Complaint Management System Has Prevented Bad Outcomes
Malpractice claims likely averted
The day after a man came to the ED at Edward Hospital in Naperville, IL, reporting low back pain and was discharged with analgesics, he received a phone call asking how he was feeling. He reported weakness and difficulty emptying his bladder.
"This resulted in a request for him to return. An MRI showed an epidural abscess, and surgery may have prevented paraplegia," says Tom Scaletta, MD, FAAEM, chair of the ED. About 18 months ago, the ED implemented a complaint management system that contacts all ED patients by e-mail or text the day after a visit.
"When we first started doing this, it was only by phone. We later tested a hybrid — both phone and electronic," says Scaletta. "Now, we only send out requests electronically."
Regardless of how the patient is contacted, if the patient’s condition has worsened, a notification is sent to the charge nurse, who calls the patient back.
"They confer with the emergency physician to determine if more testing is needed," he says.
When patients have questions about follow up or their discharge instructions, these are funneled to the case manager. If there is a service issue, one of the department leaders usually calls back to apologize for the negative experience.
"I have found this practice mitigates risk by identifying near-misses, correcting any misperceptions, and apologizing for service deficiencies before they fester and possibly become claims," says Scaletta. "I believe this is the origin of many frivolous lawsuits."
The system was developed as a result of feedback from the ED nursing director, says Scaletta, "who did not just want to funnel in patient complaints and create another stack of issues to deal with."
This led to the development of a way to quickly categorize complaints into 20 categories, with "complaint forwarding," if applicable, to the head of another department. For instance, a complaint about bathroom cleanliness goes to the head of housekeeping so that it can be used to drive improvement within that department.
"The system also automatically formulates an appropriate patient response that can be edited," says Scaletta. "The system is driven by a daily data extract, of all patients seen yesterday, which is uploaded."
Direct Response to Unhappy Patients
Requests for feedback are sent to all discharged patients by text or e-mail. "We ask five questions that relate to well-being and service. We get feedback from about 30% of patients — about three times as many by text versus e-mail," says Scaletta. About 95% of patients report they are doing fine medically, and the majority give positive feedback about their care in the ED.
"We are always in the 95th percentile or better with Press Ganey benchmarking," reports Scaletta. However, the calls give nurses a chance to respond directly to the small percentage of unhappy patients. For instance, some patients experience low back pain the day after a motor vehicle accident and believe X-rays should have been done during the previous ED visit.
The first question is about the patient’s well-being: "Are you better, same, or worse?" "About 1-2% of the time, the patient answers worse,’ and a fax goes to the charge nurse," says Scaletta. "This is handled similarly to a positive culture that returns the day after discharge."
The charge nurse looks up the case, confers with the on-duty EP, if needed, calls the patient back with the plan, and documents in the electronic medical record.
The second question asks if the patient had any problems with aftercare, such as instructions, medications, and follow-up. About 3% of patients respond "yes," and the e-mail is forwarded to the on-duty case manager, who addresses the issue.
"The third and fourth questions assess physician and nurse performance," says Scaletta. "The last question is a catch-all’ and funnels in all sorts of issues."
Several patients reported worsening abdominal pain and were told to return to the ED, where they were diagnosed with appendicitis.
This improves care continuity, says Scaletta, since EPs can compare any interval change in exams or test results and determine if any opportunity for improvement existed with the initial visit.
"While discharge instructions always state to come back if the patient gets worse, it’s nice to be more proactive and make sure the patient comes back to our hospital," says Scaletta.
For more information, contact:
- Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-5025. E-mail: firstname.lastname@example.org.