Dental Risk - Dissatisfied Patient

Complaint management – handling the dissatisfied patient, part one

In all spheres, the risk management cycle is a three part process:

  • Awareness – finding out where the risks are.
  • Control – doing something about the risks to minimise them.
  • Containment – limiting the damage when things have gone wrong.

This article deals with containment. We’re all aware of the importance of early intervention in the context of disease and disorder, and we’re also all aware of the benefits of prevention. These concepts can be just as readily applied to avoiding, minimising and managing complaints but here we address when awareness and control either haven’t been applied or haven’t worked and we’re put into damage control mode.

Why would somebody complain? Reasons include:

  • They want an acknowledgement that something went wrong and an explanation of why.
  • They want an apology for the distress they experienced.
  • They don’t want others to have to face the same kind of problem that they did.
  • They want to improve the service for themselves or others in the future.
  • They want someone to be blamed, punished or held accountable for what happened.
  • They want retreatment, a refund or compensation.

Be mindful that not every complainant is coming from the same place in terms of motivation and how you handle the complaint may help to give you a strong insight into what lies at the heart of the matter and, therefore, what the appropriate strategy should be to manage it. Never assume that all patients complain for the same reason or because they desire the same outcome. A complaining patient may be motivated by one or more of the above but don’t immediately leap to the conclusion that the last two necessarily apply. With good management techniques many complaints never progress that far. Remember too that a complaint doesn’t necessarily mean that you did something wrong. Often it is the result of nothing more than poor communication and differing expectations.

The number of complaints which are just vexatious and made by people purely out to cause trouble is generally very low. Further, it is worth remembering that receiving a complaint, while it may not make your day, gives you an opportunity to understand a patient’s perspective and may help you to improve your service delivery. In the stress of the moment you may not realise it, but receiving a complaint can lead to positive outcomes for you if you are able to objectively analyse the circumstances, learn the appropriate lessons and adapt how you practice so as to reduce the risk of receiving more complaints in the future.

What are the avenues of complaint open to the dissatisfied patient? They may:

  • Confront the dentist or staff directly.
  • Write to the dentist.
  • Write to a statutory authority (in either the health or consumer sectors or both).
  • Engage a solicitor to correspond with the dentist on their behalf (often alleging negligence).
  • Engage a solicitor to lodge a Statement of Claim in the court system (civil action).
  • Complain to another dentist and seek their opinion and/or guidance.

It’s possible, of course, that a dissatisfied patient may not complain at all. They may just never come back to your practice. If that sounds like the easy way out for you be mindful that they may not voice their concerns to you but they will tell their family, their friends and possibly the whole suburb or town. Reputation is extremely important to most dentists, so the “disappearing patient” can still be problematic for you. Therefore, we really should welcome complaints to the extent that they give us the opportunity to manage the situation rather than having no control over it.

Every complaint is different so the approach to resolving it will differ based on several considerations:

  • The nature of the complaint (i.e. its seriousness and complexity).
  • The wishes of the complainant.
  • The issues the complaint raises.
  • How the complaint came to you.

The first avenue of complaint mentioned was for the patient to confront the dentist or staff directly. This one will almost invariably catch you unprepared and off guard so the following strategies are worth remembering, and they apply equally to yourself and your staff when confronted with a complaining – and possibly irate – patient.

  • Don’t ignore them. Nothing will inflame matters more quickly than if the person making the complaint feels they’re not even engaging the person to whom they’re speaking.
  • Don’t look away and don’t be distracted. Eye contact confirms your attentiveness.
  • Listen, don’t judge and don’t interrupt. When a patient expresses a concern, you need to understand what they’re saying and feeling (“active listening”) and then communicate back in your own words what you think has been said. When you do repeat the story back, keep to the facts and take the emotion out of things. You’re trying to serve as a mirror, but only mirror those aspects that are within your power to control. This technique allows you to validate the patient’s position without necessarily agreeing with it.
  • Be empathetic. Show your human side and acknowledge theirs. Get to the heart of the issue. Ask how you can help. When someone’s angry, there is no harm in a simple “Do you want me to help?” or, if the answer to that is self-evident, “Can I do anything to help?”

Do what you can in the moment to acknowledge the patient’s concerns, make a detailed record of the interaction as soon as possible after the event (verified by others who may have witnessed the encounter) and seek advice for ongoing management from your ADA and/or your insurer. Remember not to record the advice you receive from your ADA or insurer or lawyer in your clinical record. These confidential communications should be recorded in a separate document.

The second avenue of complaint for the patient is to write to the dentist. The advantage of this one is that you aren’t forced to think on your feet in the way that you are with a face to face complaint. You also have the opportunity to seek advice before responding at all. In a written response, it’s best to:

  • Acknowledge that voicing of concerns is appreciated.
  • Acknowledge the distress and the person’s experience.
  • Say what has been, or will be, done to investigate the complaint.
  • State what has been done or could be done to address the concerns.
  • Mention any changes or action taken (or that are being considered) as a result of the complaint.
  • Offer an opportunity to discuss further, with a choice of options (meeting, telephone, written).
  • If you’re comfortable in doing so, reassure the person that they can receive further service, if needed, without any concern about having made a complaint. Obviously such reassurance depends on the nature of the complaint.

Your advisor would be happy to guide you once you have prepared a draft response.

The third avenue of complaint available to the patient is to lodge their grievance with a statutory authority. You will eventually receive notice of this and be asked to respond. This response will initially be in writing and it is important that you do so in a way that maximises your chance of achieving a successful outcome. When you’re preparing your report:

  • Endeavour to control all negative emotions. Just because a complaint is made against a dentist does not, of itself, validate the complaint. It’s just the first part of a process and it’s then up to the dentist to defend their actions by providing their own reasonable version of the matter.
  • Always show respect and always attempt to assist. A courteous reply will often be appreciatively received.
  • The report should be couched in descriptive narrative terms and should be accurate, comprehensive and fair.

Guidelines on how to structure a response are included in the webinar. Please remember to run your response by your ADA advisor and your insurer’s appointed legal advisor before you submit it.

The fourth and fifth avenues of complaint open to a patient involve the engagement of a solicitor, either to deal directly with the dentist on the patient’s behalf or to lodge a Statement of Claim in the court system. The advice for handling these matters is very, very simple. Do not respond to any letter from a solicitor or any document from a court without seeking the assistance of your ADA advisors and the legal advisors engaged by your insurer. There is no higher requirement for “containment” than in circumstances such as this. Don’t respond to these matters yourself – the potential to get yourself “in deeper” is high and you will save yourself significant heartache by enlisting the support of those who are familiar with such matters.

The sixth avenue of complaint listed was for the patient to complain to another dentist and seek their opinion and/or guidance. This is where we all have a role to play in containing the fallout which may follow once a patient is dissatisfied. If you are ever in the position of being that “second dentist” there are some points to keep in mind when a patient comes complaining to you, remembering of course that their grumbles may well be entirely justified. The other angle to consider in all of this is of the patient who was quite happy with their previous dental treatment until comments were made by another dentist and this precipitates a complaint which may otherwise never have been made. Some tips, then, for the “second dentist”:

  • If you come across a case where work done recently is going to need to be replaced, ask permission from the patient before contacting the previous dentist to research how things have got to that point. Point out the clinical problems that exist in a calm manner without criticising others.
  • Be on alert so that, when asked to give an opinion on treatment that hasn’t had a satisfactory outcome, you don’t pass comment on the standard of care of the treatment provided by another. Of course our patients pay well for our services and care and we shouldn’t turn a blind eye to problems which exist. All patients at all times are owed a proper and professional diagnosis. If, however, you find yourself in the position of being the “second dentist” your aim should ideally be a clear discussion with the patient with explanation and co-discovery of problems that are apparent at the time of consultation. No more, no less.
  • Criticism of previous work is non-productive and gives the entire profession a negative bias that can be difficult for the next operator to overcome.
  • Don’t falsely criticise others in an attempt to justify the treatment you’re recommending. You’ll never look “bigger” in a patient’s eyes by making the previous dentist look “smaller.”
  • In any discussion with a patient and their support person the dental practitioner should take care not to state or agree that another health care professional is liable for any harm which may have been caused to the patient.
  • Remember that one day you may be in the position of having your work criticised by others so be honest with the patient and fair to your colleagues.

By whatever means a complaint is received, there are strategies/actions/policies to keep in mind and apply wherever possible to achieve the best possible outcome:

Timeliness

When dealing with a complaint, no matter how trivial, time is of the essence. An irate patient who doesn’t receive a prompt response may feel ignored and be more likely to take matters further. Therefore:

  • Respond as soon as possible to the complaint, even if it’s just to explain the process and give a commitment to a certain timeframe.
  • Stick to the timeframe given.
  • Keep the complainant informed.
  • Give reasons for any delays.

Address all aspects of the complaint

  • Provide a full response so that important issues are answered and the complainant can see that the complaint has been taken seriously.
  • Explain the process of investigation.
  • Acknowledge areas of disagreement or varying accounts without dismissing what the complainant has said.

Remember

  • Try not to be defensive.
  • Acknowledge the distress of the complainant.
  • Apologise if appropriate, but in any event be sympathetic.
  • Acknowledge any errors that did occur.
  • Try to understand the situation from the complainant’s perspective.
  • Find out what will assist the complainant to resolve the matter. Examples could include a written response, a phone discussion, changes in policy or procedures, a meeting.
  • Avoid official or technical language, jargon and clichés.
  • Consider cultural background and sensitivities and the possible use of an interpreter if necessary.

Provide your perspective

If a written complaint has been received by a statutory authority you’ll generally be notified about the complaint. You’ll receive a copy of the complaint and will be able to respond to it before a decision is made about the action to be taken on the complaint.

Indicate that lessons have been learned

Outline:

  • What happened.
  • How it happened.
  • What’s being done to stop it happening again.
  • That you’re sorry that it happened.

On this last point, some people have real issues with saying sorry. There has been a historical reluctance to offer an apology to a patient on the basis that it may be misconstrued as an admission of fault. Dentists have often harboured the concern that if they offer an apology to the patient, the patient will rely on that apology to establish a case in negligence before the civil courts. Legislative reform across all states has put this concern to rest. Put simply, an apology is not an admission of liability for the purpose of civil proceedings.

The effect of an apology should not be underestimated. It is the DDAS experience that many civil claims would not have eventuated if a carefully worded, timely and sincere apology had been provided to a patient. Very often a patient will simply feel wronged and want acknowledgement. If ignored they’ll often take matters further. If for no other motivation, a further reason to make an apology is that regulatory bodies tend to place weight on an apology when determining the outcome of a disciplinary matter.

Seek support

Always do this, and do it early. It is not just important to be timely with the patient – you need to be timely for your own wellbeing. Consult with:

  • Your state branch of the ADA.
  • Your insurer and their appointed legal advisors.
  • Any relevant senior person in your workplace such as a supervisor or manager.
  • If you’re employed in the public sector, you may wish to contact the Complaints Manager of your hospital or Local Health District.
Key Points

·      A complaint does not necessarily mean that you have done something wrong.

·      Receipt of a complaint can be a valuable learning experience.

·      Good complaint management strategies can prevent escalation of a matter.

·      Take time to understand a patient’s perspective so your response can be appropriate.

·      Don’t record any advice you receive from your ADA advisor or a lawyer appointed by your insurer in the patient’s clinical record. These confidential communications should be recorded in a separate document.

In the second part of this article we provide a rationale behind some of the strategies recommended and look at three common scenarios and the thought processes to apply when considering how to manage the situation.

By Dr Craig Brown – ADA NSW Branch Peer Advisor


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