Time to take a long hard look at what we do
Litigation against Irish GPs is spiralling, but many complaints are avoidable
January 1, 2015
‘To err is human; to forgive, divine’. And patients often will be forgiving when doctors make mistakes. The problem is they are often not given an opportunity to do so, and this is a key cause of the epidemic of medical litigation in Ireland. GPs make errors – they happen. And they often lead to patient complaints. However, once we are asked to give feedback on issues that may have arisen with patients or to respond, we tend to fall down on the job and become defensive.
Often, GPs are unable to take on board negative comments or complaints, and fail to respond as other businesses would do with customers or clients. We are not good at this. We need to tackle this deficit in order to deal with the unsustainable level of medical litigation in this country, including a massive rise in the number of professional regulatory and negligence cases being taken against GPs.
If we do not encourage feedback and comments from patients about issues that arise in everyday practice, even if they may seem relatively trivial, these tend to accumulate in the patient’s mind. Ultimately, if patients get frustrated enough by this lack of two-way communication, they find they have no other place to complain to but the Medical Council, or to go through the legal system.
My experience with the Medical Council and the Medical Protection Society (MPS) has shown me that much of what happens in medical litigation has resulted from a breakdown in doctor-patient communication and trust. If GPs do nothing else, they must learn to acknowledge error or adverse events, and learn how to apologise to patients. We need to learn how to say sorry because that will often avoid what can be catastrophic consequences.
Dealing effectively with patient complaints when they arise is just one component of risk management, which is concerned with preventing these complaints from arising in the first place. We need to embrace the concept of risk management within our practices.
Risk is defined by the Oxford Dictionary as ‘a situation involving exposure to danger’, and the concept of risk management, which originally derived from the insurance industry, is one of identifying and forecasting where the danger areas are for us in our practices, and the identification of procedures to avoid or minimise their impact.
Transferring the concept of risk management into medicine is difficult, and into general practice even more complex, especially when you look at the type and range of work we do. However, just because it may be a challenge doesn’t mean we shouldn’t embrace it.
Adopting risk management
Why do we need to include risk management as one of the central components of our practices? Quite apart from the obvious patient safety and legal and regulatory issues, it’s about developing better systems of care within our practices. Improved systems allow for personal and professional development and greater satisfaction.
We need to embrace risk management in our own self-interest. Nobody wishes to be the recipient of a complaint about the service they provide. Having fewer complaints will reduce our personal stress levels, will maintain the practice’s reputation and help to prevent the considerable trauma of going through the Medical Council fitness to practise process or medical litigation.
But risk management is not just about what we do as individual GPs, it must also encompass all our practice staff. We need to make the whole practice environment safe. In order to do that we have to create a culture of openness and learning within the practice. We need to encourage our employees to come to us if they see there is an issue with something we or one of our GP colleagues are doing.
We should encourage our patients to come to us if there are issues that may be bothering them. It could be issues such as waiting times, consultation fee levels, delay in getting hospital test results, issues relating to doctor-patient communication or the level or quality of care provided.
We need to take on board this feedback, acknowledge the consequence for the patient, respond to it appropriately and convert it into a learning process.
As observed about Tiger Woods, when he was in his prime, what contributed to success was his ability to convert fear into a wonderful golf shot. Similarly with risk management, it’s important to take something that is potentially very negative and convert it into a positive outcome. It’s not just a question of learning from what goes wrong, but also from what nearly goes wrong. Every day, in all our practices, we have ‘near misses’. If we learn from these incidents we are essentially getting a ‘free pass’ to learn an important lesson.
The identification of error, adverse events, or near misses, and discussion in an open manner, fosters a culture of learning and not blame. Recent research in JAMA indicated there is good evidence that adverse event disclosure, apology, communication and resolution programmes, together with law reform, reduces claims.1
Stemming the tide of medical litigation has of course, a lot to do with the Government making the appropriate legal reforms. While we have no control over this, we can control how we deal with adverse events, or react to complaints and thereby reduce the negative consequences for ourselves, our practices and the patient.
The health system cannot afford to continue spending billions of euro in trying to sort out the consequences of doctors’ errors or omissions. And the current system of redress is far from ideal even from the patient’s perspective.
From my experience serving on the Medical Council, I often felt that patients who made complaints to the Council often came away from the process feeling that their complaint was not actually addressed. Often, they were looking for answers, or a particular outcome, but didn’t necessarily get either. Often too, they were not necessarily looking for a doctor’s head on a platter. Sometimes, the patient simply wants an apology. This is where adopting a proper complaints process as part of a risk reduction strategy in your practice comes into play.
Another important reason for embracing an in-house risk management culture is the planned introduction in general practice of HIQA’s National Standards for Safer, Better Healthcare.2
These quality standards, while challenging to implement, will provide the framework the Government says will operate for the licensing of general practices at some future date, and which will eventually make structured GP risk management unavoidable. The HIQA guidelines should serve as a wake-up call to practices to implement systems to ensure they are safe and quality-driven.
In order to adopt proper risk management we need to dispel some myths.
We do make mistakes
Adverse events occur in practice. Research in the UK last year3 estimated that 5% of prescriptions had errors in them and another study shows that if you look at repeat prescribing, the levels of error increase to 12.5 %.4 A recent US study indicated a one-in-20 (5%) misdiagnosis rate.5 The figures show demonstrable risk to patients in all of our practices.
However, unlike the hospital system, we currently have no way of collecting or recording adverse event data in general practices and primary care. The absence of such a systems approach to error and adverse event recording in primary care is a cause of concern, and impairs quality improvement.
In the absence of any formal structure, we on an individual practice basis need to commence the development of systems to collate adverse events in our practices. Such systems provide an opportunity to learn, and reduce future recurrence of risk. We need to control our individual risks where possible.
On a trial basis, it might be a good idea for a mini audit, to ask our practice secretaries, nurses or managers to check on and collate any errors, issues or adverse events that they observe, on a weekly basis. A typical event that could be recorded would be, for example, when a hospital-initiated prescription is difficult to read – a common event in a practice but one that can have serious repercussions.
GPs are rightly proud of their role in the healthcare system. Many GPs are quick to point out that numerous patient surveys have given GPs high satisfaction and trust ratings. This is undoubtedly true. A Medical Council survey from last year showed that 94% of patients surveyed were satisfied with their GPs.6
However, in looking at these surveys, we will probably learn more from looking at the dissatisfied rather than at the satisfied patients. The Medical Council survey tells us that 6% didn’t have a positive experience. That’s one-in-20 patients. If you extrapolated that into your surgery workload every day, it would indicate that if you see 20 patients in a typical day then one of those will potentially be unsatisfied. Looking at it from that perspective, the figures are a bit more worrying.
The survey also tells us the 89% of patients surveyed never experienced an event that required them to make a complaint. This also looks impressive at first glance. But if you reverse the figure you have 11% of people who did experience events that could have led to a complaint.
This shows us we are getting some ‘free passes’, and that a number of patients still do not necessarily resort to using professional complaint processes, despite their experiences. We need to be able to identify what led to these potential complaints, if we are to correct these issues and learn from the process.
Professional and personal consequences
Medical Council statistics show increasing numbers of complaints. In 2013 there were 400 complaints against doctors, covering 796 categories.7 One of the main areas for complaint is ‘poor communications’, together with some other complaints, for example, in respect of not treating patients with dignity, or issues with regard to records or confidentiality. These are potentially preventable in practice.
There is also a financial aspect to all of this. MPS figures for 2013 show that between 2007 and 2013 the number of claims against Irish GPs doubled.8 Also, the size of the claims against GPs is increasing, with the number of claims against GPs greater than E1 million rising by a factor of 3.5 in that period. It’s no surprise then, that our medical defence subscriptions keep increasing.
Current estimated liabilities for the State clinical indemnity scheme are in the order of €1.1 billion, and the potential liabilities for the medical indemnity bodies are considerably in excess of this figure. Ultimately, the current model is unsustainable without tort law reform and risk management.
The consequences of being the subject of a serious complaint can be significant. These can be reputational and financial, and can impact on personal health and family relationships. One’s practice of medicine and relationship with patients in general, often changes.
There is evidence too that as a result of these situations, colleagues often abandon you, or avoid you. As a group, our support of colleagues in difficulty is questionable.
I have known situations in which doctors have faced regulatory proceedings without informing spouses or other family members. There is an urgent need to create support networks for doctors who are the subject of legal or professional regulatory complaints, and I understand the ICGP is examining this issue at the moment.
A practical approach to risk
What practical steps should we take to achieve better risk management? Well, put simply, you’ve got to start looking all around you; looking at your own practice and considering what you think are risks that occur on a regular basis, documenting them and dealing with them.
These could be issues relating to prescribing errors, issues with repeat prescribing, patient confidentiality, communication issues (between doctor and patient or practice communication with hospitals), missed phone calls, getting results back from hospitals, DNAs, etc.
Every single day a practice encounters risks and some of them are happening so often that we no longer pay enough attention to them, and fail to see them as risks.
The MPS conducts clinical risk self assessments (CRSAs) to assess risk in practices. It visited 150 practices in Ireland and England over the past two years. It identified the top risks in general practice as: communications; confidentiality; health and safety issues; prescribing; and record-keeping and visits.9
The survey found that in every practice there was a communication risk; in every practice there were confidentiality risks; in 97% of practices surveyed there were health and safety issues and 95% had prescribing issues.
If you drill down further into the communication figure alone, you find that, for example, common communication problems include issues relating to emails and texting results to patients. Problems with in-house communication between practice staff and GPs are common – if people aren’t talking to each other within a practice, this can create significant risk.
Other communication issues were with patient involvement in treatment decisions and treatment protocols; and inadequate practice information leaflets and practice websites. Such deficiencies indicate that we may not be communicating with our patients as well as we should be.
Confidentiality risks included the overhearing of receptionists, and the faxing of clinical information. Despite rapid advances in communications technology, many Irish GPs still seem to be living in the era of the fax machine. Faxing confidential information is not recommended.
As regards health and safety, it should be remembered that we are obliged by law to have a safety statement in our practices – people should know about fire escapes, fire drills, having the correct furniture etc, and staff need to be trained on health and safety matters.
Prescribing risks in the survey included uncollected prescriptions and not having robust repeat prescribing policies.
‘Find it, fix it, confirm it’
Risk management in our practices is a major challenge but we cannot conquer the world overnight. It is all about taking small steps to improve risk management and gradually building up more robust practice risk profiling.
Successful risk management is all about honest self-assessment – and includes sitting down with your GP colleagues and practice staff and looking at what goes on in the practice and where the risks are.
However, as clinicians with a busy clinical workload, we are not necessarily going to have time to devote to leading the risk management role. This is a function that can and should ideally be taken on by a designated practice staff member, for example, a practice manager.
Practices should try and create an open culture, with consistent use of ‘find it, fix it, and confirm that you have fixed it’ approach.
The Royal Australian College of General Practitioners has identified three key areas you need to look at in risk management10: clinical knowledge; communications; and systems.
If you were to identify five key systems to streamline within your practice as part of an effective risk management programme, these would be in the areas of:
- Feedback/complaints handling
- Tracking of tests
- DNAs (did not attend)
- Infection control (eg. hand hygiene)
- Staff training.
In addition, a simple start-off point that I recommend is that a practice should do a weekly ‘risk horizon-scanning’ exercise, which would involve, say 10 minutes on a Monday morning where you meet with key staff members and try to foresee an issue that might cause a problem during the week; for example a staff member on leave and locum/ replacement arrangements etc, and plan for that week.
Finally, in a very pressurised and challenging healthcare environment, an important component of any practice risk management process is that doctors look after themselves.
Healthy doctors are really important to a well-run practice. Sick and stressed doctors often under-perform, and are more likely to make mistakes. Good systems in our practices may help keep us healthier and protect us, and our patients!
- JAMA, Oct 31 2014
- HIQA National Standards for Better Safer Healthcare: http://www.hiqa.ie/standards/healthcare
- Avery et al, BJGP, Aug 2013
- Silk N, Health Care Risk Report 2000
- BMJ April 17 2014
- Talking About Good Professional Practice, Medical Council report 2013
- Medical Council Annual Report 2012- www.mcirl.ie - under ‘Publications’
- MPS annual report 2013.
- MPS : Practice Matters May 2014
- www.racgp.org.au -under ‘Risk Management’