Handling Complaints: Considerations for Prioritizing Complaints

Complaints: Complaints. abstract Overstretched resources and steady increases in the number of complaints filed with the offices of the Quebec Service Quality and Complaints Commissioner prompted us to investigate the complaint-handling systems of health-related organizations operating in Commonwealth and Western European countries. We also examined guidelines used to identify higher priority files (i.e., urgent files). Urgent files can then be prioritized in terms of the time taken to provide a conclusion as well as Résumé Abstract La surcharge des ressources et l’augmentation constante du nombre de plaintes déposées auprès des bureaux du Commissaire aux plaintes et à la qualité des services du Québec nous ont incités à examiner les systèmes de traitement des plaintes des organismes de santé des pays du Commonwealth et de l’Europe occidentale. Nous avons également examiné les lignes directrices utilisées pour identifier les dossiers prioritaires (c.-à-d. les dossiers urgents). Les dossiers urgents peuvent ensuite être classés par ordre de priorité en fonction du temps nécessaire pour fournir une conclusion ainsi que de la profondeur de l’examen. Un système dans lequel une petite fraction des plaintes est considérée comme « urgente » a été préféré aux systèmes dans lesquels les plaintes sont classées en trois niveaux de priorité ou plus, car les dossiers classés dans le plus bas des trois niveaux de priorité ou plus risquent d’être négligés. En appliquant les leçons tirées d’autres systèmes et en tenant compte du mandat du commissaire aux plaintes et à la qualité des services, nous avons identifié trois critères directeurs pour déterminer si les dossiers méritent d’être considérés comme urgents : la menace pour la sécurité , l’implication d’une ou de plusieurs personnes vulnérables et le risque de récurrence (mais seulement lorsqu’il est associé à des problèmes de sécurité). Comme il n’est pas facile de déterminer quels dossiers doivent être considérés comme urgents, ces critères généraux peuvent être adaptés et appliqués au cas par cas. Overstretched resources and steady increases in the number of complaints filed with the offices of the Quebec Service Quality and Complaints Commissioner prompted us to investigate the complaint-handling systems of health-related organizations operating in Commonwealth and Western European countries. We also examined guidelines used to identify higher priority files (i.e., urgent files). Urgent files can then be prioritized in terms of the time taken to provide a conclusion as well as the depth of the examination. A system where a small fraction of complaints is deemed “urgent” was preferred over systems where complaints are categorized into three or more priority levels, because files categorized in the lowest of three or more priority levels risk being neglected. Applying lessons from other systems and considering the Service Quality and Complaints Commissioner’s mandate, we identified three guiding criteria for determining whether files warrant urgent status: threat to safety , involvement of vulnerable person(s) and risk of recurrence (but only when coupled with safety issues). Since determining which files should be considered urgent is not straight forward, these broad criteria can be adapted and applied on a case-by-case basis.

Overstretched resources and steady increases in the number of complaints filed with the offices of the Quebec Service Quality and Complaints Commissioner prompted us to investigate the complaint-handling systems of health-related organizations operating in Commonwealth and Western European countries. We also examined guidelines used to identify higher priority files (i.e., urgent files). Urgent files can then be prioritized in terms of the time taken to provide a conclusion as well as the depth of the examination. A system where a small fraction of complaints is deemed "urgent" was preferred over systems where complaints are categorized into three or more priority levels, because files categorized in the lowest of three or more priority levels risk being neglected. Applying lessons from other systems and considering the Service Quality and Complaints Commissioner's mandate, we identified three guiding criteria for determining whether files warrant urgent status: threat to safety, involvement of vulnerable person(s) and risk of recurrence (but only when coupled with safety issues). Since determining which files should be considered urgent is not straight forward, these broad criteria can be adapted and applied on a case-by-case basis.

INTRODUCTION
In the context of an aging population where chronic diseases are prevalent and health conditions increasingly complex, the demand for healthcare services will be high and continue to rise (1)(2)(3). Additionally, there are other drivers of increased demand for health services including higher population assertiveness, educational attainment and expectations (4). The age distribution of the Quebec (Canada) population coupled with the aforementioned drivers, have led to a steady increase in the number of complaints filed with most of the Service Quality and Complaints Commissioner offices (herein "Complaints Commissioner") in Quebec (5)(6)(7)(8)(9). The resources allocated to deal with these complaints have not matched demand, leading to delays in reaching a conclusion for a substantial proportion of complaints.
The Quebec Act Respecting Health and Social Services (Loi sur les services de santé et sociaux, LSSS) requires Complaint Commissioners to issue a conclusion within 45 days of receiving the complaint; this refers to 45 days in total, not 45 working days. However, based on the 2019-2020 annual reports from the seven health regions in Montreal, the percentage of complaint files that reached a conclusion within the legal limit of 45 days ranged from as low as 39% to as high as 76% (10,11). So, even the health region with the best performance on this metric had not rendered conclusions on one quarter of the files within the legal time limit.
In Quebec, Complaints Commissioners' offices examine processes and situations related to patients' dissatisfaction within the public healthcare system. These examinations aim to improve the quality of care and services while ensuring patients' rights are respected. Rarely are complainants interested in retribution or disciplinary measures but instead look for recognition, and that the situation prompting the complaint be improved for themselves and for future healthcare users.
When addressing complaints concerning healthcare, a Complaint Commissioner can rely on the pillars of Ombudsmanship found in the Quebec Health Act. These pillars include independence (appointed by the Board of Directors), confidentiality (complaint files are not stored with medical files), exclusivity of function (a complaints commissioner cannot be assigned functions other than complaint examination), powers of inquiry, and the possibility of intervention (sometimes referred as "ownmotion investigations"). Institutional rules, regulations, policies, and bureaucracy can, at times, conflict with these pillars. Laws and regulations do not apply in a single perfect way and the situations precipitating the complaint are often complex; for this reason, equity, fairness and humanism are essential values underlying the work of a Complaints Commissioner's office. Being flexible in one's approach to examining complaints can optimize outcomes. Applying that flexible approach to developing a more efficient complaint system may be the best way to ensure patients' rights are upheld.
While all complaints should be treated fairly and ideally within the time frame stipulated by law (i.e., 45 days), we recognize the need to explore alternate complaint handling systems; in particular, systems that prioritize more urgent complaints without delay. We identified two main types of prioritization systems: one that categorizes complaints into three or more priority levels and another that categorizes complaints in two levels, where a small proportion of complaints are deemed urgent and are thus deemed higher priority. In this critical commentary, we reviewed Ombudsperson reports from Commonwealth and Western European countries that outlined their policies and criteria for prioritizing complaints with the aim of discussing their applicability to the mandate of Complaint Commissioners operating in Quebec.

FINDINGS
Several researchers studying triage and prioritization in the healthcare sector have examined the impact that three or more priority levels had on timing and found that items classified as the lowest priority level may wait an undue amount of time or worse, not even receive follow-up (12)(13)(14). Indeed, some authors have argued that a prioritization system with only two priority levels -i.e., urgent and all others -is ideal (12)(13)(14). With just two priority levels, urgent files can be treated in a timely fashion, while the other files would not risk being neglected due to being classified in the lowest priority level. The urgent category should include a small proportion of files selected by applying broad consensus guiding criteria. Files in the "all other" category should be addressed on a first come, first-served basis to be equitable and respect the right of access for all to the complaint system. It is important to develop guiding criteria to support the Complaints Commissioner in identifying urgent complaint files. Prioritization decisions are complex, and any guiding criteria should be applied responsibly, to support (not overrule) Complaints Commissioners' critical judgment, in accordance with their mandate and values.

Guiding Criteria in Ombudspersons' Offices
The office of the Ombudsperson of British Columbia has a "mandate to investigate complaints about the administration of government programs and services offered by organizations such as provincial ministries, boards and commissions, crown corporations, local governments; health authorities, schools,…. and self-regulating professions and occupations." (15) Complaints containing more serious issues are prioritized. Some of the elements of complaints that can lead to prioritization are deprivation of a person's legal rights, significant personal injury or death, the involvement of a child, youth or other vulnerable person, the need for urgent action (e.g., immediate and serious risk of harm), whether there is a time limit for securing a practical outcome, as well as the more broadly defined reason of "sensitive issues" (15).
To identify the priority level of a complaint, Western Australia's Department of Health asks complainants to categorize the seriousness of the event from insignificant to extreme and the likelihood of the event recurring from almost certain to rare (16). These categorizations are used to assess the level of risk according to a 24-category seriousness assessment matrix (17). For example, the combination of extreme seriousness of an event with almost certain recurrence would be classified as extreme risk, whereas an insignificant event with a rare likelihood of recurrence would be classified as low risk. The purpose of this initial process is to identify complaints that carry significant risks, whether those risks are legal, financial, political or safety related. Internally, a checklist for high risk/priority complaints is completed and if even one indicator of risk is selected, the file goes to the Assistant Ombudsperson for a risk assessment (17). Risk indicators relevant to the healthcare setting include threat of harm to any person, critical infrastructure or public revenue; complaints involving significant personal injury, death or sensitive political or social issues, or high-profile figures; if the complaint involves actual or potential media interest (e.g., the complainant said they would approach the media); if the complaint was sent by a minister or member of parliament on behalf of a complainant or there was significant involvement by a minister or member of parliament in the case within the last 12 months; and, finally if the complaint is complex and is likely to be very resource intensive to investigate.
The Australian Commonwealth Ombudsman published a "Better practice guide to complaint handling" which suggests that time limits and sensitive matters such as those raised by a member of parliament, a whistleblower, or something that could attract media attention should receive higher priority (18). However, their mandate is to help resolve complaints not by issuing a new conclusion but by considering the way a decision was made and to offer recommendations on how the decision or process could be improved. The Australian Queensland Government uses a risk assessment to triage complaints. The risk assessment evaluates the severity and seriousness of the complaint to categorize it into four possible event categories (i.e., minor, moderate, serious, adverse) (19). The adverse event is defined as a sentinel event or an event with long-term damage with serious adverse outcomes, grossly substandard care or unsatisfactory professional conduct.
The Ombudsperson of Ireland's mandate is to "examine complaints from people who feel they have been unfairly treated by a public service provider in Ireland." (20). Its guideline mentions that while all files should be treated fairly, "Investigations should be conducted in a way that is proportionate to the nature and degree of seriousness of the complaint." Some guiding criteria used to identify complaints warranting a more in-depth investigation include the complexity of the issue, and the presence of issues that have been identified as serious or high-risk. The Ombudsperson of New Zealand has adopted a similar approach stating that the complaint should be assessed and assigned priority because not every complaint requires in-depth review (21).
Similar to the Western Australian Department of Health, the Medical Association of England recommends conducting a risk assessment using a matrix combining the seriousness of the event and the likelihood of recurrence (22). High priority complaints are those that raise significant issues regarding standards, quality of care and safeguarding of or denial of rights; serious issues that may cause long-term damage, such as grossly substandard care, professional misconduct or death; and those with a high probability of litigation and strong possibility of adverse national publicity.
This commentary was restricted to publicly accessible information and therefore did not provide a comprehensive overview of complaint prioritization systems. Despite this limitation, the findings of this review reveal a complex set of factors influencing the prioritization given to complaints. Factors include safety or harm, denial of rights, high complexity, risk of recurrence, involvement of a vulnerable person, and potential media or legal risks. These findings highlight how prioritization and file handling are based on a range of factors that intertwine with the mandate of each office.

Which guiding criteria should be used to identify high priority complaints?
For Complaints Commissioners' offices, complaints that fall within our mandate should be examined on a first-come, firstserved basis, and ideally within the legal delay; however, a minority of complaints should be prioritized based on the guiding criteria described in Table 1.

Table 1. Guiding criteria for prioritizing complaints Factor
Included as guiding criteria Explanation Threat to safety Yes A situation where significant threats to the safety of patients or staff is alone sufficient to warrant prioritization. Safety can include the significant deterioration of health.

Vulnerable patient
Yes, but on a case-by-case basis and combined with safety issues or risk of recurrence Highly vulnerable patients, generally including a combination of the following factors: elderly, low socioeconomic status, complex health conditions, no social network, not speaking either official language (French or English), and/or have mental health issues.

Risk of recurrence Yes, but only when combined with safety issues
Since more serious safety issues are prioritized (whether or not another factor is present) the risk of recurrence can require prioritizing safety issues that first appear more minor in nature.
Since some complaints are prioritized based on specific factors, there is no target limit on the proportion of complaints that would receive prioritization. Classifying a file as urgent has two implications. One is that the examination into that complaint is deeper, and more employee hours could be dedicated to an examination process. Another implication is the time taken to render a decision on that file is shorter than it would be without being given priority. Some situations brought to our offices specifically benefit from a rapid involvement and conclusion. For example, someone who was denied healthcare services may require rapid involvement of the Complaints Commissioner to ensure that, if our conclusion suggests that the care and services were required as per the current norms of practices, that these would still be offered within the clinically relevant time frame. Of note, particular care has to be given to managing complaints dealing with the death of a patient. While it is not always necessary to examine a situation immediately (i.e., out of respect for the family needing time to carry out the initial grieving process without disruption), the examination that pertains to those within the organization, such as nurses or doctors, should be considered urgent and started immediately so that the memories of the specific event(s) are at the forefront of health providers' minds.
The collaboration of the healthcare providers and managers during the examination is essential to the effective functioning of Complaints Commissioners' offices. These prioritization guiding criteria should thus be widely shared within the relevant institutions. Additionally, in the initial communication with the concerned healthcare providers and managers, Complaints Commissioners' offices can verbalize or write that "a minority of complaints are given priority designation and that the following complaint has received such designation and should be treated without delay." In addition to prioritization methods, other strategies can be used by the Complaints Commissioners' offices, including opening an intervention file for recurrent or systemic issues (own-motion investigations), or opening an assistance file to quickly deal with the safety or care issues and then later opening the complaint file. Indeed, an assistance process can help patients navigate the healthcare system. For example, the Complaints Commissioner could ensure that the coordinator of a department is informed of a patient's difficulties in obtaining care and services so that a review is initiated to ensure that patients do not "fall through the cracks." Although complaints that put the reputation of the institution at risk or that present media or legal threats were part of some of the guides we reviewed, this is not suggested as a criterion in the public healthcare context. While our role includes mediation/conciliation, which may prevent litigation and reduce media intervention, our primary mandate is to ensure patients' rights and quality of care, hence a threat to reputation alone is not sufficient to prioritize a complaint.
It is also necessary to ask whether the prioritization guiding criteria should be public facing, such as on the office website. In short, no. However, the guiding criteria can be publicly accessible through the internal policies of the Complaints Commissioner. While it is our belief that prioritizing a small proportion of complaints based on a limited set of guiding criteria prompts fairness, the guiding criteria could be misconstrued by complainants as meaning that complaints that do not meet the guiding criteria are not important. Since one of the purposes of complaints is to improve patient care and services, and to make complainants feel heard, posting the guiding criteria may jeopardize this role. Complainants need to have the confidence that they will be treated fairly, as per the legal requirements and as per our mandate. The guiding criteria are intended to be internal to ensure that more serious pressing complaints are given an in-depth examination that leads to a decision within the required legal time frame (45 days). As such, the criteria are not very specific; rather, they are presented here to be discussed, shared, and adapted on a case-by-case basis alongside the critical judgment of the Complaints Commissioner as well as any unique circumstances surrounding the complaint.

CONCLUSION
Until resource limitations are fully addressed, delays of more than 45 days are an unavoidable feature of many Complaints Commissioners in the Quebec public healthcare system. There is thus a pressing need to develop priority guiding criteria that are grounded in the mandate and values of Complaints Commissioners. Based on a review of the literature, we suggested a two-level priority system, where a small proportion of files are granted urgent status based on whether they involve vulnerable person(s), the likelihood that the situation would recur and/or if the issue described poses a threat to safety. In essence, the proposed two-level priority system promotes fairness by preventing any urgent complaints from experiencing delays due to a lack of resources. The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal's standards of excellence.
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