers (31 per cent) rather than private (21 per cent).
37 Dasu and Rao, (1999); Tax et al, (1998). 38 Bark et al, (1994); Vincent et al, (1994); Bismark et al (2006); Friele et al, (2006); 39 In Victoria, the Wrongs and Other Acts (Law of Negligence) Act 2003 requires that for a complainant to be eligible for financial
compensation, the damage caused has to be at a minimum of 5 per cent for a physical injury and 10 per cent for a mental or psychological injury.
36
Figure 16. Desired outcome(s)
Complainant desired outcomes n=717 no. of outcomes provided by 436 respondents
0% 5% 10% 15% 20% 25% 30%
Other
Record complaint
A clear explanation
An investigation
Disciplinary action
Reimbursement
Compensation
An apology
Institutional/practice change
Figure 17. First-mentioned desired outcome per complainant
First-mentioned desired outcome n=436
0% 5% 10% 15% 20% 25%
Record of complaint
Investigation
Disciplinary Action
Reimbursement
Explanation
Compensation
Apology
Sys/practice change
% of complainants
When the first mentioned hoped-for outcomes per individual respondent are examined the preference order changes little. The large difference in ratio between institutional/practice change and the other outcomes is explained by many complainants mentioning it as a second or third desired outcome. Although many complainants expect the Commissioner to investigate the complaint, far fewer mention that as a primary outcome.
Modification of expectations
Advice received from the Commissioner about desired outcome
The Commissioner’s officers provide complainants with information and advice about what can reasonably be achieved when making a complaint. This advice is important to ensure that complainants enter the process with realistic expectations and have appropriate information to inform their decision making about whether to proceed.
The 433 respondents who provided information were closely split between having received advice and not having received advice. Two hundred and sixteen respondents (49.4 per cent) responded in the negative that upon their first contact with the Commissioner they were not informed what could be achieved and 217
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(49.9 per cent) provided a positive response. Three participants (0.7 per cent) did not respond to this question. Thirty of those who did respond (14 per cent) could not remember the details or could not remember if they were provided with information. Just over 10 per cent reported that the complete process and possible outcomes were explained to them.
Table 7. Commissioner advice regarding desired outcomes and explanatory comments n=451 responses provided by 433 respondents
Response No. Per centNo 216 49.4%
Yes 217 49.9%
Refused 3 0.7%
Total 436 100%
The advice received by 217 respondents in order of frequency was:
Explained the complete process and the possible outcomes Said they would seek a response from provider Said they would arrange compensation Said they could not help Said they would investigate claim Said they would arrange mediation Said they would help me file a complaint Said they would arrange conciliation
Of the responses coded as ‘other’ (18 per cent), the majority related to advice that was either vague or unhelpful (6 per cent) while there were a scatter of responses where complainants said that the Commissioner had been sympathetic, said the complainant ‘had a case’ or referred the complainant elsewhere.
Review of initial expectations of desired outcome: the conciliation group of respondents
The Commissioner’s records indicated that 155 participants in the sample had complaints closed at conciliation but when asked there were 53 respondents who were not clear about whether their case was closed at conciliation which could reflect that the administrative procedural classification of a complaint is not understood or clear to respondents, or alternatively, is not important or meaningful.
The respondents whose cases had proceeded to the conciliation stage were asked to reflect on their expectations of the conciliation stage:
One hundred and two (102) respondents answered the question. Of the 102, 6 responded, ‘don’t know’.
Twenty-one respondents provided more than one desired outcome with the majority wanting system/practice change as a second outcome.
Twenty-two respondents provided verbatim ‘other’ comments some of which are:
- Honest reports from the doctor that the reports wouldn’t be written after the fact, that is to say, falsified. Medical notes were rewritten after my complaint. I hoped the Commissioner would see that it was a sham and not accept this obviously concocted evidence.- I expected him to be disciplined, that’s all.- I expected my rights would be exercised over the damage I received from the endocrinologist.
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- I expected that the practitioner concerned would attend. I was told just beforehand though that only hospital administration would attend. I felt that the practitioners concerned weren’t accountable. It wasn’t very satisfactory.- I expected to get a response from the provider.- I wanted them to see what I’m saying - that they have to have better control.- I was hopeful that the service provider would attend and they didn’t.- I was hoping a dental plan could be restarted with another dentist- I was not sure but I was hoping that I would get new dentures or a refund. I wrote to them and I said that I just don’t want a sore mouth anymore.- Issues brought to the attention of the hospital.
- Negotiation with both parties.
Examination of the responses to the question and comparison with their responses to the earlier question about what they hoped to achieve revealed that 43 respondents (42 per cent) changed their expectations about what they hoped to achieve in some way but, despite this, an apology remained the most common primary desired outcome for this group of respondents.
Disciplinary action features in the earlier set of expectations (7 per cent of the conciliation group respondents), which seems to be moderated in responses to the later question where it only appears in two of the ‘other’ comments. Both ‘an investigation’ and ‘recording the complaint’ are not registered in the later response, but ‘resolving the complaint to my satisfaction’ is (5 per cent). Examination of the explanations provided by the group of respondents who chose ‘other’ (21 per cent) to this later question reveals that these complainants also wanted resolution of the complaint. Listed below are examples of the nature of the change in expectation from first contact to when embarking on the conciliation phase of the complaint process.
Respondent 787 at the outset wanted an apology, but at conciliation hoped ‘that we would understand and finish up’. Respondent 155 expected a clear explanation but by the time they were conciliating they expected an apology. Respondent 722 initially expected an apology but at conciliation hoped ‘that we would get to speak with the doctor concerned’. Respondent 1010 initially wanted a clear explanation, but by the time their case was being conciliated they wanted a ‘payout’. Respondent 827 initially wanted compensation, but at conciliation wanted ‘negotiation with both parties’. Respondent 874 initially want disciplinary action for the practitioner but at the conciliation stage ‘wanted to be heard, that the matter would be taken seriously’. Respondent 9 originally expected to be reimbursed, but at conciliation wanted an apology.
Respondent 40 initially wanted compensation and an investigation, but at conciliation ‘wanted to understand why it had happened to start with and why things weren’t looked into more. We wanted answers which we didn’t get’.
These results suggest a modulation of complainant expectation which could be the result of the type of engagement with the Commissioner’s officers during the conciliation process and the extra ‘effort’ exerted as Tax et al suggest.40 This modulation appears evident in the change in order of the desired outcomes in the figures below.
40 Tax. S., Brown, S. and Chandrashekaran, M. (1998). Customer evaluations of service complaint experiences: Implications for relationship marketing, Journal of Marketing. 62 (April), pp. 60-76.McColl-Kennedy and Sparks, (2003).
39
Figure 18. Conciliation respondents first mentioned desired outcome at the conciliation stage
First mentioned desired outcome at conciliation n=102
0 5 10 15 20 25
Resolution
Don't know
Reimbursement
System/practice change
Compensation
Clear explanation
Apology
Other
% of complainants
Figure 19. Conciliation respondents’ first mentioned desired outcome at first contact
Conciliation respondents initial first mentioned desired outcome n=155
0 5 10 15 20 25 30
Complaint recorded
Investigation
Reimbursement
Disciplinary action
Clear explanation
Sys/practice change
Compensation
Apology
% of complainants
System or practice change is the most common desired outcome across the study population whether considered as a percentage of all desired outcomes or as the first-mentioned desired outcome. However, when the first-mentioned desired outcome is examined for the conciliation group, the picture is different: an apology is the most common first-mentioned desired outcome with system or practice change a frequent second desired outcome. This is the case for the response to the question about desired outcome at first contact with the Commissioner’s office as well as to the repeat question at the conciliation stage.
Outcomes
Outcome of contact: enquiry group The Commissioner reports that a large proportion of enquiry cases (40 per cent) never proceed any further.41
Just over half (30) of the 53 complainants whose case was closed at the enquiry stage could recall receiving a copy of the complaint form from the Commissioner. Of this 30, 11 said they returned the form, 13 said they had not and six did not know. Four respondents (8 per cent) said that although they had returned the form they heard nothing further from the Commissioner.
41 Annual report 2012, Office of the Health Services Commissioner, p.15.
40
Of participants that had cases closed at the enquiry stage (n=53), approximately 30 per cent reported that the outcome of their contact with the Commissioner was what they expected, 60 per cent said that it was not and 10 per cent did not know. Only 15 per cent of respondents reported that their complaint was resolved with 83 per cent reporting that it was not. Two per cent did not know.
Outcome of case: assessment and conciliation groups When the verbatim comments about the outcome were examined and counted for each respondent 39 per cent achieved an outcome in some form with 61 per cent not achieving an outcome. Of the 383 assessment and conciliation group respondents, 234 (61 per cent) indicated that they had achieved a negative outcome, which was frequently reported as having achieved nothing. One hundred and twenty (31 per cent) achieved a positive outcome and 27 (7 per cent) received a partial outcome. Two assessment group respondents were not able to report the outcome.42
Some differences were evident between the assessment and conciliation groups, with positive final outcomes generally more likely among the conciliation group (48 per cent) compared to the assessment group (32 per cent). The assessment group was more likely to have been told they could not be assisted further and were less likely to receive an apology.
Figure 20. Conciliation and assessment respondents perceptions of their outcome n=381
Perceived outcomes as reported by conciliation and assessment respondents n=381
0% 10% 20% 30% 40% 50% 60% 70%
Partial outcome
Outcome
Total outcome
No outcome
Of those study respondents reporting a negative outcome, the most commonly selected response (31 per cent) was ‘that the Commissioner could not assist them any further’ with 22 per cent reporting that they gave up when the case was closed and did not pursue the complaint any further. A number of respondents selected both these responses.
The most commonly reported positive outcome was receiving reimbursement (11 per cent), followed by an apology (9 per cent). In total, 69 respondents43 received either reimbursement or compensation (44 per cent of the 157 who had originally hoped for such an outcome).
Table 8. Reported final outcome for assessment and conciliation respondents n=474 responses provided by 381 respondents*
42 When qualitative analysis of the verbatim responses to this question were further analysed two assessment group respondents could not report an outcome, altering the size of the total population from n=383, to n=381. One reported having thrown out the final letter without reading it, and the other who was acting on behalf of another person, could not report the outcome because the final action was left up to the patient to transact with the health service provider and the complainant did not know the outcome of that interaction, or whether in fact it had occurred.
43 Two assessment group respondents reported achieving both reimbursement and compensation.
41
Outcome (a respondent could report more than one outcome) Assessment Conciliation TotalThe Commissioner’s staff told me they couldn’t assist me any further 31% 17% 25%
I gave up/didn’t pursue complaint further 19% 16% 18%
Other 14% 9% 12%
Received reimbursement 10% 9% 9%
I took my complaint elsewhere 7% 10% 8%
Received an apology 6% 10% 8%
Received compensation 2% 11% 6%
Steps were taken to ensure that this didn’t happen again 2% 7% 4%Provided with a clear explanation of how and why the problem occurred 3% 4% 4%Received assurances that action would be taken to put things right 2% 4% 3%
Health service provider refused to take part in mediation 3% 4% 3%
* Two respondents did not know the outcome.
Overall, 15 per cent reported ‘other’ in response to the question about the achieved outcome. Examination of the verbatim responses reveals that most of these statements are negative. Representative comments are provided below:
- They just closed the case and no explanation as to why. (R192/c)- Went to conciliation but didn’t get a satisfactory explanation. (R525/c)- Provider eventually did all that could be done. (R442/a)- The medical centre denied that I had even been there. (R552/a)- The hospital organised a meeting with a doctor from a different department, they told me I was suffering from unresolved grief resolution. He had no business diagnosing me. I wrote to the CEO. I went with an open mind, how can he arrange a diagnosis like this? (R488/a)- Nothing. Just deadly silence. (R671/a)- Nothing happened, the whole thing was a shemozzle, neither the Commissioner nor the hospital gave a reason, neither took responsibility for it. (R512/a)- My waiting time for a consultation went from 7 years to 3 weeks! (R185/a)
- It felt like a stalemate. They didn’t apologise or acknowledge my complaint. (R243/c)
The outcomes reported by the study population are quite different from the outcomes reported by the Commissioner in each of the yearly reports associated with the years of engagement of the study population. For example, the Commissioner reported that for assessment cases closed in 2012, 45 per cent were declined44 and approximately 50 per cent were recorded as having achieved an outcome. For the conciliation group of the same year, 91 per cent were reported by the Commissioner as having achieved a positive outcome recorded as ‘resolved in conciliation’.45
The difference between the study respondents’ report of outcomes achieved and the report by the Commissioner suggests that how complainants perceive an outcome or what constitutes an outcome for
44 The Commissioner declines a case for a range of reasons including referral to another agency, case determined elsewhere, outside of jurisdiction or time limit. In 2012, just over half the cases were declined because the Commissioner decided that the case didn’t warrant investigation, the complaint was not confirmed in writing, insufficient detail was provided or reasonable steps were not taken.
45 Annual report 2012, Office of the Health Services Commissioner, pp. 17-18. Note that the term used has recently been changed to ‘conciliated’ rather than resolved in conciliation.
42
complainants can be quite different from what is recorded. Amongst that group were conciliation and assessment group respondents with high seriousness rating cases who reported that ‘nothing was sorted out’ (R140/c), that the Commissioner, ‘took little notice’ (R173/c), ‘that there was no outcome’ (R22/a), that it was incomplete (R79/c).
Financial recompense: hoped for and achieved outcome
In 2006, Bismark et al explored the differences between New Zealand claimants seeking financial recompense for injuries sustained using the legal system and complainants lodging complaints with the Health and Disability Commissioner (who does not provide a compensatory function).The researchers concluded that injured patients seek ‘manifold forms of accountability many of which are nonmonetary in nature’.46 They confirm the findings of previous research that severe nonfatal injuries are associated with litigation but their work adds further information that those injured during their prime working years are more likely to seek financial recompense.
In the Victorian context, specified objective measurements for either physical injury (five per cent) or mental injury (10 per cent) must be present for litigation to proceed. For those whose injuries fall below these levels, complaints are handled via the Commissioner, including those seeking financial recompense. Of those respondents using the Commissioner’s service and who seek financial recompense is there a correlation with age (prime working years)?
The results shown in the figure below are not conclusive. There are more people in their prime working years who achieve either reimbursement or compensation as an outcome (40 respondents), however, as a percentage of a single age group, those aged 70-79 constitute the largest group.
The total number of respondents seeking financial recompense via either reimbursement or compensation was n=157 and the total number reporting either as an outcome was n= 70. Only 30 per cent of those who hoped for either reimbursement or compensation achieved it as an outcome. There were 23 respondents (33 per cent of the total) who received financial recompense as an outcome who did not say that it was what they hoped to achieve as an outcome.
Overall, 41 respondents were reimbursed and 29 received compensation. Forty-one per cent who received reimbursement were conciliation respondents and 59 per cent were from the assessment group whereas the majority of those receiving compensation were from the conciliation group, at 83 per cent.
46 Bismark, M., Dauer, E., Paterson, R. and Studdert, D. (2006). Accountability sought by patients following adverse events from medical care: the New Zealand experience. CMAJ, October, 175(8), pp. 889-894, p. 893
43
Figure 21. Proportion of respondents seeking and achieving reimbursement or compensation by age
Respondents seeking reimbursement or compensation (n=157) Respondents achieving reimbursement or compensation (n=70)
as a percentage of total population n=436 by age
0%10%20%30%40%50%60%70%80%90%
100%
20-29
30-39
40-49
50-59
60-69
70-79 80
+
Unkno
wn
Respondents not seeking reimb/comp Respondents seeking reimb/comp
Respondents achieving reimb/comp
Mapping the gap between expectation and outcomeThe data presented so far suggest that there is a gap between the complainants’ expectations or desired outcome and the outcome achieved. Cross tabulation of responses about the expectation and outcome47 provide evidence of a gap across the three groups.
The figure below presents information across the three respondent groups. Although the enquiry group have limited contact and involvement with the Commissioner’s complaint process, there is a large gap between expectation and the outcome of their contact.
There is also a large gap between expectation and outcome in the assessment group who form 80 per cent in any year of the Commissioner’s client case load. That the gap identified between expectation and outcome is less for the conciliation group respondents is not surprising, as this group benefits from more intense activity by the Commissioner’s officers and they report the majority of achieved outcomes (48 per cent of conciliation group respondents achieve an outcome).
47 For the enquiry group this refers to the outcome of contact and for the assessment and conciliation groups the outcome of the case. The cross tabulated survey questions were: C2, C1, D16. Some outcome categories had to be combined to facilitate the cross tabulation.
44
Figure 22. Cross tabulation of respondent expectations at stage of case closure with the outcome achieved
Did the outcome meet expectations? n=436
0%
10%
20%
30%
40%
50%
60%
70%
80%
Enquiry Assessment Conciliation
Yes No Don't know
Satisfaction with outcome rating
The enquiry group
Of the total population of the enquiry group, there were 48 complete records. Satisfaction levels with the outcome were low with only five respondents satisfied and two, very satisfied. Nine respondents recorded ‘neither satisfied nor dissatisfied’ yet when their explanations for this rating are examined five respondents provided negative explanations and four, positive explanations. Nine respondents were dissatisfied and 22 very dissatisfied. One person did not answer the satisfaction question and there were 5 missing records.
The study population
Complainant satisfaction with the outcome of their complaint was very low across the three stages.
Figure 23. Complainant satisfaction with outcome
Satisfaction with outcome by stage of case closure n=434
0% 20% 40% 60% 80% 100%
Enquiry
Assessment
Conciliation
Total
Dissatisf ied Ambivalent Satisfied
Overall, 65 per of the study population was either very dissatisfied or dissatisfied. Forty-six per cent of complainants were extremely dissatisfied with the outcome of their complaint, and another 19 per cent were dissatisfied. A minority of complainants were satisfied (11 per cent) or extremely satisfied (11 per cent) and 12 per cent were ambivalent (neither satisfied nor dissatisfied, and including seven respondents who ‘didn’t know’). The assessment group respondents were the most dissatisfied at 68 per cent (21 per cent satisfied)
45
and the conciliation group were the most satisfied at 26 per cent (61 per cent dissatisfied). The enquiry group had the smallest group who were satisfied, 13 per cent, a larger group ambivalent, 17 per cent and 64 per cent who were dissatisfied. Two respondents did not answer the question.
Although further analysis identified no significant differences in satisfaction on variables including public/private provider, seriousness rating of complaint, female/male, rural/metropolitan location, or level of education, there was some variation. Respondents making complaints about public providers were slightly more dissatisfied (by four per cent) and less satisfied (by six per cent) than those making complaints about private providers, and metropolitan complainants were slightly more likely than their rural peers to be dissatisfied (by four per cent).
Explanation provided for satisfaction rating
Participants were subsequently asked to explain their level of satisfaction with the outcome. Across the study population, by far, the most common negative response given was lack of closure, which was identified by 30 per cent (129 respondents). Further examination of the data revealed that these 129 respondents were either dissatisfied or very dissatisfied with the outcome of their complaint.
The next most common negative reasons were lack of power to effect system or practice change (14 per cent) and lack of interest, assistance or advocacy48 by Commissioner (12 per cent). The most commonly identified positive reason relating to satisfaction was, ‘obtained closure or favourable outcomes’, 6 per cent. Sixty-six people gave multiple reasons. Five respondents answered, don’t know and 39 provided ‘other’ responses. As a percentage of the 509 reasons/explanations, ‘lack of closure’ totalled 25 per cent and for those who achieved a positive response ‘closure’ was the most common explanation at 5 per cent.
Figure 24. Reason for complainants stated level of satisfaction with outcome n=509 reasons provided by 431 respondents
Negative reasons% 509 reasons
givenLack of closure/resolution 25%
Lack practice change or action by provider 12%
Lack of interest, assistance or advocacy by the Commissioner 11%
Provider refused to apologise or admit fault 8%
Perceived bias towards provider 5%
Provider refused to pay adequate compensation 4%
Took too long 3%
Provider refused to reimburse 2%
Positive reasonsObtained closure or favourable outcome 5%
Happy with courtesy, interest, or assistance by the Commissioner 4%
Provider reviewed processes subsequent to complaint 3%
Was reimbursed 3%
Got apology 3%
Was compensated 2%
Quick resolution 2%
Received appropriate care subsequent to complaint 1%
The statements below are representative of the respondent explanations about their level of dissatisfaction with the outcome:
- I still did not get an answer or explanation or apology. (R286/a)
48 Very few respondents used the term advocacy but it was used as a coding name and included responses where for example, the respondent made a reference to the Commissioner acting on their behalf.
46
- Because there was no resolution and no support. I wouldn’t have sought their help unless I felt like I was drowning and needed help and expertise. (R67/e)- We should have been told that there were meetings, actions or procedures changed and we were not made aware of anything. Whether we did something wrong we were never told. We were just left alone and it was a matter of paper contact. I would have appreciated a call to let me know. There was no conciliation or any efforts done for that. (R900/c)- The problem is both structural and related to inadequate staff. The Commissioner is a toothless tiger. The office has no power to compel those complained about to respond in a timely manner. Any responses I got were then lost as they asked for extensions. It reinforces the power imbalance between the doctor and the patient. What happened to me was traumatic and through the ‘affidavit’ thing I had to relive the details again and again, it was very distressing and traumatising. (R679/a)- Because I didn’t get any result. I expected to get a letter explaining something to me but I got nothing. A dead bat. (R671/a)- It wasn’t the outcome I thought I would get, the Commissioner didn’t refer me to anyone else, I felt I was left high and dry. (R31/a)- Because of the fact no attempt was made to pick up the phone and make contact after I put the complaint in writing and nothing was done about it, it disappeared into thin air basically. If someone was now to give me a call I wouldn’t mind it, though I don’t hold much hope. (R345/a)- There was no net result of me contacting them, I know I can make my own way through it, when one goes so far as contacting an independent body and they hand it back to you, they didn’t fulfil their role. (R492/e)
- Because it was a cop out. She advised me to take the offer rather than trying to get justice. (R667/c)
Simple responses, like ‘Well I did not hear the final outcome or if there was action taken’, (R399/c) are repeated in this set of responses. For some who achieved a positive outcome similarly, closure was important – even when they may not have achieved everything they hoped for.
It’s closure, I was happy with what I got. It was a total surprise and it was through the Commissioner and lawyer listening to me when no one else was. I did want the hospital to be put ‘through the wringer’ and across the papers but the fact that I was listened to began the healing process. (R102/c)
The extent of complainant dissatisfaction with the outcome is large and is consistent across stages. Because of the recurrence of the ‘lack of resolution’ theme in respondent explanations this result suggests that for the respondents the problem lies with what they perceive to be the lack of an outcome, and the closure process associated with closing the case. Both Tax et al49 and McColl-Kennedy et al50 highlight the importance of effort by the provider and/or complaint body to resolve the complaint. They conclude that resolution is a key factor affecting satisfaction.
Explaining complainant (dis)satisfaction
Fairness: process, interaction and outcomeIt has been proposed by researchers that fairness across three variables – process, interaction and outcome – affects complainant satisfaction and that there is a relationship between the three variables.51 Respondents were asked a number of questions to ascertain their perceptions of fairness across these variables. Analysis
49 Tax et al. (1998).50 McColl-Kennedy and Sparks, (2003).51 Tax et al, (1998).
47
of the responses to questions about the process and interaction with the Commissioner’s officers was undertaken and then considered alongside analysis of responses regarding the fairness of the outcome.
Respondents whose cases were closed at the assessment (228) or conciliation (155) stage were asked to indicate on a five-point scale the level of agreement or disagreement with the following statements:
the Commissioner did not take sides the complaints process was fair to all parties involved
the Commissioner’s officers were unbiased.
Complainants were more likely to have positive rather than negative perceptions of whether Commissioner’s officers were impartial or unbiased, and whether the process was fair to all parties (see figures below). The exception was complainants whose cases were closed at the assessment stage, who were more likely to disagree than agree that the process was fair to all parties.
The finding that across groups there is agreement that the Commissioner’s officers are unbiased and do not take sides is positive because lack of impartiality has been shown in other studies to negatively affect complainant satisfaction levels.52 However, the negative finding from the assessment group about the fairness of the process and the consistently high level of dissatisfaction of this group across a range of indicators is of concern because this group represents 80 per cent of complaints received per year.
Across these three satisfaction questions respondents who had a complaint closed at the conciliation stage had more positive perceptions of staff fairness and bias.
Table 9. Perceived fairness and bias of the Commissioner’s officers - the assessment group*
Impartiality of people and process: Assessment respondents n=228
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
The HSC did not takesides
The complaints processw as fair to all parties
The HSC staff w ereunbiased
Agree Ambivalent Disagree
*1% of the assessment respondents did not answer the first statement and 2% did not provide responses to the third statement
52 Friele, R., Sluijs, E. and Legemaate, J. (2008). Complaints handling in hospitals: an empirical study of discrepancies between patients’ expectations and their experiences. BMC Health Services Research, 8(199). doi:10.1186/1472-6963-8-199.
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Table 10. Perceived fairness and bias of the Commissioner’s officers - the conciliation group*
Impartiality of people and process: Conciliation respondents n= 155
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
The HSC did not takesides
The complaints processw as fair to all parties
The HSC staff w ereunbiased
Agree Ambivalent Disagree
* 1% of the conciliation respondents did not answer the second or third statements.
Respondents from the conciliation group were asked an extra question about the impartiality of the officer they dealt with during conciliation. The responses confirm the earlier and more general response. A majority of complainants strongly agreed with the statement that the conciliation officer who had been involved in their complaint was impartial (33 per cent) and another 28 per cent agreed giving a total of 61 per cent. Approximately 16 per cent disagreed or strongly disagreed and 23 per cent responded that they don’t know or ‘neither agree nor disagree’.
Figure 25. Conciliation officer impartiality
Impartiality of conciliation officers: Conciliation respondents n=101
15%
23%
61%
Disagree Ambivalent Agree
Rating process and interaction
Respondents from the assessment and conciliation groups were asked to rate the following range of statements that probe for the complainant’s appraisal of the complaint process and interaction with the Commissioner’s officers:
49
you were dealt with fairly you understood the complaints process it was easy to contact the person you wanted to speak to you had the opportunity to respond to correspondence from the health services provider matters were dealt with in a timely way you were provided with enough information you felt you were listened to you were provided with clear explanations you were kept informed as to progress and next steps the commissioner understood your situation efforts were made by the commissioner to resolve the situation
you were dealt with in a caring manner.
Participants’ perceptions of their dealings with the Commissioner were more positive than negative across respondents from both groups although there was a slightly less favourable response to the statement about timeliness from the conciliation respondents (see tables below). There are time limits for how long a case can remain at the assessment stage with the result that some cases move into conciliation because of delays during the assessment stage. The only exception to the dominant positive response was that participants in the assessment group were more likely to disagree or strongly disagree that ‘effort was being made to resolve the situation’. Researchers advise that the effort expended to assist resolve the complaint by the provider or complaints body is an indicator of process convenience and organisational responsiveness which is highly valued by complainants.53 Other researchers add that it is also an indicator that the provider or complaints officer cares.54
Figure 26. Assessment respondents’ perceptions about their dealings with the Commissioner n=228
How strongly would you agree or disagree with these statements n-228
0% 20% 40% 60% 80% 100%
Were dealt with fairlyUnderstood the complaints process
Could easily contact the relevant personHad opportunity to respond to provider cor.Felt matters were dealt with in a timely way
Were provided with enough informationWere listened to
Were provided with clear explanationsWere kept informed of progress/next steps
Felt the HSC understood their situationFelt effort was made to resolve the situation
Were dealt with in a caring manner
Disagree / strongly disagree Neither agree nor disagree Agree/ strongly agree
53 Tax et al, (1998).54 McColl-Kennedy and Sparks, (2003).
50
Figure 27. Conciliation respondents’ perceptions about their dealings with the Commissioner n=155
How strongly would you agree or disagree with these statements n=155
0% 20% 40% 60% 80% 100%
Were dealt with fairlyUnderstood the complaints process
Could easily contact the relevant personHad opportunity to respond to provider cor.Felt matters were dealt with in a timely way
Were provided with enough informationWere listened to
Were provided with clear explanationsWere kept informed of progress/next steps
Felt the HSC understood their situationFelt effort was made to resolve the situation
Were dealt with in a caring manner
Disagree / strongly disagree Neither agree nor disagree Agree/ strongly agree
Respondents from the conciliation group consistently provided responses that showed a higher level of agreement than those from the assessment group. This may be explained by their more active engagement with the Commissioner’s office during conciliation. For example, a case worker usually conducts a face-to-face interview with complainants at this stage.
Apart from the assessment group’s negative appraisal of the Commissioner’s ‘effort’, these results provide evidence of the mostly positive interaction and good practice of the Commissioner’s officers in their dealings with complainants and the positive aspects of the current process.
A fair outcome?
Fairness is an important element in complaint management because ‘seeking justice’ for a perceived or actual wrong is one of the identified motivators for complainants. Lack of fairness during the complaints process has been identified as a major contributor to complainant dissatisfaction.55 The assessment and conciliation group respondents were asked three questions that sought to elicit whether they felt that the outcome was fair and to identify factors that led to that assessment. The questions were:
Do you feel this was a fair outcome? Was this the outcome you were expecting?
Has the complaint been resolved to your satisfaction?
Overall, 26 per cent of the assessment and conciliation group respondents (n=383) thought the outcome was fair and 70 per cent thought the outcome was unfair. Respondents in the conciliation group responded more favourably to this question than assessment group respondents - 29 per cent to 24 per cent respectively - with the negative response being 65 per cent (conciliation group) to 73 per cent (assessment group).
The slightly more favourable response from the conciliation group could be the result of the longer and more intense engagement with the Commissioner, which may have both had a moderating effect on the complainants’ expectations of outcome and on their satisfaction because of a perceived increased effort by the Commissioner’s officers.
55 Friele et al, (2008); Tax et al, (1998).
51
Figure 28. Respondent perceptions of a fair outcome
Do your feel this was a fair outcome? n=383
0%
10%
20%
30%
40%
50%
60%
70%
80%
Assessment Conciliation Total
Yes No Don't know
The expected outcome?
For the majority, the outcome was neither fair nor what respondents expected (67 per cent), with more negative responses from the assessment group (69 per cent) than the conciliation group (65 per cent).
Figure 29. The expected outcome: conciliation and assessment respondents
Was this the outcome you were expecting? n=383
0%
10%
20%
30%
40%
50%
60%
70%
80%
Assessment Conciliation Total
Yes No (Don't Know )
Complaint resolved?
Seventy-one (71) per cent of complaints reported that the complaint had not been resolved to their satisfaction. When reflecting on the responses provided to the question about what actions respondents expected of the Commissioner to assist them resolve the complaint, the most common response was ‘resolve the issue/get an outcome’. Tax et al found that unresolved complaints are universally considered unfair.56 It is unsurprising that such a large proportion of the study population responded that the complaint was not resolved to their satisfaction given that the majority perceived that an outcome was not achieved.
56 Tax et al, (1998).
52
Figure 30. Was the complaint resolved to your satisfaction?
Complaint resolved to your satisfaction? n=383
0%
10%
20%
30%
40%
50%
60%
70%
80%
Assessment Conciliation Total
Yes No (Don't know )
Friele et al have demonstrated that lack of impartiality can be a major contributor to complainant dissatisfaction. Evidence from this study does not reveal lack of impartiality by the Commissioner’s officers to be a significant factor because the majority of respondents consistently attest to their impartiality. However, lack of fairness of the process may be a factor affecting responses from the assessment group respondents.
The findings presented suggest that along with the lack of, or poor quality of, the outcome itself, other influential factors are the perceived unfairness of the outcome, that it was not what was expected, and that resolution was not achieved.
Other aspects of satisfactionTowards the end of the telephone interview, respondents were asked two more questions that probed other aspects of complainant satisfaction. Respondents were asked:
how they felt about the Commissioner’s complaint process how well the case was handled, disregarding the outcome of the case.
Complainant feelings about the process n=436
How do you feel about the Commissioner’s complaint process?
A majority of respondents, 51 per cent, answered negatively to this question with 43 per cent answering in the positive.57 Two per cent of responses were not able to be coded (for example they were incomplete or the meaning was unclear) and three per cent responded with ‘don’t’ know’. Dissatisfaction is higher in the assessment and enquiry groups. For the conciliation group, respondents are equally divided.
57 When these percentages are scaled to account for the oversampling of conciliation group respondents, the difference between the negative and positive responses is 53% and 42% respectively.
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Figure 31. Participant feelings about the Commissioner’s process by stage
Respondent feelings about the complaint service process by stage n-436
0%
10%
20%
30%
40%
50%
60%
Enquiry Assessment Conciliation
positive negative other/don't know
Among those in the enquiry group 49 per cent of respondents provided negative comments and the corresponding proportions in the assessment and conciliation group respondents were 54 per cent and 48 per cent respectively. The positive responses were higher from the conciliation group respondents at 48 per cent, 40 per cent for assessment group respondents and 36 per cent for the enquiry group respondents.
This is an interesting result. It does not show the extremes that have been witnessed above with regard to satisfaction with the complaint outcome. It is a more moderate response. What explains this response, when many of the verbatim comments to a wide range of the survey questions have invited very frank, negative commentary? This question provided respondents the opportunity to speak to the complexity of their engagement with the Commissioner’s office and to mention some of the more positive aspects.
Representative responses are presented below:
- It’s a great service. Process was good, just the outcome wasn’t. (R357/c)- It’s good to have it there. A lot of people aren’t aware of it, I don’t know if that is done purposely. (R312/c)- It was very much focused on an old fashioned form of complaint process. Needs to be more about problem solving. (R179/a)- I believe it’s been a rubber stamp for poor behaviour. There may be good people working there but this made it worse for us. (R114/c)- It leaves the complainants feeling extremely disempowered and vulnerable and I feel they are on the side of the respondent not the complainant. (R252/a)- It’s very confusing especially for anyone who is disabled or has language difficulties. It’s a very complicated and confusing process. (R805/e)
- Good. You feel like you’re doing something. If I can help anyone to not go through what I did I’m all for it. (R903/e)
Handling of the case
Regardless of the outcome, how satisfied are you with the way the Commissioner handled your complaint?
54
Complainants’ satisfaction with how the Commissioner had handled their complaint was more positive than their feelings about the complaint process and their satisfaction with the outcome of their complaint. Although there are large differences in satisfaction levels across the sample with regard to the Commissioner’s handling of cases, overall there were slightly more complainants who were satisfied or extremely satisfied (46 per cent) than those who were dissatisfied or extremely dissatisfied (42 per cent), with 10 per cent neither satisfied nor dissatisfied and 1.5 per cent indicating that they ‘don’t know’.58 Presented below are the satisfaction ratings per stage. Consistently, the assessment and enquiry group respondents are more dissatisfied than the conciliation group respondents.
Figure 32. Satisfaction with Commissioner’s handling of the case
Satisfaction with Commissioner's handling of the case n=436
0% 20% 40% 60% 80% 100%
% Enquiry
% Assessment
% Conciliation
Dissatisfied / extremely dissatisfied Ambivalent Satisfied / extremely satisfied
The satisfaction rating for ‘handling of the case’ is much lower across the study population than for complainants who voluntarily submit an evaluation form which is reported in the Commissioner’s annual report.59 It is unclear why there is such a difference in rating especially as it might be expected that dissatisfied complainants might be more likely to return an evaluation form as was the case with the study respondents who participated in the public consultation process associated with the Review of the Act. Thirty-two who made submissions were dissatisfied with the outcome of their complaint, five were ambivalent and 9 were satisfied.
Further analysis of the results from this question using the variables of public and private provider, rural and metropolitan residence, female and male and education level was also undertaken. There was no significant difference in whether the case involved a male or female complainant, rural or metropolitan residential address or education level, although there was a trend that the higher the level of education the higher the level of dissatisfaction with the Commissioner’s handling of the case.
There was a significant association between public or private provider and how well or otherwise the case was handled. Those making complaints about public providers were more dissatisfied with how the Commissioner handled the case compared with those making complaints about private providers who were more satisfied overall. This finding might be explained in part by the different experiences at the local level where in the private sector there is less often a formal option for complaint resolution available. For some of those lodging complaints with the Commissioner from the public sector, they may have already had an unsatisfactory attempt to resolve their complaint, which might explain their higher level of dissatisfaction.
58 When these percentages are scaled to account for the oversampling in the conciliation group the difference is reduced between those who are dissatisfied / extremely dissatisfied (43%) and those who are satisfied / extremely satisfied (45%).
59 In the Commissioner’s 2012 annual report, the proportion of complainants who were satisfied with how the case was handled was 71 per cent, p 40.
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Outcome and (dis)satisfaction: a direct relationship?
Examination of the respondents’ verbatim responses provides fuller information about the contributing factors to complainant satisfaction and dissatisfaction and the relationship to the achieved outcome (or lack thereof). Responses to the questions about the outcome, satisfaction with outcome and the explanation given for the stated satisfaction level were analysed.
Enquiry group Of the total population of the enquiry group (n=53), there were 48 complete records. Satisfaction levels with the outcome were low, with only five respondents satisfied and two very satisfied.
Thirty-six respondents (75 per cent) identified poor process issues, lack of closure, lack of support and poor interaction experiences as the principal reasons for the level of dissatisfaction. For the 11 respondents (23 per cent) who responded positively, good service, good processes and positive interaction experiences were the explanations provided.
In total numbers in any one year, the enquiry group constitute a large group. The contact between the Commissioner and those whose cases were closed at the enquiry stage is minimal however the responses from this group of complainants indicate a high level of dissatisfaction with that contact.
Assessment and conciliation groups Of the total population of the assessment and conciliation respondents (n=383), there were 375 complete records. For 22 per cent, there was a direct positive relationship between the outcome achieved and satisfaction level and for 34 per cent, a direct negative relationship, including for 6 per cent of the group who received a partial outcome. In total, there was a direct relationship between the outcome achieved and satisfaction with outcome rating for 56 per cent.
There were 8 respondents (2 per cent) for whom the relationship between the satisfaction or dissatisfaction levels and the outcome were unclear or apparently contradictory.
The remaining 157 respondents (42 per cent) provide more complex explanations for both negative and positive satisfaction levels – the outcome being only a partial explanation, which supports the observation made by Tax et al60 that the value of the outcome can be compromised or enhanced by interactions and processes. It also raises the question as to whether, for a good proportion of complainants, ‘the outcome’ is a composite of the various elements of the complaint handling experience: process, interaction and outcome.
Complexities of complainant (dis)satisfactionFurther in-depth qualitative analysis of the complainant responses was undertaken across the dataset to answer two questions:
do those who are dissatisfied with the complaint outcome respond negatively to the other satisfaction questions?
is there a relationship between having achieved the desired outcome or having achieved no outcome with consistent positive or negative responses to the three satisfaction questions listed below?
Individual complainant responses to three questions probing complainant satisfaction were examined. Those questions related to:
satisfaction with outcome feelings about the complaint process
handling of the case.
60 Tax et al, (1998).
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(Dis)satisfaction consistency across the three questions
There were 27 incomplete records61 across the three questions, leaving 409 complete records for examination, 44 of which related to enquiry respondents. Thirty-nine per cent (158 respondents) answered negatively to all three questions and 20 per cent (82 respondents) answered all three positively. Forty-one per cent (169 respondents) had a mixed response.
The figure below describes the two sets of responses, one where respondents have registered both negative and positive responses to one or other of the three questions above. The other type of response is where the respondents answered consistently (negatively or positively) to all three questions. The differently coloured bar in the figure below presents the overall proportion of respondents who consistently responded negatively or positively to the three satisfaction questions.
Figure 33. Responses per respondent to three satisfaction questions
Responses across three satisfaction questions per respondent n=409
0 10 20 30 40 50 60 70
All consistent
Consistent neg
Consistent pos
Mixed neg + pos
Satisfaction consistency across the three questions cross tabulated with the outcome achieved
Those who consistently responded negatively and positively across these three key satisfaction questions were examined in the context of their responses to the question about the outcome achieved, excepting the enquiry group respondents who were not asked the question about the outcome of the case making the total population for examination n=365.
In total, 59 per cent responded consistently positively or negatively to the three satisfaction questions. Of that 59 per cent:
35 per cent responded consistently negatively and had achieved no outcome 19 per cent responded consistently positively and had achieved an outcome
5 per cent provided contradictory responses in the context of the outcome achieved or not achieved
Forty-one per cent of respondents provided mixed responses across the three satisfaction questions with the majority not having achieved an outcome.
The result of this analysis points to a direct relationship between the outcome achieved and overall satisfaction (as gauged by the three questions above) for the majority of complainants (54 per cent) and a more complex or nuanced relationship for a substantial minority where procedural and interactional issues as well as the outcome affect the respondents’ overall satisfaction with the Commissioner’s complaint service.
The figure below presents the proportions of respondents whose consistent responses to the satisfaction questions appear to be directly related to the outcome achieved, or not achieved (as perceived by the respondents). There is a substantial group of respondents for whom the relationship between outcomes and
61 Nine of whom were enquiry respondents.
57
satisfaction rating is more complex, a small group who, despite having achieved their desired outcome, are consistently negative and a similar sized group who did not achieve their desired outcome but are consistently positive across the three satisfaction questions. The coloured bar in the graph represents the total proportion of respondents whose satisfaction rating across the three questions appears to be directly related to the outcome.
Figure 34. Satisfaction across three questions and the relationship to the achieved outcome
Satisfaction across three satisfaction questions and relationship to outcome: assessment & conciliation groups
n=365
0 10 20 30 40 50 60
Total direct relationship betw een satisfactionrating and outcome
All neg satisfaction rating/ w ith neg outcome
All pos satisfaction rating/ w ith pos outcome
Opposite satisfaction rating to outcomeachieved
Mixed satisfaction & mixed outcomes
Case closure
Advice or referral to other services
More than half (52 per cent) reported that the Commissioner did not advise them of who else could be contacted regarding the complaint. Thirty per cent (132 respondents) reported that the Commissioner did provide this information, while 12 per cent did not know and 5 per cent reported this not being applicable. Conciliation group respondents were more likely than the other two groups to respond in the affirmative which perhaps could be partly explained by the different nature and length of their engagement with the Commissioner.
The responses to this question may have some relevance to the explanations for the high level of dissatisfaction with outcomes reported by complainants where ‘lack of closure’ is the most common explanation.
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Figure 35. Advice about who else could be contacted about the complaint
Advice received about who else to contact n=436
0%
10%
20%
30%
40%
50%
60%
Enquiry Assessment Conciliation Total
Yes No It w asn’t applicable (Don't Know )
Enquiry group referral and follow-up
It is noteworthy that only 13 enquiry group respondents said that they had received advice about who else to contact and of that 13 only four followed-up the referral. Two made contact with APHRA and two made ‘other contact’.
Contacts followed up
One hundred and eight complainants said that the Commissioner had advised them to contact a range of other services or providers. Most commonly mentioned included a lawyer or legal service, APHRA, the Ombudsman or the health service provider.
Contacts provided were followed up by 65 respondents. The most common contact that was followed up was a lawyer or legal service (35 per cent). ‘Other’ contact or AHPRA were both reported by 19 per cent of complainants. The ‘other’ contact included the police, government departments, politicians and professional associations including those representing unregulated providers.
Action taken since case closure assessment and conciliation group only
The majority (82 per cent) had not taken further action but a small group 17 per cent (65 respondents) had acted. There were slightly more people from the conciliation group who had taken further action, 19 per cent, than assessment group respondents, 15 per cent. For 65 complainants who had taken action, it was most commonly to contact a lawyer, legal service, or AHPRA.
Table 11. Type of action taken after the Commissioner closed complaint only those who took action, n=65
Type of action NumberContacted a lawyer or legal service 30
Contacted AHPRA 16
Other (Ombudsman, Medicare, Medical Board) 8
Contacted the hospital or clinic you complained about 4
Contacted VCAT 3
Contacted AMA 1
Contacted coroner 1
Contacted a different health professional 1
Contacted media 1
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An unexpected outcome
Recommend the Commissioner’s service
Towards the end of the phone interview, respondents were asked whether they would refer other people to the Commissioner’s service and all responded to this question. Despite high levels of dissatisfaction with regard to outcomes achieved and mixed feelings about the Commissioner’s service, 66 per cent of complainants reported they would recommend the service to others. This is an unexpected result in the context of the other findings.
The positive response to this question was reasonably consistent across stages as well as whether the complaint was about a public or private provider. The seriousness rating of the case did not affect whether or not the respondent would recommend the service. As would be expected, those who were dissatisfied or extremely dissatisfied with the outcome of their complaint were less likely to recommend the service.
Reason for recommending the service n=429
Many people would recommend the Commissioner’s service because of their own positive experience (16 per cent) but a larger group that included many people who did not have positive experiences themselves (26 per cent) would recommend the service because it is viewed as an important institution – even if it didn’t ‘work for them’. This response was consistently high across all stages.
In the two categories ‘nowhere else to go’ and ‘depends’, the majority of respondents reported negative experiences but acknowledged that ‘it’s all we have’ and that although it didn’t work out with a particular complaint, it might work out for someone else. An apparent civic theme emerges in the explanations given:
- You have to try to work in the system even if it is not working. (R662)- If you don’t, how the heck are you going to improve the service? (R375)- The outcome for me was positive. It’s a great service and a good experience. (R112)- Because I believe if people have a problem and they don’t talk about it nothing can happen. I believe in honesty and integrity and I have the hope that somewhere someone will do something if the problem is talked about. (R650)- I think people need to be aware that they have rights in these matters – many are not. (R132)- I would say they should contact the office as it’s a good concept but in practice it’s something else. (R366)
- It’s an independent advocate with some strength and they will do something and take you seriously and I have recommended them to other people. (R376).
Table 12. Reason for recommending or not recommending the Commissioner’s service n=436
Reasons Enquiry % Assessment % Conciliation % Total%PositiveThe Commissioner’s service is an important/useful/skilled or-ganisation
26.4% 26.3% 26.4% 26.1%
Satisfactory experience/resolution to complaint 3.8% 18.0% 3.8% 16.3%Nowhere else to go 7.5% 12.7% 7.5% 10.8%Depends. It’s good for some, not others. 9.4% 6.1% 9.4% 7.1%Satisfactory experience with Commissioner’s staff 5.7% 2.6% 5.7% 3.0%It’s free 1.9% 0.4% 1.9% 0.9%It provides useful advice/information 3.8% 1.3% 3.8% 1.4%Negative %
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Unsatisfactory experience/resolution to complaint 37.7% 28.9% 37.7% 28.2%It lacks power/authority 1.9% 2.2% 1.9% 3.7%Unsatisfactory experience with Commissioner’s staff 0.0% 0.4% 0.0% 0.9%
Figure 36. Satisfaction with outcome by Yes or No to recommend the Commissioner’s service
Satisfaction w ith outcome by recommend the Commissioner's service n=436
0%10%20%30%40%50%60%70%80%90%
100%
Extremelydissatisf ied
Dissatisf ied Neithersatisfied nordissatisf ied
Satisf ied Extremelysatisfied
%Yes %No %(Don't know )
Positive aspects of the Commissioner’s service
When asked to describe what the Commissioner did well in handling their complaint, the most common response (24 per cent) was that nothing was done well. However, the responses varied depending on which stage the complaint had reached. Thirty-two per cent of those who had their cases closed at the enquiry stage felt nothing had been done well, compared with 27 per cent of those in the assessment group and 17 per cent of the conciliation group respondents. Six per cent of respondents answered ‘don’t know’ to this question, more in the enquiry group than the other two.
These rather negative views are in contrast to responses given earlier to questions where a set of statements was presented to the respondent to elicit appraisal ratings of various aspects of the complaint process and the respondent interaction with the Commissioner’s officers. These overall negative responses may reflect question fatigue towards the end of the interview and/or the different responses elicited to different question types.
Although the proportion of complainants making positive comments is small, the most commonly reported action that the Commissioner’s officers did well was: ‘listened and understood’. Being ‘courteous and polite’ and ‘regular contact through the process’ were both much more commonly identified among the conciliation group than participants that had cases closed at either of the other stages.
Particularly good aspects of complaint handling by the Commissioner
In total 36 respondents (8.7%) did not provide a response that could be coded including 5 who gave no response. The remaining 31 answered either, ‘no comment’, ‘no suggestion’ or ‘don’t know’. Two respondents (0.4%) refused to provide an answer. The first-mentioned comment of those who provided a response is presented in the figure below.
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Figure 37. Respondent assessment of what the Commissioner did well
First-mentioned respondent assessment of what was done well n=436
0 5 10 15 20 25
Delivered an acceptable outcome
Followed up on my requests
Were informative/explained things clearly
Provided assistance
Regular contact
Were courteous/polite
Don't know/no response/no suggestion/refused
Quick response
Felt listened to
Did nothing well
% of respondents
Sixty-six respondents provided more than one comment that could be coded. When the total number of comments about what was done well is examined the order changes little apart from ‘a quick response’ which moves from third to second. The table below provides the breakdown of all responses (543) per respondent group.
Table 13. Particularly good aspects of complaint handling n=398 providing 543 responsesParticularly good aspects of complaint handling % Enquiry % Assessment % Conciliation % TotalFelt listened to and understood 23% 15% 21% 18%Regular contact through process 3% 13% 15% 13%Were courteous, polite, nice, non-judgemental 6% 5% 17% 10%Quick response 11% 13% 5% 10%Were informative or explained things clearly 15% 6% 9% 8%Provided assistance 3% 9% 6% 7%Followed up on my requests 3% 7% 5% 6%Delivered acceptable outcome 0% 2% 4% 2%Did nothing well 26% 23% 13% 20%
Areas for improvementRespondents were asked for their views about how the Commissioner could do better in relation to complaint handling. All respondents except one answered this question. The issue that was most commonly identified related to improving frequency and quality of communication, including improving explanations and listening/understanding more effectively. A faster process and more powers to act in the public interest were also commonly identified. It is noteworthy that process issues do not feature prominently in the responses. This may be explained by the position of the question at the end of the survey, and that a number of questions stimulated detailed responses about the process.
Respondents were asked for their views about how the Commissioner could do better in relation to complaint handling. In the figure below, the first mentioned recommendation is presented. All except one respondent provided comment. When all 523 recommendations are examined, the order is substantially the same.
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Figure 38. Areas for improvement: first-mentioned recommendation
The complaints process - what could be improved n=435
0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%
Compel doctors to pay compensationNeed more resources
Reduce rudeness of staffThey need more legal or medical expertise
Resolve claim/solve problems
Dissatisfied with entire service or processOther
Facilitate mediationBe more proactive
Revise policies/restructure their systemPerceived bias in favour of provider
Explanations were unclearDid not listen or understand
Don't know
More powers to act in the public interestProcess too slow
Not enough contact/communicationNo problems or everything was good
In the table below the 523 recommendations made by 435 respondents are presented per respondent group.
Table 14. Areas for improvement n=435, providing 523 responses
Areas for improvement % Enquiry % Assessment % Conciliation % Total
Improve contact/communication 24% 19% 11% 17%Increased powers to act in the public interest 8% 7% 12% 9%Speed up process 3% 7% 12% 8%Don’t know 8% 7% 9% 8%Less bias in favour of provider 3% 7% 6% 6%Better explanations 8% 6% 5% 6%Revise policies/restructure the system 5% 7% 4% 5%Listen 6% 5% 4% 5%Be more proactive 6% 3% 3% 3%Organise and facilitate mediation 2% 4% 1% 3%Increased resources 3% 2% 3% 2%Less rudeness 6% 1% 3% 2%Resolve claim/solve problems 2% 2% 3% 2%Other 2% 2% 3% 2%Dissatisfied with entire service or process 3% 2% 2% 2%Compel medical professionals to pay compensation 0% 2% 3% 2%Better access to legal / medical expertise 0% 1% 3% 2%No problems or everything was good 11% 16% 15% 15%
Recommended improvements to the conciliation process
Fifty-four respondents did not respond to this question. The two most common responses were ‘nothing’ could be improved and ‘don’t know’. In total, 101 respondents provided 111 comments. In the figure below the first mentioned recommendation is presented as well as those who answered don’t know and who said nothing needed to be improved. The code ‘better conciliation process’ includes a range of recommendations such as, permit support people to speak during conciliation, permit the use of information disclosed during
63
conciliation to be used in other forums for example, VCAT, ensure continuity of staff. Representative verbatim comments are provided.
- Too long and stressful, I had to go over the case again and again. (R311) - More information about what happens during the conciliation process. I think it was a letter, so out of my arena. (R142)- I think conciliation is putting the cart before the horse. You have to look at what powers the Commissioner has before getting to that point. If the Commissioner has no power to enforce decisions and initiate changes in the health providers practice, then conciliation is a waste of time. (R323)- Rather than me having to go and speak to a lawyer, maybe the Commissioner could provide someone to speak to who had the legal knowledge. (R389) - Get three parties or all parties involved, so everyone knows what’s going on, not just a letter from the Commissioner saying that everything’s finished because the hospital said so. (R174)- More information should be provided and we should be kept updated by phone, email or mail. I was only told that my money was ready to be picked up, but no information was given beforehand. (R205)- I was not present at the conciliation. (R212) - The support person you have should be able to speak. You should be able to have legal representation in the meeting. There should be a way for the questions asked to have to be answered.- There should be follow up and consequences. (R222)- Efforts should be made to bring the parties together. (R322)- I wasn’t as assertive as I could’ve been as it was my first time. The conciliator could’ve given me more support. (R357)- Provide people like myself with a better understanding of exactly what the process entails and what to expect. Clearer explanations. (R351)
64
Figure 39. First-mentioned recommendations for improvement of conciliation process.
Conciliation respondents first-mentioned recommendation for improvement to conciliation process n=101 respondents
0% 2% 4% 6% 8% 10% 12% 14%
Provide support
Inform complainant of system/practice changes
Provide options post conciliation
Redress imbalance of pow er
Better conciliation process
Communicate regularly
OTHER
Compel provider participation
Faster conciliation process
Increase Commissioner's pow ers
More sympathetic/less rude staff
Don't know
Nothing
Proportion of respondents
65
66
67
Appendices
Appendix AMethodology
Appendix BScan of relevant literature
Appendix CCATI technical report
Appendix DSurvey tool
Appendix A
Appendix A: Methodology
Research method
Survey using computer assisted telephone interview (CATI) was chosen as the most appropriate research method as it could accommodate respondent verbatim explanations as well as gather descriptive quantitative data across the sample. The in-scope population consisted of a representative sample of 383 complainants over 18 years of age who had lodged complaints with the Commissioner and had them closed during the three financial years of 2009-10, 2010-11and 2011-12. Another 53 respondents randomly selected from a convenience sample of complainants who had had their cases closed at the enquiry stage during the same timeframe also formed part of the survey population. 62
A research company, the Social Research Centre which has experience administering CATI surveys with vulnerable populations was contracted to refine the survey instrument and collect data from respondents. Details of the CATI process and outcomes are at Appendix B.
RecruitmentThe sample for the project was drawn from the Commissioner’s database of complainants. Limited personal and complaint data associated with all in-scope complainants was used for recruitment purposes. The named complainant who registered the complaint with the Commissioner was considered the in-scope respondent, regardless of whether they complained on behalf of another party. The encrypted information was provided to The Social Research Centre to facilitate data collection.
Approach to samplingThe sample was composed of representative numbers of complainants from two of the four stages of the complaints process: assessment and conciliation. Because the Commissioner rarely undertakes formal investigations – perhaps one or two a year, giving very small numbers over three years – this group was not included in the study. To report reliable prevalence estimates of 25 per cent or more (which assumes a 95 per cent confidence level and a relative standard error <25 per cent), a sampling frame was developed which guided recruitment (see the table below). It included the required numbers in each category of case closure, which were stratified by the type of provider complained about. Other complainant characteristics, including the ratio of female to male and metropolitan to rural complainants, broadly reflected the Commissioner’s usual yearly ratios for complainant gender63 and residence.
Table 15. Sampling framePractitioner type
Assessment population
Conciliation population
Total cases
Assessment sample
Conciliation sample Sample size
Dentist 358 29 387 43 18 61Medical doctor 682 131 813 45 36 81Public hospital 532 264 796 45 41 86Private hospital 108 32 140 34 19 53Other* 417 63 480 44 28 72Totals 2,097 519 2,616 211 142 353
Enquiry group 46Total 399
*Includes registered, unregistered and ‘not’ specified providers
Quotas were set on the stage of complaint to ensure a representative number of respondents from the assessment and conciliation stages were included. The ratio for the cases closed at the assessment stage
62 Over the three year period there were 2,700 complainants with cases closed at enquiry. There were 717 for whom contact information was available. The number for recruitment calculated for inclusion in the study population was calculated on 717.
63 The Commissioner reports a 55 per cent to 45 per cent female to male ratio. The respondents recruited to the study resulted in a slightly higher proportion of females to males: 67 per cent to 33 per cent.
Appendix A
and at the conciliation stage was 80:20, which is based on the usual distribution in both categories as per the Commissioner’s records. There was some oversampling of the conciliation group. During analysis where comparisons between the two groups were undertaken, the assessment and conciliation results were rescaled to reflect the 80:20 ratio. For the most part, the changes in the results were small. Examples of the difference is noted on occasions throughout the report in an associated footnote.
The enquiry group is a ‘cohort of interest’ or a convenience sample and not a representative group. Different practices by the Commissioner’s officers have resulted in data being recorded for only 25 per cent of those who make enquiries (717 of 2,700). The sample for this study is a proportion of the 717, selected randomly, for whom there was recorded contact information. Final achieved surveys are detailed in the table below.
Table 16. Final achieved surveys
Stage Achieved
Enquiry 53
Assessment 228
Conciliation 155
Total 436
Initially, the approach to sampling was to achieve a stratified, representative sample to include the health service provider complained about. However, the extremely compressed timeframes for data collection prevented representative stratification and the sample was collected randomly.
The table below presents the achieved sample compared with the complainant population at the point that the sample was drawn. In the context of the parameters of the project and very short timelines, respondents were recruited by a random process, which resulted in a relatively small number of achieved surveys in certain practitioner groups (notably private hospitals and dental practitioners). As shown in the table below, while the groups are well represented proportionally as a percentage of the complainant population (complaints about private hospitals accounting for 6 per cent of the complainant population, and 9 per cent of completed surveys), care should be taken about drawing any conclusions about sub-groups.
Table 17. Achieved sample stratification
Practitioner type
Complainant population Achieved sample
Assessment Conciliation Total cases
Assessment sample
Conciliation sample Total sample
Dental practitioner 358 29 387 30 8 38Medical practitioner 682 131 813 68 30 98Public hospital 532 264 796 48 45 93Private hospital 108 32 140 25 11 36Other* 417 63 480 57 61 118Totals 2,097 519 2,616 228 155 383
Enquiry group 717 Enquiry group 53Total records 3,333 Total surveys 436
*Includes registered/unregistered, not specified providers
Survey instrument development and testingA survey concept tool was developed based on an analysis of the available research literature. This tool informed the development of the survey instrument. Before the main survey interviews commenced, qualitative pre-testing of the draft survey instrument was undertaken with 12 complainants, followed by piloting the refined instrument with another 15 complainants.
Appendix A
Data collectionData was collected from complainants in the context of the public Review of the Health Services (Conciliation and Review) Act 1987. In July 2012, the Commissioner individually invited complainants and providers (who had had cases closed in the previous three years) by letter to participate in the Review by sending in a submission. The subsequent approach to complainants inviting them to take part in the research was by telephone.
The Social Research Centre made an initial phone call to complainants to provide them with information about the research and to invite them to participate. If complainants were interested, informed consent was secured before an interview was undertaken. Where the complainant’s first language was one other than English, attempts were made to complete the survey via the Department of Immigration and Citizenship’s Translating and Interpreting Service (TIS). TIS interviews were completed with three respondents.
AnalysisAll personal identifying information was de-linked by the research company and destroyed prior to providing the principal researcher with the complete de-identified dataset. Data were checked for completeness prior to analysis. For a number of questions that invited a verbatim response, a coding frame was developed after the first round of qualitative analysis. The coding frame was checked by the principal researcher before being applied to the data. This process permitted the development of descriptive statistics from the verbatim responses.
Qualitative
Both thematic and content analysis approaches were employed in the analysis of the verbatim data, the latter permitting for counts to be made on much of the qualitative data. All verbatim data were initially reviewed by the Social Research Centre analysts and in conjunction with the principal researcher initial coding frames were developed and applied to the data. Checking of the initial coding, recoding and further analysis of the data was undertaken by the principal researcher which involved examination of the data per question and subsequently verbatim responses per respondent. A number of adjustments were made to coding names to improve accuracy and for some questions the data required significant recoding. Where there was an unexpected result the verbatim responses were re-examined by the principal researcher to check the accuracy of the analysis.
An intensive iterative process between the verbatim data and the quantitative results per question and per respondent was undertaken to ensure the veracity of the results and to check any conclusions drawn from the analysis. In the final stage of analysis, the verbatim data from each respondent were considered with responses to pre-coded questions. For example, the respondent’s verbatim description of the hoped-for outcome was considered alongside the outcome achieved and the satisfaction rating given across the three satisfaction questions. The draft results were tested with the acting Commissioner and staff. Further interrogation of the verbatim data was undertaken where queries were raised or extra questions asked to check and augment the integrity of the analysis and findings.
Quantitative
Analysis was conducted using Microsoft Excel 2007. Data were summarised by counting the responses for each level of a given variable (question). These counts (frequencies) and percentages were created using the pivot table function in Excel. For a number of questions, cross tabulation (contingency table) was constructed to understand the association between two questions. For example, was the outcome more satisfactory for metropolitan versus rural complainants? Like a frequency table, the cross tabulation shows the counts and percentages for all level combinations for both variables. The Chi square test was used to test for the statistical significance of the cross tabulation results. The test compares the counts observed in the data to the counts that would be expected if there is no relationship between the variables.
Appendix A
Ethics approval
The study was given interim approval by the Chair of the DH HREC in September 2012 which was confirmed by the DH HREC in October 2012. Data collection was undertaken during October 2012. Information about the study, the consent process, privacy, confidentiality of the data and security for data handling approved by the DH HREC was posted on the Commissioner’s website prior to the commencement of the research. A 1800 phone line was advertised so that potential or actual respondents could contact the principal researcher at any time during the research process.
Approximately, 15 calls were received by the principal researcher on the 1800 line. Most callers were survey participants either seeking further information about the research or expanding on their contribution already made via the survey process. There was one call received where a concern about complainant privacy was raised. This matter was fully discussed and the complainant was referred to the Secretariat of the DH HREC. A few calls were received from other interested parties in the research and a couple from potential complainants wanting to lodge a complaint with the Commissioner who were provided with the complaints phone number.
Limitations of the study
There are two major limitations to this study. Firstly, a small proportion of respondents had had their cases closed as far back as 2009 and may have found it difficult to recall their experience. However, only a very small number of respondents said that they couldn’t remember in answer to an occasional question. What the verbatim comments reveal is that the respondents felt very strongly about their engagement with the Commissioner’s service and that recall did not appear to be a major problem.
The second major limitation is that, although verbatim responses are reported in this study and the telephone interviews were lengthy (averaging approximately 26 minutes), they were not in-depth, face-to-face interviews. Face-to-face interviews may have provided a more complete understanding of the complainant perspective. However, when the respondent comments are examined per respondent, a clear picture of the key elements of each respondent’s perspective is evident.
Appendix B
Appendix B: Scan of the relevant literature
Key themes
Who complains and why?Complaints to formal complaint resolution bodies such as the Commissioner represent ‘the tip of the iceberg’.64 Many complaints are resolved at the local level – the hospital, the GP practice, the specialist’s rooms - but it is suggested that an even greater number are never reported either at the local level or to formal bodies. There are a number of explanations for this including:
many complaints are informal and are received by front-line staff lack of knowledge of the right to complain and how to complain by health consumers access barriers such as language or cultural issues
intimidation or fear of possible retribution.
Previous studies have investigated the reasons why health consumers lodge complaints, the profile of these people and the health professionals complained about, the type of complaints and outcomes achieved, and complainants’ satisfaction levels.65 More recently, the distribution of formal complaints across Australia’s medical workforce has been examined by Bismark et al.66 The most frequent source of complaint relates to treatment or clinical care,67 with communication and interpersonal behaviour being another very common cause of complaint. Complaints often involve more than one aspect of the care episode,68 for example, clinical treatment and communication or interpersonal behaviour of clinical staff. Female gender is associated with a higher number of complaints made,69 and medical practitioners are the health professionals most commonly complained about. A number of studies have found that complainants tend to have a higher educational level than the general population.70
Context and complaint handling The formal complaint system operating in a country or state is an important contextual frame within which to consider complaint activity. Bismark et al comment on the outcome of plaintiff surveys from the United States and the United Kingdom, which suggest that monetary compensation is frequently not the primary reason for 64 Wessel, M., Lynoe, N., Nikas, J. And Helgesson, G. (2012). The tip of an iceberg? A cross-sectional study of the general
public’s experiences of reporting healthcare complaints in Stockholm, Sweden. BMJ, Open 2:e000489. doi:100.1136. 65 Vance, M., Ward, M. and McKenzie, D. (2012). Prevalence and characteristics of complaint-prone doctors in private practice
in Victoria. The Medical Journal of Australia, 196(1), pp. 38-38Buntine, J. A. (2011). Prevalence and characteristics of complaint-prone doctors in private practice in Victoria. The Medical Journal of Australia, 195(6), pp. 325-325. Bismark, M. M., Spittal, M. J. and Studdert, D. M. (2011). Prevalence and characteristics of complaint-prone doctors in private practice in Victoria. The Medical Journal of Australia, 195(1), pp. 25-28.Manouchehri Moghadam, J., Ibrahimipour, H., Akbari, A., Farahbakhsh, M. and Khoshgoftar, Z. (2010). Study of patient complaints reported over 30 months at a large heart centre in Tehran. Quality & Safety In Health Care 19(5): e28-e28. Mailis-Gagnon, A., Nicholson, K. and Chaparro, L. (2010). Analysis of complaints to a tertiary care pain clinic over a nine-year period. Pain Research & Management: The Journal Of The Canadian Pain Society = Journal De La Société Canadienne Pour Le Traitement De La Douleur 15(1), pp. 17-23. Wu, C.-Y., Lai, H.-J. and Chen, R.-C. (2009). Patient characteristics predict occurrence and outcome of complaints against physicians: a study from a medical center in central Taiwan. Journal Of The Formosan Medical Association = Taiwan Yi Zhi 108(2), pp. 126-134. Daniel, A., E. Burn, R. J., and Horarik, S. (1999) Patients’ complaints about medical practice. MJA, Vol 170. June, 598-602.
66 Bismark, M., Spittal, M., Gurrin, L., Ward, M. and Studdert, D. (2013). Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. Quality and Safety in Health Care, 0:1-9, doi:10.1136/bmjqs-2012-001691.
67 Daniel et al, (1999); Annual report 2012, Victorian Health Services Commissioner, Melbourne.68 Bark, P., Vincent, C., Jones, A. and Savory, J. (1994). Clinical complaints: a means of improving quality of care. Quality in
Health Care, 3, pp. 123-132.69 Daniel et al, (1999); Taylor et al, (2004).70 ibid.
Appendix B
lodging a complaint. 71 Bismark examined complaints and outcomes of a cohort of clients who used litigation and those who lodged a complaint with the New Zealand Health and Disability Commissioner (noting that some will use both systems), and found key differences that included:
those who pursued legal action sought accountability in four categories: communication, correction, restoration and sanction those who sought nonmonetary outcomes were primarily interested in better communication and correction
injury during prime working years and severe nonfatal injuries were associated with higher odds of seeking monetary compensation.72
Learning from complaints and quality improvementLearning from health complaints is recognised to be an essential element of the quality and safety improvement process.73 Understanding more about the consumer assessment of the Victorian health complaints system has the potential to inform the development of its role into the future as well as contribute to improvements to health service delivery. For example, consumers identify the feedback loop as a very important part of the process.74 They want to know whether, as a result of the complaint, action has been taken to prevent the problem they encountered occurring again and they want complaints linked into the quality and safety improvement systems. 75 Vincent et al observed in 1994 that complaints procedures ‘seldom lead to any real assurance that changes to clinical practice have been made’,76 an observation that still appears to be relevant.
Examining the Commissioner’s health complaints service from the complainant perspective can also provide valuable information about improvements to complaint resolution at the local level, which would prevent complaints from being escalated to an external body such as the Commissioner. Complainants repeatedly say they want information and clear explanations about what has happened. A number of studies have identified that front-line staff training to improve communication with clients and to assist to them respond to and handle client concerns more effectively is an important priority. 77 An insightful observation made by Kooienga and Stewart is that ‘in the aftermath of a medical error, a lack of shared understanding may make
71 Bismark, M., Dauer, E., Paterson, R. and Studdert, D. (2006). Accountability sought by patients following adverse events from medical care: the New Zealand experience. CMAJ, October, 175(8), pp. 889-894.
72 ibid.73 Hsieh, S. Y. (2011). A system for using patient complaints as a trigger to improve quality. Quality Management in Health
Care, 20(4), pp. 343-355.Haw, C., Collyer, J. and Sugarman, P. (2010). Patients' complaints at a large psychiatric hospital: can they lead to better patient services? International Journal Of Health Care Quality Assurance, 23(4), pp. 400-409.Parry, J. and Hewage, U. (2009). Investigating complaints to improve practice and develop policy. International Journal of Health Care Quality Assurance, 22(7), pp. 663-669.Cowan, J & Anthony, S. 2008Problems with complaint handling: expectations and outcomes. Clinical Governance: An International Journal, 13(2), pp.164-168. Taylor, D. McD., Wolfe, R.,S. and Cameron, P., A. (2004). Analysis of complaints lodged by patients attending Victorian hospitals 1997-2001. MJA, 181(1), July, pp.31-35.Anderson, K., Allan, D. and Finucane, P. (2001). A 30-month study of patient complaints at a major Australian hospital. J. Qual. Clin. Practice, 21, pp.109-111.Moghadam, J., Ibrahimipour, H., Akbari, A., Farahbakhsh, M. and Khoshgoftar, Z. (2010). Study of patient complaints reported over 30 months at a large heart centre in Tehran. Qual Saf Health Care. 19:e28. doi:10.1136/qshc.2009.033654.Bark et al, (1994).
74 Vincent, C., Young, M & Phillips, A. (1994). Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 343, pp. 1609-13, p. 1613.
75 Howard, M.,I (2011). Raising the voice of dissatisfaction: a qualitative study of the Queensland acute health care consumer and the experience of complaining. PhD thesis, Queensland University of Technology.Bismark et al, (2006).
76 Vincent et al,. (1994), p.1613.77 Bark et al, (1994).
Taylor, D., Wolfe, R. & Cameron, A. (2002). Complaints from emergency department patients largely result from treatment and communication problems. Emergency Medicine, 14, pp. 43-49.
Appendix B
communication difficult’,78 which underlines the importance of adequate staff training to assist practitioners to interact appropriately with clients at this time. In a study of 227 patients and relatives who took legal action Vincent et al record that claimants:
... were disturbed by the absence of explanations, a lack of honesty, the reluctance to apologise ... Where explanations were given they were seldom thought to be clear or sufficiently informative. In most cases, these secondary problems contributed to a decision to take legal action.79
Vincent et al conclude that there are four major themes explaining the reasons why people litigate, with only one of those themes relating to financial recompense. The other themes were standards of care, clear explanations and accountability. These researchers suggest that a no-fault compensation system would not adequately address claimants’ concerns. This finding has been supported by others, for example, Bismark et al who observe that many complainants ‘do not seek financial restoration and ensuring alternative options for redress would be an efficient and effective response to their needs’.80 Understanding what clients are seeking when they express concern or make a complaint is crucial so that health service providers can respond promptly and appropriately.
Friele et al reveal that there are lessons to be learnt at each stage of the complaints process including at the local level – the practitioner(s) and local complaints process – and formal complaints bodies.81 Better and more open communication by practitioners, communication about implementation of corrective action by hospital management and impartial conduct by complaints committees are identified as the areas that offer opportunities for learning from complaints.
Complainant (dis)satisfaction: explanationsLow complainant satisfaction levels are commonly reported by researchers investigating health complaints across a range of countries. To account for this phenomenon, it has been proposed that there is a gap between complainants’ expectations of what will be achieved by making a formal complaint and the actual outcome of lodging the complaint.82
A qualitative study of Victorian complainants to professional boards in 2004provides insight into the nature of the disjuncture between complainant expectations and the outcomes delivered. 83 In this study, the tension between complainant expectation regarding resolution of a complaint and the role of the professional boards to deal with such complaints is revealed. The professional boards investigate and make determinative judgements about failures of professional standards of care. Their focus is not necessarily resolution of a complaint. The consumer, when dealing with professional boards, is no longer a complainant but rather a ‘notifier’ with the board’s focus being the identified practitioner and whether that practitioner’s practice has fallen below accepted professional standards of care. The notifier is the catalyst to action to protect the public interest. This study reveals that the notifier has expectations with regards to the process and how they should be treated as well as expectations about a fair outcome – all dimensions that other studies have identified as affecting satisfaction. The majority of respondents in this study were dissatisfied with some or all aspects of the process including the lack of responsiveness, clear and timely communication, and impartiality. One quarter of the respondents did not understand the reasons for the decision (outcome) and three quarters did not agree with the outcome or feel that it was reasonable. The study respondents valued support when provided but found it to be insufficient.
78 Kooienga, S and Stewart, V. (2011). Putting a face on medical errors: a patient perspective. Journal of Healthcare Quality, 33(4), pp. 37-41.
79 Vincent et al, (1994).80 Bismark, M., Dauer, E., Paterson, R. and Studdert, D. (2006), Accountability sought by patients following adverse events from
medical care: the New Zealand experience. Canadian Medical Association Journal, 175(8), pp. 889-894.81 Friele, R. D., Sluijs, E. M. and Legemaate, J. (2008). Complaints handling in hospitals: an empirical study of discrepancies
between patients' expectations and their experiences. BMC Health Services Research, 8(199), doi:10.1186/1472-6963-8-199. 82 Bismark et al, (2011); Cowan et al, (2008); Friele et al, (2008); Friele et al, (2006); Daniel et al, (1999).83 Resolution Resource Network and Health Issues Centre (2004). Bringing in the consumer perspective. Final Report.
Consumer experiences of complaints processes in Victorian Health Practitioner Registration Boards. Department of Human Services.
Appendix B
Over a decade ago, Daniel et al surveyed 290 complainants who had lodged a complaint about a medical practitioner with the New South Wales (NSW) Health Care Complaints Commissioner.84 The majority wanted the doctor deregistered, reprimanded or counselled. A smaller group wanted an apology. Over a third of complaints were dismissed and the majority of complainants were dissatisfied with the outcome even when the practitioner had been disciplined or counselled. Daniel et al suggest that complainant dissatisfaction mounts from the point of lodgement onwards as a result of unsatisfactory and protracted processes as well as the outcome achieved.
The study undertaken by Daniel et al is unusual amongst those examined for this study as it is the only one where the majority of complainants seek punishment of the medical practitioner as their primary outcome. Other studies identify that complainants far more commonly report institutional or practice change as the most common desired outcome, ‘so that the event does not occur to someone else’, an apology or compensation.85 Researchers commonly acknowledge that complainants have regard for the public interest and are keen to see Commissioners exercise their authority in this area.
Daniel et al also suggest that what complainants want out of lodging a complaint can be complex and other researchers claim that poor processes and/or interaction with complaint staff can compound the level of dissatisfaction.86 In addition, Daniel et al observed about the NSW Commissioner role:
‘... that complainants’ expectations seem to be at odds with the role and cannot be met by its statutory functions. Its role is protection of the public, not punishment or restitution.’87
Observations made by some other researchers88 including the authors of the 2004 Victorian report referred to above, accord with the statement made by Daniel et al with regard to a disjuncture between what complainants expect form lodging a complaint and the Commissioner’s actual role and powers.
Daniel et al appear to imply that a relatively high degree of complainant dissatisfaction is likely when complainant expectations are unrealistic, unreasonable or beyond the authority of the Commissioner. This view has some support from others. Bismark et al 89 observe that complainant satisfaction is not the only priority of a Commissioner who has to be an ‘honest broker and facilitate an outcome that is fair to all parties’.90 Bismark et al acknowledge that for some complainants the Commissioner’s complaint process in Victoria ‘will not, and sometimes cannot, deliver the complainant’s desired outcome either because of lack of authority, lack of statutory power or because the Commissioner deems it inappropriate in the circumstances’.91
In 2004, Thomas describes the complex field in which the Health Complaints Commissioners in Australia operate, including the relationship between the Commissioners and the government of the day and with powerful professional organisations such as the Australian Medical Association.92 In individual cases, these larger forces may be distant, but Thomas reminds us that, while constituted as statutory authorities, the Commissioners operate in a charged field – an organisational ‘minefield’.
Transacting complaints brings the Commissioner’s office into ongoing contact over time with professional associations, insurers and the larger health service providers. Research into inter-organisational relations suggests that it is common in this context that shared understandings develop through recurrent transactions, the norms of obligation and personal relationships, and that these shared understandings
84 Daniel et al, (1999).85 Vincent et al, 1994; Friele et al, 2006.86 Tax et al, (1998); Bark et al (1994); Bismark et al, (2011); Friele et al, (2008). 87 Daniel et al. (1999), p. 599.88 Bismark et al, (2011).89 Thomas, D. (2003-04). Walking through minefields: Health Complaints Commissions in Australia. The Australian Health
Consumer, 1, pp. 12-14.90 Bismark et al. (2011), p. 809.91 ibid.92 Thomas, (2003-04).
Appendix B
contribute to positive business outcomes.93 In the context of the Victorian Health Services Commissioner, although engagement with health service administrators, professional representatives and insurers may be sporadic around particular complaints, these groups have long term, ongoing relationships with the Commissioner which is reported to assist with the resolution of a substantial number of complaints. These longer term inter-organisational relations are different from the type of relationship the Commissioner has with complainants which is usually, time limited and on a ‘one-off’ basis.
The wider lens that Thomas provides permits complainant dissatisfaction to be viewed in a broader context. It also draws attention to what others have described as the considerable power imbalance between the professional parties to a case and the lay complainant.94
Although recommendations from researchers about how better management of complainants’ expectations may result in lower levels of dissatisfaction, questions about whether complainants are being ‘short-changed’, whether the high levels of dissatisfaction may have cause and may indeed be ‘reasonable’ are infrequent. There is little discussion about how to improve the quality of the outcome for complainants notwithstanding that some researchers warn that better management of complainants’ expectations is only part of the solution to high complainant dissatisfaction.
Concepts of justice and fair dealing in the context of complaint service experiences
Tax et al report that researchers across several fields including legal and organisational have found justice concepts valuable in explaining people’s reactions to conflict situations. 95 Distributive, procedural and interactional elements of justice theory has been used in empirical research to assist explain consumer satisfaction and behaviour. Analysis of the consumer/complainant experience has revealed that satisfaction can be affected by the service process, interactions with personnel and the outcome of service engagement. The development of these three justice elements has drawn on a broad suite of justice concepts. In the figure below a reproduction of material from Tax et al traces the antecedents of the justice concepts used in complaint handling research. Identified under each major concept are the related key principles and relevant dependent variables. The source literature is noted for each principle and variable.96
Tax et al undertook an inquiry into customer experiences with complaint handling using survey responses of 239 people employed across four large organisations in one town in the United States97. The study found
93 Bradach, J. and Eccles, R. (1989). Price, authority and trust: From ideal types to plural forms. Annual Review of Sociology, 15, pp. 97-118.
94 Thomas, (2003-04).95 Tax et al, (1998).96 For a fuller discussion of the justice concepts used in consumer behaviour and complaint handling research, refer to the
article by Tax et al, pages 61-64. For discussion of more general justice concepts see, Beauchamp, T. and Childress, J. eds., (1994), Principles of biomedical ethics (4th ed). Oxford University Press, New York, and Thiroux, J., (1990) Ethics theory and practice (4th ed), Macmillan Publishing Company, New York.
97 Tax et al. (1998).McColl-Kennedy, J. R. and Sparks, B. A. (2003). Application of fairness theory to service failures and service recovery. Journal of Service Research, 5(3), February, pp. 251-266.
Appendix B
Figure 40. Definition of justice elements and associated research (reproduction)98
that customers evaluate complaint incidents in terms of the outcomes they receive (described as a form of distributive justice), the procedures used to arrive at the outcomes (described as a form of procedural justice), and the nature of the interpersonal treatment during the process (described as a form of interactional justice) and further, that there are two-way interactions among at least two of the three justice components. That is, the value of outcomes can be compromised or enhanced by interactions and procedures. Polite, courteous and swift action, where responsibility for the service failure is acknowledged and effort to remedy the situation exerted, positively affects complainants’ assessments of the outcome and the reverse is the case where rudeness, delay and lack of effort have a negative impact.99
Tax et al conclude that when judging the fairness of the outcome, complainants consider its value in terms of the cost to them of making the complaint and the degree to which it provides psychological equity. Tax et al also found that unresolved complaints were universally considered unfair. Similarly, Dasu and Rao observe:
98 Tax et al, (1998), p. 63.
Appendix B
Parties to a psychological contract not only exchange promised goods and services, but they also implicitly promise to execute the exchange according to a set of values, beliefs and norms.100
People using healthcare services like customers of other service providers will expect a service recovery response after what they perceive to be an episode of poor or unsatisfactory service (otherwise referred to as ‘service failure’). In healthcare, a service recovery response may be more complex than in other service sectors, and client expectations may differ,101 but there are some expectations that can be expected to hold across the disparate sectors including being treated with respect, receiving an apology, an explanation, reparation and follow up.
In 1999, Dasu and Rao undertook an exploratory study using critical incident technique and phenomenographic methods with 15 participants in a classroom situation. From this experiment, they proposed a model of consumer expectations following service failure in healthcare. Dasu and Rao challenged the accepted explanation of consumer satisfaction, which they explain is largely based on meeting or exceeding expectations where expectations are formed and then confirmed. By drawing on previous theoretical work, Dasu and Rao propose that service users approach a service recovery event with two types of expectations: ‘will’ and ‘should’ expectations. ‘Should’ expectations are drawn from normative moral standards ‘what ought to have been done’ and ‘will’ expectations are based on previous personal experience and reputation. Dasu and Rao also claim that consumer expectations of healthcare services, both service delivery and service recovery after failure, are different from expectations of other service industries because of the peculiar nature of healthcare services:
Healthcare services are less communicable; their features cannot be displayed, illustrated or compared. They are often unique to each buyer and impossible to sample or test on a limited basis.102
The results from their exploratory study were that consumers’ ‘should’ expectations are higher than their ‘will’ expectations in healthcare service recovery and that when an episode of poor or unsatisfactory service cannot be undone, of primary importance to consumers is information and explanation, with compensation being less important. The service provider’s responsiveness and the effort exerted are indicators that they care and constitute a form of service recovery in the healthcare context.103 They claim that it is not necessarily the service failure that affects customer satisfaction but the service provider’s following actions. Dasu and Rao suggest that there is much the service provider can do to affect consumer satisfaction. They remind us that in general service industries it is the consumer who decides if there has been a service failure and, therefore, it is imperative that the provider responds swiftly with information and empathy even when they do not perceive a service failure. They contend:
Service providers can turn negative customer emotions into positive emotions and negative emotions into greater negative emotions.104
Perhaps another important distinguishing feature of healthcare services is that it is not always the customer who decides if there has been an episode of poor or unsatisfactory service. Where a complaint falls into the jurisdiction of the professional boards, the boards make that decision. When it falls into the jurisdiction of the Commissioner, acknowledgement by the health service provider (through voluntary participation in the process) of a problem is required for a case to be resolved. In the healthcare setting, the consumer is not only ‘not always right’ but can be disadvantaged when attempting to establish what they perceive to be an
99 ‘Service failure’ is a term used in the literature to describe situations where a client or consumer perceives that they have experienced some form of problem with the service. In many service industries the form of the problem relates to a faulty product or unsatisfactory service. In the health context, when a client experiences a problem with a service, the term service failure is not the term usually applied - adverse event or health (service) complaint are the terms usually used by health administrators and others.
100 Dasu, S. and Rao, J. (1999). Nature and determinants of customer expectations of service recovery in health care. Quality Management in Health Care, 7940, 32-50, p. 44.
101 ibid.102 Dasu and Rao, (1999), p.36103 ibid.104 McColl-Kennedy and Sparks. (2003), p. 263.
Appendix B
incident of poor or unsatisfactory service by a number of factors including ill-health, lack of specialist knowledge and language skills.
In 2003, McColl-Kennedy and Sparks105 presented a fairness-based conceptual framework of the role of emotions in the service recovery process based on the findings of a qualitative study exploring the justice concepts presented by Tax et al: interactional, procedural and distributive. Five focus groups were conducted involving 32 participants from two large Australian universities who had complained about a service in the hospitality and tourism industry in the previous 12 months. These researchers examined the role that situational effort plays in the complainants’ assignation of accountability. Service providers are held accountable for the effort exerted to resolve a complaint as well as the initial incident of poor or unsatisfactory service. The study findings include that complainants will judge whether the service provider could or should have done something more to remedy the situation and will assign blame. Like Dasu and Rao before them who observed that consumers are problem solvers and will often have thought about ways to resolve the problem, McColl-Kennedy and Sparks describe consumers’ ‘counterfactual’ thinking where they develop options the service provider could have taken to assist resolve the problem:
When service providers do not appear to exhibit an appropriate level of effort, consumers attribute this to the service provider not caring.106
These findings echo, in part, the earlier findings of Dasu and Rao.
Further work: service recovery in healthcare
In seeking to understand the apparent gap between complainant expectation and outcomes, a number of health researchers have more recently applied justice theory to the analysis of healthcare complaints.107 In particular, Friele et al explored complainant perceptions that justice has not been done or that fair dealing has been compromised in the complaint resolution process.108 Friele et al report that some complainants feel a duty to lodge a complaint and that they seek justice by taking action to prevent it from happening again. Although complainants’ motives for lodging a complaint are reported to be multiple and varied, this fairly consistent altruistic theme can be observed across studies examined for this review. Friele suggests that this apparent altruism is related to the complainant seeking to ‘right the wrong’ – to restore a sense of justice after a perceived injustice has occurred.
In the Netherlands, Friele et al investigated the expectations of 424 patients who had made complaints during the first six months of 2003 to independent complaint committees of 74 academic or general hospitals approached.109 The complaint committees in the Netherlands provide a non-legal complaint service and were developed to fill the gap between informal and formal processes, with the latter including litigation. The inquiry conducted by Friele et al followed an earlier study, which had found that while two thirds of providers were satisfied with the complaints process, only one third of complainants were satisfied, and of the two thirds who were dissatisfied one third had had their complaints adjudicated as valid.
Friele et al’s 2006 paper reported on the findings of a survey conducted at the commencement of the complaints process where complainants’ expectations were mapped. A questionnaire was developed through interviews with a subset of complainants. The findings of the research revealed that complainants were unanimous in their opinions about a fair complaint handling process. They thought that the complaint committee should investigate, adjudicate the validity of the complaint and recommend change to the hospital concerned. The process should be impartial and respectful throughout. Interestingly, this study showed that the most severely affected complainants have the highest expectations of complaint handling, but they don’t seek different outcomes to other complainants, they just want them more intensely. Friele et al hypothesise
105 McColl-Kennedy and Sparks. (2003).106 ibid, p. 251.107 Friele et al, (2006); Friele et al, (2008); Bismark et al, (2011).108 Friele et al, (2008).109 ibid.
Appendix B
that complainants will be more satisfied with the complaints process when all three dimensions are fair from the complainants’ perspective: procedures, interaction and outcome.110
Friele et al continued their research with the same cohort of complainants and in their 2008 paper reported the findings of the survey undertaken of 279 of the same complainants after the complaints procedure.111 The findings from this research were that less than a third of complainants felt they had received justice from the complaints process. Friele et al found that the satisfaction was influenced not only by the outcome (well-founded or not) but by the conduct of those involved: the complaints committee, the hospital and the professional. Fifty-one (51 per cent) of the discrepancy between complainants’ expectations and outcomes can be explained by their experiences with the complaints committee. The degree to which the committees demonstrated impartiality appears to be the primary determinant of dissatisfaction but other factors are also important, including the transparency of procedures, the swiftness of a response and the willingness of committee members to listen to the complainants’ story. Other findings related to the hospital and the professional. One-third of the discrepancy between expectations and experience can be explained by the hospital not communicating to complainants that corrective action had been taken. Complainants remained largely uninformed perceiving the hospital as ‘not caring’. With regard to professionals, the discrepancy between expectation and experience related to disclosure. Complainants wanted the health professional to admit a mistake, to explain how it occurred and to be sympathetic.
The complaint handling system in the Netherlands is different from systems used in Australia and specifically, in Victoria. Notwithstanding the different systems the conclusions from these studies are relevant to the Australian context and worthy of consideration. The key conclusions from Friele’s work are that complaints committees should be impartial and invest at the beginning and throughout the process in understanding and moderating complainant expectations and that hospitals and professionals need to offer apologies and inform complainants about lessons learnt and about changes implemented. A number of these findings echo the findings from the 2004 Victorian study discussed earlier.
Bismark et al reported on a study in 2011 of complainant data held by the Victorian Commissioner.112 They too sought to understand complainant dissatisfaction. Bismark et al mapped a gap between expectations of a desired outcome and the outcome achieved in a Victorian cohort of 227 complainants lodging a complaint that related to informed consent. The researchers found that the gap was widest in those cases where the outcome sought did not relate to communication, but rather to restoration, correction or sanction.
A relevant observation about the focus on complainant satisfaction made by these researchers is that for the Commissioner, complainant satisfaction is not the only priority. The onus on the Commissioner is fairness to all involved. However, as Friele et al observed in their 2006 study, where there is a large difference in satisfaction with the complaints process between one or other group (complainants/health service providers) rigorous inquiry is warranted.
SummaryHigh levels of complainant dissatisfaction following closure of a complaint in healthcare settings has been recorded and investigated by researchers across a number of countries during the last 20 years. Researchers investigating this phenomenon have employed justice theory in an endeavour to explain it and to make recommendations for improvement. Whether or not the outcome of a complaint is considered fair by complainants affects satisfaction levels, but so too does whether the complainant is treated well throughout the process and whether the process is fair. The service provider taking responsibility and exerting effort to resolve a complaint is also very important in the complainant’s assessment of their experiences of complaints procedures.
110 Friele et al, (2006),111 Friele et al, (2008).112 Bismark et al, (2011).
Appendix B
Complainants may have a heightened sensitivity to additional episodes of poor service after having lodged a complaint about what they perceived to be an episode of poor or unsatisfactory service. The influence of emotion on how the experience of the complaints process is perceived, and the need to set things right are other factors that have been identified as affecting complainant satisfaction.
Complainants come to a complaints process with expectations about service delivery, how they should be treated and what should result. Many of these expectations are grounded in social norms of fair behaviour and interaction. However, the research suggests that these expectations across the three areas of process, interaction and outcome can be moderated by swift and appropriate action on the part of the service provider and complaints body that is perceived as fair by the consumer.
Appendix C
Appendix C
Technical report
IntroductionThe Health Services Commissioner (the Commissioner) commissioned the Social Research Centre113 to conduct a survey of complainants as part of the Commissioner’s statutory function to review and improve the operation of the office and the complaints process. The main survey interviews with complainants commenced on 8 October and concluded on 31 October.
Table 18. Key project statistics
MilestoneTotal phone numbers initiated 1,373
Total completes 436
Telephone interview start date 8 October 2012
Telephone interview end date 31 October 2012
Total average interview length (mins:secs) 25:50
Inquiry (mins:secs) 23:57
Assessment (mins:secs) 25:15
Conciliation (mins:secs) 27:14Response rate as a proportion of interviews plus refusals 72.7%
Project sample
The sample for the project was drawn from the Commissioner’s database of complainants where the complaint had been closed between 1 July 2009 and 29 June 2012. The formal criteria for inclusion in the research were:
Complainants who registered a complaint with the Commissioner or did so on behalf of another person with their permission. Complainants whose case had been closed by the Commissioner between 1 July 2009 and 30 June 2012.
Encrypted sample files containing names, addresses and phone numbers of complainants registered with the Commissioner were provided. The Commissioner provided sample files cleaned to remove records where the complainant was known to be deceased, and where no valid phone number was available. The Social Research Centre confirmed these results and checked for duplicate telephone numbers. None were present in the sample files provided.
Questionnaire designThe questionnaire was developed by the Social Research Centre in close consultation with the Commissioner. A conceptual survey frame for the survey tool was provided by the Commissioner which the Social Research Centre used to draft a preliminary survey tool and a discussion guide for a series of (n=15) cognitive interviews. These interviews were undertaken to ensure participants’ comprehension of the questions was as clear and accurate as possible.
113 The technical report was prepared by the Social Research Centre in collaboration with the principal researcher.
Appendix C
Once feedback from the cognitive interviewers was integrated into the questionnaire and agreed upon by the Commissioner, the survey tool was provided to DH HREC for approval.
Table 19. Overview of questionnaire design
Topic QuestionsPART A - Introduction & screeners IntrosPART B – Context for complaint, and who was complained about B1 – B10PART C – Motivations for making complaint and expectations of outcome C1 - C4PART D – Experiences with the Commissioner’s process, who else contacted in relation to complaint D1 – D17
PART E – Complaint outcome, further action taken E1 – E15PART F – Demographics F1 – F7
Questionnaire testingComprehensive questionnaire testing was undertaken to ensure that the CATI and online questionnaires exactly matched the agreed hard copy versions. These included:
Reading the questionnaire directly into the programming environments, and programming the skips and sequence instructions as per the hard copy questionnaire Rigorous checking of the questionnaire in “practice mode” by The Social Research Centre project manager, the project quality supervisor, including checks of the on screen “presentation” of questions and response frames
Randomly allocating dummy data to each field in the questionnaire and examining the resultant frequency counts to check the structural integrity of the CATI and online scripts.
Interviewer briefing and quality control
Interviewer briefing
A total of 14 interviewers worked on the project. All interviewers and supervisors who worked on the CATI surveys attended a comprehensive two-hour briefing session. The briefing was delivered by The Social Research Centre project manager and included:
All aspects of administering the survey questionnaire Practice interviewing and role play The importance of adhering to sample management protocols and the call regime, and
Reinforcement of call tailoring and call maintenance techniques to minimise refusals.
In addition, interviewers also attended a further one hour session led by a representative from the Office of the Chief Psychiatrist (OCP). In this session, the representative from the OCP mediated a discussion on dealing with respondents who were potentially vulnerable, had complex mental health conditions, or were aggressive.
Fieldwork quality control procedures
The in-field quality monitoring techniques applied to this project included:
Validation of 28 interviews across all 14 interviewers (or 6.4% of the total interviewing workload) via remote monitoring Field team de-briefing after the first shift, and thereafter, whenever there was important information to impart to the field team in relation to data quality, consistency of interview administration, techniques to avoid refusals, appointment-making conventions or project performance, and
Examination of verbatim responses to “other specify” and open-ended questions.
Appendix C
Response analysis
Analysis of contact outcomes
In all, 3.2 numbers were initiated for every interview achieved. Of the 436 surveys that were completed, 28.9 per cent (n=126) were completed on the first contact (see the table below). Despite the relatively short fieldwork period, the benefits of not limiting the call cycle are apparent by the number of surveys completed after six calls or more (n=67, or 15.4 per cent of total completes).
Table 20. Number of calls per completed interview n=436
No. of calls
Completed interviews (n) %
1 126 28.9%
2 98 22.5%
3 75 17.2%
4 44 10.1%
5 26 6.0%
6 17 3.9%
7 8 1.8%
8 15 3.4%
9-17 27 6.2%
Total 436 100%
The table below presents the final call result for each of the 1,373 numbers to which calls were initiated for the CATI surveys. Percentages of final call outcomes (contact, non-contact, unresolved, unusable and out of scope) are based on the total numbers initiated, whereas subgroups are displayed proportionally to their final call outcome category.
Table 21. Analysis of call outcomes n=1373
Call outcome n= %
Contact 600 43.7%
Complete 436 72.7%
Midway termination 5 0.8%
Household refusal 48 8.0%
Named respondent refusal 111 18.5%
Non-contact 248 18.1%
No answer 79 31.9%
Answering machine 138 55.6%
Engaged 31 12.5%
Unresolved contact 121 8.8%
Hard appointment 5 4.1%
Soft appointment 116 95.9%
Unusable 229 16.7%
Fax 7 3.1%
Disconnected 170 74.2%
Wrong number 51 22.3%
Incoming call restrictions 1 0.4%
Appendix C
Call outcome n= %
Out of scope 175 12.7%
Not a residential number 13 7.4%
Claims to have completed survey 2 1.1%
Away for duration of survey 32 18.3%
Deceased respondent 3 1.7%
LOTE no follow up 1 0.6%
Respondent not known 4 2.3%
Didn’t recall contacting the Commissioner 56 32.0%
Didn’t recall complaint details 34 19.4%
Complaint still open 30 17.1%
Total 1,373 100.0%
Survey participation rate
Response rate is defined as a per cent of interviews plus refusals. The response rate workings are shown in the table below. The final overall response rate was 72.7 per cent.
Table 22. Participation rate
Interviews n=600Completed interviews 436
Refusals 164
Base for response rate calculation 600
Response rate 72.7%
Refusal analysis
This distribution of refusals is consistent with other surveys conducted by the Social Research Centre. For every refusal recorded, there was an attempt to determine the reason. The table below summarises the reasons obtained. One hundred and fifty-nine reasons were provided for refusal from 164 refusals.
The most frequently cited reason for refusal was “lack of interest” (33 per cent), followed by the respondent claiming to be “too busy” (12 per cent), a similar percentage preferring not to take calls associated with the Commissioner (11 per cent) and nine per cent% of refusals furnishing no comment. The remaining reasons for refusal attracted a prevalence under n=10 and are not included.
Table 23. Reason for refusal n=159
Refusals where reason was collected (n=) n=159 %Not interested 52 33%Too busy 19 12%Prefers not to take calls associated with the Commissioner 17 11%
No comment/hung up 15 9%
Appendix D
Appendix D
Survey tool
Overview
Interviewers will participate in a 3 hour briefing session prior to commencement on the survey, during which time a full ‘dress rehearsal’ will be undertaken, as well as background informa-tion with regard to the Office of the Health Services Commissioner, the complaints process, the aims and objectives of the study and the likely issues to arise during the interviews. The principal researcher will attend the briefing session and will be available to answer any ques-tions from interviewers.
The script below is to be programmed as a Computer Assisted Telephone Interview script (on screens for the interviewers, with automated question filtering, logic checks etc.)
Interviewers will also be able to direct respondents to the Health Services Commissioner’s web page for further information about the study
Contact details for Dr Clare Carberry via a 1800 telephone line will also be available to re-spondents.
Respondents will be from one of three groups, in terms of the complaints stage reached: En-quiry stage only, Assessment Stage, Assessment and Conciliation stage. All respondents will be asked about their expectations, experience, complaint outcome and satisfaction with the Health Services Commissioner’s complaint service.
PART A INTRODUCTION
PROGRAMMER CREATE SAMPLE VARIABLE: STAGE1=Enquiry2=Assessment3=Conciliation
ANSWERING MACHINE MESSAGE 1 (Used when no-one answers the phone)Good morning/afternoon/evening. My name is <SAY NAME> calling from the Social Research Centre in Melbourne on behalf of the Health Services Commissioner.I am calling you as part of an important study for the Commissioner who is interested to improve the operation of her office and wants to hear the views of people who have used the complaints service and any suggestions they have for improvement.The study is entirely voluntary but if you would like to participate , please call the Social Research Centre on 1800 023 040 and we will call you back at a time that is convenient to you. Thank you.
INTRO1Good morning/afternoon/evening, my name is <SAY NAME> from the Social Research Centre in Melbourne. May I speak to <NAMED RESPONDENT>?(In the case that the interviewer discerns that the person contacted is unclear about what the interviewer is saying, the following prompts could be used:
Would you like to speak with me in another language? Can I arrange for a telephone interpreter to join us on the call?Do you think you need someone to help you with my call? Would you like me to call back at another time?)
Otherwise continue:1. Selected respondent (CONTINUE with INTRO2)2. Arrange call-back3. RESPONDENT NOT KNOWN (GO TO TERM1)4. AWAY FOR DURATION OF DATA COLLECTION PERIOD (GO TO TERM2)5. DECEASED (GO TO TERM3)
Appendix D
6. REFUSED (GO TO RR1)7. RESPONDENT DOES NOT REMEMBER COMPLAINT DETAILS (GO TO TERM6)
INTRO2You might recall that you have recently received letters from the Health Services Commissioner inviting you to participate in a public consultation process about a review of legislation associated with the Commissioner’s role. This call is to make sure that people who have used the Health Services Commissioner’s complaints service have opportunities to contribute their views about how it could be improved.
INTERVIEWER TO CHECK – is respondent familiar with the Health Services Commissioner?
IF NECESSARY:The Health Services Commissioner is reviewing the complaints handling process and has asked the Social Research Centre to speak with people who have made a complaint in the past few years, to talk about their experiences of the complaint process. Your participation in this study is entirely voluntary. More information about the research can be located on the internet – would you like me to give you the website address <http://www.health.vic.gov.au/hsc/> or would you prefer me to email or post the information to you?
1. Continue (INTRO3)2. Make appointment3. Take details for information to be emailed or posted to potential participant4. Does not recall contacting HSC (GO TO TERM4)5. Refused (GO TO RR1)
INTRO3
The purpose of the interview is to help the Health Services Commissioner understand, from your perspective, the process that you went through, what you understood they would be able to do for you, what you hoped would be achieved and how you felt as you went through the complaints process. We will also ask you for your suggestions about how the HSC complaints process can be improved.
I’d like to reassure you that we don’t need to go over the particular problem that you complained about and I’m not going to ask you for detail on the health issue – what we are really interested in now are your views on what you think about how your complaint was handled and whether there is anything that the Commissioner could do to improve the complaints process.
The Department of Health’s Human Research Ethics Committee has approved this survey.
Can I just check that your complaint is closed with the HSC?
1. Is closed, continue2. Complaint is still open (GO TO TERM5)3. Refusal (GO TO RR1)
*(ALL)CONSENTINTERVIEWER NOTE: YOU MUST RECEIVE INFORMED CONSENT TO CONTINUE
If you participate in this survey all the information supplied is confidential and no identifying material will be used in the analysis of survey results. You are free to not answer any of the questions or to end the interview at any time. This interview should take between 15 - 45 minutes but its actual length will depend on your answers and experience.
Do you agree to take part in this survey?
1. Yes (GO TO B1)2. No (GO TO RR1)
Appendix D
PART B: CONTEXT
From now on, we will refer to the Health Services Commissioner as the HSC. First of all I’d like to ask you some questions about the process of making the complaint.
*(ALL)B1 How did you find out about the HSC’s complaints process?
1. General internet search2. Advertising (brochure, poster)3. Health service (e.g. complaints or liaison officer at hospital)4. Medical Practitioner5. Friend/family/colleague6. OTHER (SPECIFY)7. Can’t remember
*(ALL)B2 How many separate complaints have you ever made to the HSC?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)B3 PROGRAMMER NOTE: IF B2>1, SUBSTITUTE “Thinking about your most recent complaint
only,” when did you first get in touch with the HSC?
1. RECORD MONTH/YEAR2. (Don’t know)3. (Refused)
*(ALL)B4 And when was the last time you had any contact with the HSC?
INTERVIEWER NOTE: THIS CAN BE ANY FORM OF CONTACT (LETTER, PHONE, FACE TO FACE)
1. RECORD MONTH/YEAR2. First contact was only contact respondent has had3. (Don’t know)4. (Refused)
*(ALL)B5 Was your complaint about a public or private health provider, or both?
1. Public 2. Private 3. Both4. (Don’t know)5. (Refused)
*(ALL)B6 Could you briefly tell me the main reason why you lodged a complaint with the HSC?
INTERVIEWER NOTE: PROBE TO IDENTIFY WHETHER IT’S FOR MEDICAL TREATMENT, TREATMENT FROM STAFF, THE AMENITIES, COST ETC.)
1. SPECIFY (RECORD VERBATIM)2. (Refused)
*(ALL)
Appendix D
B7 Just to confirm, can you tell me specifically WHO you complained about?INTERVIEWER NOTE: PROBE FOR MULTIPLES: HOSPITAL, TYPE OF HEALTH PROFESSIONAL, FACILITY, OR PROCESS.
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)B8 Did you approach the health service provider about your complaint before contacting the
HSC?
1. Yes (GO TO B10)2. No (CONTINUE)3. (Don’t know) (GO TO B10)
*(B8=2)B9 What stopped you from approaching the health service provider directly?
1. I didn’t feel comfortable contacting the health service provider or was too upset2. I was unsure how to make a complaint to the health service provider3. The health service provider had moved or I was unable to contact them4. I wanted to be better informed before contacting the health service provider/wanted to
know my rights5. Health service provider refused to discuss unless through HSC6. OTHER (SPECIFY)7. (Don’t know)8. (Refused)
*(ALL)B10 Why wasn’t the problem wasn’t resolved where it occurred (e.g. at the hospital, the clinic, or
with the health professional)?
(MULTIPLE RESPONSE)1. The complaint wasn’t taken seriously2. The complaint was ignored3. The health provider did not take responsibility for the problem4. The health provider would not admit that a mistake had been made5. The health provider did not provide a clear explanation6. The health provider took too long in dealing with the matter 7. I wanted an apology. The health provider would not apologise8. The health provider apologised but that was not enough9. The health provider wouldn’t provide compensation10. I wanted it to go to a higher level11. I wanted the health professional disciplined12. Due to the nature of the complaint, I could not approach the health professional
involved.13. OTHER (SPECIFY)14. (REFUSED)
PART C: MOTIVATIONS AND EXPECTATIONSI would now like to ask you a couple of questions about what you hoped would happen by making the complaint to the HSC.
*(ALL)C1 When you first got in touch with the HSC, what did you understand their role to be?
1. SPECIFY2. (Don’t know)
Appendix D
3. (Refused)
*(ALL)C2 When you contacted the HSC about your most recent complaint, what did you hope the
outcome of making your complaint would be?
(MULTIPLES ACCEPTED)1. A clear explanation2. An apology3. Compensation4. Reimbursement5. Disciplinary action6. To make changes to the ‘system’ so that this did not happen again7. That my complaint would be recorded8. An investigation9. OTHER (Specify)10. (Don’t know)11. (Refused)
*(ALL)C3 What did you expect the HSC would be able to do to help you achieve that outcome when
you contacted them?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)C4 And did the HSC say what they thought could be achieved when you first contacted them?
1. SPECIFY (OPEN-ENDED)2. No 3. (Refused)
PART D EXPERIENCES
PRED1 IF STAGE=1 GO TO D3 ELSE CONTINUE
I would now like to ask you a few questions about your experiences of the HSC complaints process and what you thought about it.
*(STAGE=2 OR 3)D1 Just thinking about the HSC’s role specifically, how strongly would you agree or disagree with
the following statements:
(STATEMENTS)a) The HSC did not take sidesb) The complaints process was fair to all parties involvedc) The HSC staff were unbiased
(CODE FRAME)1.1. Strongly disagree
2. Disagree3. Neither agree nor disagree4. Agree5. Strongly agree6. (Don’t know)7. (Refused)
Appendix D
*(STAGE=2 OR 3)D2 Throughout your contact with the HSC, how strongly would you agree or disagree that:
(STATEMENTS)a) You were dealt with fairlyb) You understood the complaints processc) It was easy to contact the person you wanted to speak to d) You had the opportunity to respond to correspondence from the health services providere) Matters were dealt with in a timely wayf) You were provided with enough informationg) You felt you were listened toh) You were provided with clear explanationsi) You were kept informed as to progress and next stepsj) The HSC understood your situationk) Efforts were made by the HSC to resolve the situationl) You were dealt with in a caring manner
(CODE FRAME)1.1. Strongly disagree
2. Disagree3. Neither agree nor disagree4. Agree5. Strongly agree6. (Don’t know)7. (Refused)
PRED3 IF STAGE=2 OR 3 GO TO D8, ELSE CONTINUE
*(STAGE=1)D3 According to the HSC records your complaint did not progress further than your initial enquiry.
Is that correct?
1. Yes2. No3. (Don’t know)
*(STAGE=1)D4 Can you tell me the main reason why that was?
)
1. SPECIFY (RECORD VERBATIM)2. (Refused)
*(STAGE=1)D5 Do you recall getting a copy of the complaint form from the HSC? (either sent to you or
downloaded from the HSC website)
1. Yes (CONTINUE)2. No (GO TO D8)3. (Don’t know) (GO TO D8)
*(D5=1)D6 Did you complete and return it?
4. Yes (GO TO D8)5. No (CONTINUE)6. (Don’t know) (GO TO D9)
*(D6=2)D7 Can you tell me the main reasons why you chose not to complete and return the form?
Appendix D
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)D8 Did the HSC advise you of who else you could contact about your complaint?
1. Yes2. No3. It wasn’t applicable4. (Don’t know)
PRED9 IF D8=1 CONTINUE ELSE GO TO PRED12
*(D8=1)D9 Who did the HSC advise you to contact?
1. The hospital or clinic you complained about2. The health practitioner you complained about3. Lawyer or legal service4. Coroner5. AHPRA (Australian Health Practitioner Regulation Agency)6. AMA (Australian Medical Association)7. VCAT (Victorian Civil and Administrative Tribunal)8. Ombudsman (SPECIFY)9. Office of the Chief Psychiatrist10. OTHER (SPECIFY)11. (Don’t know)12. (Refused)
*(D8=1)D10 Did you contact any of these people or organisations after your contact with the HSC?
1. Yes2. No3. (Don’t know)4. (Refused)
PRED11 IF D10=1 COTINUE ELSE GO TO PRED12
*(D10=1)D11 Who did you contact?
PROGRAMMER NOTE: Feed responses from D9
1. The hospital or clinic you complained about2. The health practitioner you complained about3. Lawyer or legal service4. Coroner5. AHPRA (Australian Health Practitioner Regulation Agency)6. AMA (Australian Medical Association)7. VCAT (Victorian Civil and Administrative Tribunal)8. Ombudsman (SPECIFY)9. Office of the Chief Psychiatrist10. OTHER (SPECIFY)11. None of these12. (Don’t know)13. (Refused)
Appendix D
PRED12 IF STAGE=3 CONTINUE ELSE GO TO D14)
*(STAGE=3)D12 The HSC records indicate that your case went to Conciliation. Is this correct?
INTERVIEWER NOTE: RESPONDENTS ARE ADVISED OF THIS BY THE HSC VIA PHONECALL AND LETTER
1. Yes2. No (GO TO D14)3. (Don’t know) (GO TO D14)
*(D12=1)D13 What did you expect would be achieved at this stage?
1. SPECIFY2. (Don’t know)3. (Refused)
*(D12=1)D13a How strongly would you agree or disagree that the Conciliation Officer was impartial?
(CODE FRAME)1.1. Strongly disagree
2. Disagree3. Neither agree nor disagree4. Agree5. Strongly agree6. (Don’t know)7. (Refused)
*(D12=1)D13c In what ways, if any, could the Conciliation process be improved?
INTERVIEWER NOTE: WE WANT TO KNOW ABOUT THE CONCILIATION PROCESS ONLY HERE
1. SPECIFY2. Nothing3. (Don’t know)4. (Refused)
PRED16 IF STAGE=1 CONTINUE ELSE GO TO E1
*(STAGE=1)D16 Was the outcome of your contact with the HSC what you expected?
1. Yes2. No3. (Don’t know)4. (Refused)
D17 Was your complaint resolved?
1. Yes2. No3. (Don’t know)4. (Refused)
PREE1 IF STAGE=1 GO TO E9 ELSE CONTINUE
Appendix D
PART E OUTCOMES AND IMPROVEMENTS
*(STAGE=2 OR 3)E1 What was the final outcome of your complaint to the HSC?
(MULTIPLES ACCEPTED)1. Provided with a clear explanation of how and why the problem occurred2. Received an apology3. Received compensation (money awarded to make amends for loss or harm suffered)4. Received reimbursement (a refund of the monies spent)5. Received assurances that action would be taken to put things right6. Steps were taken to ensure that this didn’t happen again7. Health service provider refused to take part in mediation8. HSC told me they couldn’t assist me any further9. I gave up/didn’t pursue complaint further10. I took my complaint elsewhere (e.g. AHPRA, lawyers)11. OTHER (SPECIFY)
PREE2 IF E1=5 OR 6, CONTINUE ELSE GO TO E3
*(E1=5 OR 6)E2 Were you informed later that corrective action had been taken as a result of your complaint?
1. Yes2. No3. (Don’t know)
*(STAGE=2 OR 3)E3 And do you feel that this was a fair outcome?
1. Yes2. No3. (Don’t know)
*(STAGE=2 OR 3)E4 Was this the outcome you were expecting?
1. Yes2. No3. (Don’t know)
*(STAGE=2 OR 3)E5 Have you taken any further action since the complaint was closed by the HSC?
1. Yes2. No3. (Don’t know)
*(E5=1)E6 What action have you taken?
1. Contacted AHPRA (Australian Health Practitioner Regulation Agency) 2. Contacted AMA (Australian Medical Association)3. Contacted VCAT (Victorian Civil and Administrative Tribunal)4. Contacted coroner5. Contacted the hospital or clinic you complained about6. Contacted a lawyer or legal service7. Contacted the health professional you complained about8. Contacted a different health professional (for another opinion)
Appendix D
9. Contacted media10. OTHER (SPECIFY) 11. (Don’t know)12. (Refused)
*(STAGE=2 OR 3)E7 In your view, has the complaint been resolved to your satisfaction?
1. Yes2. No3. (Don’t know)
*(ALL)D14 On a scale where 1 is Extremely Dissatisfied and 5 is Extremely Satisfied, how satisfied were
you with the outcome of your complaint?
(RESPONSE FRAME)1. Extremely dissatisfied2. Dissatisfied3. Neither satisfied nor dissatisfied4. Satisfied5. Extremely satisfied6. (Don’t know)7. (Refused)
*(ALL)D15 And why do you say that?
5. SPECIFY6. (Don’t know)7. (Refused)
*(ALL)E9 How do you feel about the HSC complaints process?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)E10 Regardless of the outcome, how satisfied would you say you have been with the way that the
HSC has HANDLED your complaint?
(CODE FRAME)1.1. Extremely dissatisfied
2. Dissatisfied3. Neither satisfied nor dissatisfied4. Satisfied5. Extremely satisfied6. (Don’t know)7. (Refused)
*(ALL)E11 In your view, what did the HSC do particularly well while handling your complaint?
1. SPECIFY2. (Don’t know)
Appendix D
3. (Refused)
*(ALL)E12 And what do you think the HSC could do better , in relation to the complaints process?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)E13 If you knew someone who had a problem with a health service, would you recommend that
they contact the HSC?
1. Yes2. No3. (Don’t know)
*(ALL)E14 Why do you say that?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)E15 There has recently been a public consultation, for which the Commissioner invited people to
make a submission about the HSC. Did you lodge a submission as part of that process?
1. Yes2. No3. (Don’t know)
PART F DEMOGRAPHICS
And now we have just a couple of final demographic questions to ensure we’ve spoken to a good cross-section of people
*(ALL)F1 Could you confirm your age please?
1. Specify2. (Refused)
*(ALL)F2 RECORD GENDER
1. Male2. Female
*(ALL)F3 Do you speak a language other than English at home?
1. Specify2. (Refused)
*(ALL)F4 Do you identify as Aboriginal or Torres Strait Islander?
1. Yes2. No
Appendix D
3. (Refused)
*(ALL)F5 What is the highest level of education you have completed?
1. Primary school2. Year 7-10 (Forms 1-4)3. Year 11 (Form 5)4. Year 12 (Form 6)5. Trade / apprenticeship6. TAFE / Technical Certificate7. Diploma8. Bachelor Degree9. Post-Graduate Degree10. (Refused)
*(ALL)F6 Could you tell me your postcode please?
1. SPECIFY2. (Don’t know)3. (Refused)
*(ALL)F7 It’s possible that we may wish to speak to you in the future about the HSC and your
experiences. Would you be willing to participate in future studies of this nature?
1. Yes (SAY: To protect your privacy, your name and number will not be stored with the survey responses you have just given me)
2. No
CLOSE
And that’s the end of our questions. Thank you very much for telling me about your experiences. Just in case you missed it earlier my name is (…) and this survey was conducted on behalf of the Office of the Health Services Commission.
I really appreciate the time that you gave me. I just want to check, would you like to speak to anyone about the issues that we have talked about?
IF NECESSARY:I can give you the telephone number of a help line that provides free and confidential information and advice about xxx. Would you like this telephone number? Offer contact details for Beyond Blue, HSC and the Chief Psychiatrist’s Office, as appropriate.
TERMS
TERM1 Thanks for your time but we need to speak with a specific personTERM2 Thanks for your time but we need to speak with a specific personTERM3 I’m sorry, I won’t trouble you any further.TERM4 Thanks for your time, however we’re only speaking to people who have contacted the
Office of the Health Services Commissioner.TERM5 Thanks for your time, because we’re talking to people about the outcome of their
complaint, we need to speak to people whose complaints are closed.TERM6 Thanks anyway for your time.
Appendix D
ALLTERMINTRO1=3 Respondent not knownINTRO1=4 Away durationINTRO1=5 DeceasedINTRO1=3 Household refusal
RR1 OK, that’s fine, no problem, but could you just tell me the main reason you do not want to participate, because that’s important information for us?
1. No comment / just hung up2. Too busy3. Not interested4. Too personal / intrusive5. Don’t like subject matter6. Not applicable7. Don’t believe surveys are confidential / privacy concerns8. Silent number9. Don’t trust surveys / government10. Never do surveys11. 15-20 minutes is too long12. Get too many calls for surveys / telemarketing13. Too old / frail / deaf / unable to do survey (CODE AS TOO OLD / FRAIL / UNABLE TO DO
SURVEY)14. Not a residential number (business, etc) (CODE AS NOT A RESIDENTIAL NUMBER)15. Language difficulty (CODE AS LANGUAGE DIFFICULTY NO FOLLOW UP)16. Going away / moving house (CODE AS AWAY DURATION)17. Other (SPECIFY_______)18. Asked to be taken off list and never called again19. Respondent unreliable / drunk (CODE AS OTHER OUT OF SCOPE)20. Prefers not to take calls associated with HSC