[This article appeared as an op-ed piece in the September 28, 2007 Brattleboro Reformer. It is not online so since I cannot give a link, I am asking ibrattleboro to run it in full. I am very interesting in hearing about other people's experiences and impressions. SK-B]
Patients are naturally vulnerable, and rely on the hospital staff and administration for kindness and protection. To prevent lapses, there must be a trustworthy complaint procedure.
When the administrators welcome a complaint as an opportunity to improve quality and to build patient confidence, then there is no problem. But formalities are needed to check those institutions where a complaint is treated as an attack on the hospital's image, to be warded off. Vermont hospitals generally leave disposition of complaints to the personal discretion of administrators. If those administrators were always fair minded in handling a concern, there would hardly be a need for a formal complaint. But when there is a need for a complaint because the administrators have not responded satisfactorily to patient concerns, then the complaint must be filed with the very individuals who did not give the patient satisfaction in the first place.
A complaint process, which is typical of Vermont hospitals, is explained on the Brattleboro Memorial Hospital website. The description of the process is vague, and provides no information which a patient could rely on to draft a properly formatted complaint. There is no complaint form, no rules of procedure, and no criteria for how the ruling will be made. According to the site, a patient first brings the problem to the Quality Specialist, and then, if not satisfied, to the Vice President of Quality/Patient Safety who, “will conduct an investigation and render a written decision within one week.” The final appeal is to the hospital president whose, “decision will be final.”
There is no mention of what rules the Vice President's investigation will follow or what is required of the president in ruling on appeals. Apparently the patient has no right to a fair hearing at which evidence can be presented, witnesses examined, and arguments presented. This means that the “process,” in fact, depends entirely on the personal whims of individuals who have a vested interest in justifying the hospital rather than on consistent standards. The website mentions four agencies which the patient or their family can contact, “if they feel it is necessary to discuss the complaint with someone outside the hospital,” but a discussion is no substitute for the oversight of an outside, independent appeal authority with the power to overrule the hospital brass.
Having been an in-patient at three hospitals over a two month period including 3 weeks in intensive care, and now an out-patient in the BMH cardiac rehab program, I am familiar with being vulnerable and and relying on care-givers. At all three hospitals I found that the nursing staff was incredibly dedicated, and responded intelligently when problems arose.
But I found a huge difference in the outlook of administrators. Generally, the reliability of the formal complaint process never became an issue because the hospitals were responsive to concerns. Although I was grateful for the care I received, there is always something which can be improved. At Grace Cottage, when I made suggestions to improve food service, an administrator contacted me to let me know that my suggestions were taken seriously and were being acted upon. The reaction at BMH to reasonable suggestions was quite different.
At first when I asked to speak with the head of food service, he would not even speak with me, and the director of rehab scolded me for persisting in my request. Finally, after much persistence, I was granted an appointment to speak with the food service director, but instead of the friendly chat I had originally envisioned, it turned out to be a tense confrontation in a conference room with three hospital officials confronting me. In addition to the heads of rehab and food service, the Quality Specialist showed up, unannounced, and instead of mediating, she took sides so that her presence served to make it a three to one majority.
They had set up an adversarial encounter, and they were going to prevail no matter what. The issue had to do with the hostility of the food service director to providing an appetizing vegan entrée at special, heart-healthy "Mediterranean Dinners" held by the hospital. Since the curriculum at rehab taught that plant-based nutrition is the "gold standard" for arterial health, I felt that it would be perfectly reasonable for heart-healthy dinners, meant to demonstrate good dietary choices, to include an appetizing, vegan option.
At our meeting, the head of food service said (somewhat disgusted): "I'm not going to make tofu!"
I had not even mentioned tofu. In fact the three of them gave me an adamant refusal so fast that I did not have a chance to even mention any ideas for what they could serve. The Quality Specialist never tried to find out what each party needed in order to feel OK about the outcome, or to seek common ground: She treated it as a conflict in which there would be a winner and a loser.
My wife and I spoke with the president of BMH, and at his request agreed that we would trust him to work things out quietly, without formalities. As it turned out, nothing changed and I came to realize that his concern was not in resolving issues, but in deflecting problems and quieting things down. Having tried personal diplomacy only to run into a stone wall, that would logically be the time to file a complaint. But when I inquired about the complaint process and found that it would simply be the same administrators ratifying their own actions, it made no sense.
My good experiences at other hospitals have come about because of sensitive administrators, but next year or five years from now those same institutions may be headed by people with a different outlook. Rules, procedures, written standards, and outside review are needed to insure a trustworthy process. Reform is needed. As a start, the State of Vermont Department of Banking, Insurance, Securities & Health Care Administration (BISHCA) should conduct an audit of hospital complaints. In any fair process a certain percentage of decisions will be reversed on appeal. Would an audit show that presidential reviews in Vermont hospitals consistently result in a plausible percentage of reversals, or would it show that the presidents in certain hospitals consistently ratify every ruling? BISHCA is the regulatory agency responsible for acting in the public interest, and to do so that agency should investigate the integrity of the complaint process at Vermont Hospitals.
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Steven K-Brooks