Are hospitals and doctors accountable to patients?

[Kurtis Kitagawa]

I would like to hear from others in the PAN Community about their experiences of, and insights into, whether hospitals and doctors are accountable for their actions or inactions to patients. My experience is that as a patient, I have to rely on the personal ethics of doctors and administrators.

For example, hospital codes of conduct apparently don't apply to psychiatrists, who are not employees of hospitals.

The Patient Ombudsman in Ontario--an office established to help make hospitals accountable to patients--has limited powers. All the Patient Ombudsman can do is to ensure that a hospital has a complaints process in place and that it goes through the motions of adhering to its process. The Patient Ombudsman cannot review the behaviour of clinicians. Nor can it do anything to correct the behaviour of a hospital. All it can do is to ensure procedural justice, leaving substantive justice very much up in the air.

The College of Physicians and Surgeons cannot ask a medical doctor to apologize and take responsibility of his or her conduct.

All of which begs the question, are hospital and doctors actually accountable to patients? If so, how so? If not, why not?

[Carolyn Canfield]

Hi Kurtis,

You are right, accountability to patients and the public for everything from a lack of courtesy to malpractice causing death is full of holes. I don't know much about hospitals' or health authorities' accountability, but here is some information about doctors.

Apology is so fundamental to reconciliation (or at least accommodation) and rebuilding trust. If there is no trust, my belief is there cannot be healthcare. I'd refer you the the Canadian Medical Protective Association that is the physicians' insurer against (for example) law suits brought by patients. The cards are very much stacked against the patient and settlements are based on the injured party's compromised earning potential, so very few people sue in Canada (unlike the USA that has a different legal structure but controls popular opinion).

However, the CMPA also has an educational arm, and they do a reasonable job of trying to persuade docs to say "I'm sorry" in their "Good Practices Guide" (2016). Most provinces in Canada have an Apology Act that says expressing regret and sorrow, apologizing, is not an admission of culpability from a legal standpoint. So there should be no barrier to saying "I'm sorry", remarkably powerful words that may often begin the reconciliation so deeply needed by both patient/family survivor and by the doctor/healthcare worker. The website has some guidance (slowly getting better) for docs on responding to adverse events LINK.

You are asking about an advocacy role for change perhaps more than an advisory role. So if you correspond with someone at CMPA (my connection there has retired. ) ask if CMPA has any interest in developing a patient and citizen advisory panel to help with accountability. You never know: they might say Great Idea, step right up! My connection there has retired but you might want to try Dr Guylaine Lefebvre, the Director of Practice Improvement: GLefebvre@cmpa.org. The worst she can say is no, if you ask for a conversation. And she is a younger generation and may want to encourage better behaviour by doctors towards patients.

As far as advocacy goes, you might want to write to Allison Kooijman, chair of the WHO chapter: Patients for Patient Safety Canada. She is young, experienced with medical harm and lack of accountability, and very motivated for action. We've met and you can say I recommended her to you. Here is her profile on the website. Write to me at carolyn.canfield@ubc.ca for her personal email.

Best wishes in exploring this complicated and fraught topic. It's high time Canada had accountability for patients. The UK, Australia, New Zealand, nordic countries, the Netherlands and many more treat the public and patients much better.

Cheers, Carolyn

[Kurtis Kitagawa]

Dear Carolyn,

Thank you so much for your messages. I really do appreciate your insights and suggestions. I am going to be making a statement and answering questions at a Health Professions Appeal and Review Board hearing this time next week.

I am living on a very modest disability benefit, after having run down all of my savings and losing my house dealing with 10 years of very poor health. I could not afford legal advice and legal aid lawyers won't touch health law or administrative law (the two categories of law that apply to my case). The doctor has the Canadian Medical Protective Association behind him and has got a lawyer from one of the most expensive law firms in the country.

All I ever wanted was to have my discharge plan from the hospital honoured--the doctor refused to see me, and emails from within the hospital that I obtained through an Access to Information Request show a pattern of utter disrespect and utter lack of regard for me as a patient among clinicians and administrators.

I took my concerns about the hospital to the Patient Ombudsman and my concerns about the behaviour of the doctor to the College of Physicians and Surgeons. This was 2 years ago.

The Patient Ombudsman is still trying--after all this time--to get the hospital to meet with me. The College determined that the doctor erred, but advised me they cannot ask the doctor to apologize or now do his duty.

I was shocked by all of this. As a patient, there has been nothing for me in all of this. I only wanted the help that I was promised.

Anyway, would be grateful if you have any suggestions.

Out of interest, I will follow up with the Canadian Medical Protective Association contact you provided. I will also follow up with the contact you provided from Patients for Patient Safety Canada. I don't want what happened to me to happen to anybody else. Given my experience, I don't imagine change will come quickly, but I feel I would be remiss if I did not use the skills I have to advocate for change.

Would you mind sharing how you got your honourary lectureship at UBC med school? Early in my career I was a professor, but am wondering whether I might help in the training of new MDs at the Univ. of Ottawa. I already help with medical research methodology as a volunteer there.

Thanks once again. Norway sounds like fun!

All the best to you

Kurtis

[Carolyn Canfield]

How did I get an honorary lectureship, now promoted to "adjunct professor" at the University of British Columbia's Faculty of Medicine?

First, let there be no misconceptions: these appointments are unpaid. However, this has opened amazing learning opportunities (I LOVE to learn) and some access to influencing the next generation of practitioners. Also a bit of evaluation and even an occasional podium to promote my ideas as a collaborative change agent.

This happened because I began to invite myself to UBC lectures on healthcare that I learnd about from the university webpages. The topics might interest me, or "should" interest me as a change agent for better care, or were about things I had never thought about before.

At these events, I kept to best behaviour, perhaps asking a question that I could preface by introducing myself as a keener member of the public. Confrontation is not helpful, so the emotional toll of restraint can be difficult.

I was soon invited to conversations with professors, offered a chance to present a graduate seminar, and then offered a desk. When I asked for a library card so I could access articles in professional journals with subscription barriers, I was offered "honorary lecturer" appointment as an easy way to open library access.

WOW! No academic credentials required, and I have none. In turn, that has opened an amazing array of opportunities in the university. Suddenly as "faculty" it became okay for me to co-teach classes, get invited to committees where a public or patient voice was wanted, and much more. No pay. Lots of chance to influence.

So my advice is follow your curiosity, engage in conversations with scholars and professors. People like to be asked for advice, so do that, too. Ask also about opportunities to share your patient perspective with them and their students. You never know when you will find a mentor or sponsor. This is not so common in university circles, as you may know, since generosity is not a trait often rewarded. But some great people can enable an influential citizen-patient role.

As I say in most of my life's activist adventures: you know how it comes out if you do nothing. That inspires my courage to try. So invest in action with that precaution that it may come to naught. Come in with a collaborative and forgiving attitude and you may go far to change the world.

I hope this helps to encourage you. Best wishes. Keep PAN informed with how you fare.

Warm regards, Carolyn

[Kurtis Kitagawa]

Dear Carolyn,

Thank you so much for your email. I rather suspected there would be no pay attached to your positions--and, by the way, congratulations on the adjunct professorship! I am pleased to hear of your interest in helping to create change and your practicality in continuing to find ways to educate doctors and bring your perspective forward. Bravo!

I certainly have no expectation of getting paid for giving guest lectures or co-presenting or co-facilitating at other events. But I do feel this kind of role would suit me down to the ground and I do feel there would be lots of opportunities to make a difference in constructive ways. I do appreciate hearing about your experience and I will certainly share what happens as I explore what might possible here in Ottawa.

I hear you about not getting my hopes up. I also agree with you about doing nothing producing predictable results.

All the best to you

Kurtis

[Annette McKinnon]

Good luck with your HPARB Hearing Kurtis. The Colleges like to have all their ducks in a row for these events I believe, but this at least gives you a chance to be heard.

Currently the Patients For Patient Safety group is looking for stories of harm from members - I put the details in brackets. I got this info because I am a member myself

("a story related to the [Never Events report](https://www.patientsafetyinstitute.ca/en/toolsResources/NeverEvents/Documents/Never Events for Hospital Care in Canada.pdf). Those 15 events are: 1. Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure; 2. Wrong tissue, biological implant or blood product given to a patient; 3. Unintended foreign object left in a patient following a procedure; 4. Patient death or serious harm arising from the use of improperly sterilized instruments or equipment provided by the health care facility; 5. Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient's allergy had been identified; 6. Patient death or serious harm due to the administration of the wrong inhalation or insufflation gas; 7. Patient death or serious harm as a result of one of five pharmaceutical events; 8. Patient death or serious harm as a result of failure to identify and treat metabolic disturbances; 9. Any stage III or stage IV pressure ulcer acquired after admission to hospital; 10. Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area; 11. Patient death or serious harm due to an accidental burn; 12. Patient under the highest level of observation leaves a secured facility or ward without the knowledge of staff; 13. Patient suicide, or attempted suicide that resulted in serious harm, in instances where suicide-prevention protocols were to be applied to patients under the highest level of observation; 14. Infant abducted, or discharged to the wrong person; 15. Patient death or serious harm as a result of transport of a frail patient, or patient with dementia, where protocols were not followed to ensure the patient was left in a safe environment."

Never Events report: <https://www.patientsafetyinstitute.ca/en/toolsResources/NeverEvents/Documents/Never Events for Hospital Care in Canada.pdf>

[Kurtis Kitagawa]

Dear Annette,

Thank you for your message and for the information on "never events". Must the stories of harm your group is looking for be "never events", or do you take a broader view of patient safety, e.g., including psychological trauma?

Thank you.

Kurtis

[Annette McKinnon]

They are generally interested in all types of harm. This call for stories is for a particular campaign that is under way now I think.

I once gave a talk to the Ontario Hospital Association about harms. In my case it was the lesser versions that so many people have to deal with and yet never gets addressed. I was the last speaker and the audience shrunk dramatically as the attendees left early to avoid the traffic. The kind of talk you chalk up to good practice.

I hope you can join our Pan Parle on Thursday at 1:00 to talk about compensation for patients. It does happen sometimes and takes a variety of forms. A very hot topic.

Annette

[Gwen Piller]

Kurtis,

I am not sure if you tried the complaint process with the Champlain LHIN. I believe from your post you are in the Ottawa area. The LHIN funds the hospital. Although they may not be able to get the apology you want the LHIN may be able to find another care solution for you as they fund area services.

So, if I understand your post, one problem you had was regarding your discharge papers and obtaining them and no follow through with the discharge plan the LHIN "should" be able to assist with that.

It's unfortunate the Ontario Patient Ombudsman is limited in his scope of duties, but the LHIN has a broader reach. I have even dealt with my LHIN ombudsman as an advocate over bedbug issues for a friend whose housing program was not supporting him in regarding the building mangers lack of action to fumagate.

http://www.champlainlhin.on.ca/AboutUs/GetConnectedwithCare/Complaints.aspx

[Kurtis Kitagawa]

Dear Gwen,

Thank you so much for your post about the Champlain LHIN. I have not tried that route. I didn't even know there was an appeal/complaint option through the LHIN, but I will certainly give them a try.

The Ontario Patient Ombudsman's office is swamped with open investigations and there is no actual Patient Ombudsman and hasn't been for years. That position remains unfilled. As a result the Patient Ombudsman's responsibility to deliver an annual report to Queen's Park about their activities is and has been in abeyance for 2 years. That is unfortunate, as it does not allow MPPs or patients like me the opportunity to see what the progress of the Patient Ombudsman's office has been--where they are experiencing successes and challenges. This means that the public has no way of knowing whether hospitals and other institutions whose behaviour falls within the oversight of the Patient Ombudsman are fulfilling their obligations to patients. It also means, in practice, that hospitals are not in any tangible way accountable to MPPs and the public for the mistreatment that patients continue to report to the Patient Onbudsman in record numbers. I say record numbers, because how else could the Patient Ombudsman have year long backlogs on cases if the number of complaints had not risen since the first and only year (2016) for which we have numbers of number of complaints, how many complaints resulted in formal investigations, average length of time to resolve complaints, what percentage of complaints remain unresolved and so on.

I am all in favour of restoring public accountability so that patients like me know that someone has our back when hospitals fail in their duty of care to patients.

Thanks again

Kurtis

[Gwen Piller]

Hi Kurtis

check here https://patientombudsman.ca/Complaints/Before-you-make-a-complaint

There is a patient Ombudsman I worked with him and others recently on a committee reviewing the above website. Though his scope is small and only includes hospitals CCAC and long term care. They also ask that you first try other processes and they are used to review complaints that have not been solved by other agencies below them.

I’m sure the Patient Ombudsmans back log is unmanageable as is that of the Ontario Ombudsman. I find a change in government never helps either, just slows down the process even further until new policies are in place and government changes again. It’s never ending.

[Kurtis Kitagawa]

Dear Gwen,

Thank you for your post. The Patient Ombudsman has had my file for more than 18 months. The Ontario Ombudsman has already formally intervened once and provided advice to me for a second time very recently.

I had exhausted all other channels of having my concerns addressed before going to the Patient Ombudsman, so it has been almost exactly 2 years since I have been seeking to have my concerns addressed.

I would be grateful if you are able to share the name of a contact person at the office of the Patient Ombudsman who would be willing to receive feedback on their processes and how it feels from a patient's point of view not to have concerns addressed for 18 months. There is still no end in sight in my particular case.

Thanks again

Kurtis

[Alies Maybee]

Kurtis, I am so dismayed but not surprised by your experience. Your original post caught my eye because I have felt that the system sees accountable very differently from how patients do. The accountability seems to be all to the payor (government) for money spent with a nod to "outcomes". The patients is the inert object being acted upon in this thinking.

There, as you so clearly demonstrate, no accountability to patients. I have been wondering how we turn this around. Unlike consumers, we can really pick and choose what treatments to have and who will deliver them if at all. The "consumer" model doesn't work for me for this reason.

Just musing.... what about provincial patient/caregiver tribunals (or other body) who hear issues like yours and have the power to fine, recommend for disbarment, post public results of hearings, etc? What about the requirement to have "contract" type care plans with consequences for providers given that the patient does their bit?

Thoughts? Alies

[Kurtis Kitagawa]

Dear Alies,

Thank you for your post. I have been working with the Patient Ombudsman in Ontario for 19 months now, but the hospital still has not answered my questions. The Patient Ombudsman initially closed the file--because, according to them, the hospital had a complaints process in place and that was all the Patient Ombudsman felt it important to investigate. The Ontario Ombudsman intervened and asked the Patient Ombudsman to reopen the investigation, but almost a year later on the 2nd investigation and all the Patient Ombudsman has said is that the hospital seems to have followed its own internal process for responding to complaints. The fact that they have not addressed my concerns or worked with me to achieve a resolution is not an issue the Patient Ombudsman can hold the hospital accountable for. Nor can the Patient Ombudsman hold the hospital for not having a complaints process that is consistent with the hospital's client statement of values. Both the complaints process and the client statement of values are required by the Excellent Care for All Act in Ontario, but that piece of legislation (and the supporting regulations) leaves it open to hospitals to design their own processes, does not require them to communicate with patients in any particular way and does not require hospitals to resolve complaints. The legislation does not give any detail about what is meant by ensuring that the complaints process in a hospital is aligned with its client statement of values. So, breaches of privacy, failure to communicate, failure to involve clients in the process, failure to respect the dignity of a patient, failure to take responsibility for mistakes and correct them--none of these things are required of a hospital. The hospital's code of conduct for all staff (including administrators) states that all staff have a primary fiduciary duty to the patient, that staff must take responsibility for their actions and correct errors, that they must work collaboratively with patients, etc., but if the hospital does not hold its own staff accountable for their actions, nobody can do anything to address the problem.

You mention provincial patient/caregiver tribunals--is there something in ONtario beyond the Patient Ombudsman? The Patient Ombudsman has no power to level fines, post results of their investigations or anything else. All they can do is to make recommendations to the hospital.

The Patient Ombudsman apparently can look to see if there is a pattern of similar complaints relating to a particular hospital, but the process of making a complaint and following through is so emotionally difficult and onerous in terms of writing letters that it is unlikely that a patient in distress will ever be able to come forward, let alone see the process through to its end. I happen to be well educated and have lots of practice writing letters, but this has been the most difficult thing I have done in my life--doing a PhD was a breeze compared to this.

YOu also mention the requirement to have contract type care plans with consequences for providers who don't honour their end of the bargain. What are you referring to? I didn't know about this? Any illumination on this would be helpful.

I am now part of a continuous quality improvement consortium whose sole focus is addressing patient dissatisfaction with discharge planning and transitions in the mental health care system. At a recent meeting, the representative from the hospital in question did not participate in the root cause analysis that was the focus of the daylong meeting hosted by the hospital in question. That was astonishing.

Anyway, I am doing all I can to make change in this area so patients in the future may be spared the horrors I have experienced.

Hospitals seem to put all of their energy into shielding themselves from liability and pay little to no attention to the impact of their actions on patients. I don't know by what right such institutions even have the nerve to call themselves hospitals.

The funders of hospitals in this province have performance agreements that do not specify much--if anything--that hospitals must demonstrate to be eligible for ongoing funding. So, for example, a mental health hospital's performance agreement lists cardiac procedures, hip replacements and dozens of other criteria, but then indicates that these things are not applicable. The only customized performance indicator relates to connectivity, leaving even the quality of patient care and patient experience out. I don't know what governments are thinking.

Anyway, happy to hear other suggestions and if you think there are other groups/associations I could be involved with as a volunteer to help make change in this area, please let me know.

Thanks again

Kurtis

[Alies Maybee]

Kurtis, I wish there were tribunals and contract care plans. These unfortunately they are only thoughts about how to address the issues you raise and how to find ways to make the individuals and orgs in the system accountable TO PATIENTS!!!

Your story is replicated everywhere and yet no one addresses accountability to the patients and how to design, systems, mechanisms, funding to support that. I do think if we put our heads together, we might come up with some good ideas we can shop around.

I feel like we keep demanding that the systems/processes we have currently should change but in fact, they are doing what they are designed to do. It just isn't accountability to patients or problem-solving for patients however they market it.

What if patients came up with solutions based on us instead of the system? What would that look like? How could we get decision-makers to come on board? Thoughts? Alies

[Annette McKinnon]

As a member of a Consumer Advisory Council for my local hospital for the past 3 years I have noticed that the community is nowhere close to being the main focus of the hospital priorities. And if they aren't really community oriented how can they be truly considering the individual patient?

What I have seen is lots of partnerships with other large organization for their mutual benefit through consolidating services and swapping types of patients. When they look at outpatient services (which I think encompasses community) it's with an eye to cutting what does not make a profit.

The idea of having hospitals in charge of most of our Ontario Health Teams is concerning - how can orgs with decades of being controlled and in effect managed by the Ministry through their budgets suddenly develop an ability to lead us to a seamless experience of care?

Annette

[Kurtis Kitagawa]

Thank you, Annette. Yes, hospitals are compensated by flipping patients out of beds and for procedures performed. Transitions are not part of their DNA. I don't know how change will come about but I have a few years left in me and will keep doing what I can in the hope that we will see transformation some day. Hospitals have not yet adopted the language of recovery and when they mouth the language of patient centred care they are only using the words and are either not aware of their meaning or believe that they are doing what they are supposed to be doing regardless of patient feedback.

Kurtis

[Alies Maybee]

Kurtis, I am learning more and more about the new Ontario Health Teams (OHTs) and the new Super Agency. While many of us a little (or a lot) alarmed by the magnitude and speed of change, within all this is opportunity. I also get the sense there is a real desire to actually make things better for patients. So I'm seeing opportunity here -- call me Pollyanna!

A couple of things I've heard: Initially it seemed the 30-50 OHTs were seen to be hospital-based -- now I'm hearing quite to the contrary, the Govt want proposal where leads are community-based orgs. Obviously it is still up in the air but if this is the case, it is promising. I am on a board of a little Family Health Team with a focus on a highly specific disadvantaged population. In our area, there are 19 such orgs never mind other care providers. I am hoping some good combination of these could be an OHT. Also, patient engagement (PE) is a requirement for the OHTs. We all need to be involved when and where we can. My guess is, the Govt will review the several different models at some point and lean towards the couple or more how are most successful. Who knows! They are also talking a lot about the Accountability Care Organizations in the US. I don't know, but are there elements to those that actually allow for accountability to patients? Should we learn from them?

Secondly, I know the person, Susan Fitzpatrick, who is the new interim chair of the Super Agency. She is the most excellent former CEO of the Toronto Central LHIN. I can't think of a better person who totally "gets" care transitions, has sponsored good projects in that area and is committed to PE. She is also most adept at dealing with bureaucracy and government.

While none of this directly deals with your issues, I do hope a) that you are feeling the winds of change a little and are a touch optimistic and b) that you will keep your eyes and ears open for where you can influence things in this changing environment.

Love discussing all this with you,

Alies

[Kurtis Kitagawa]

Thank you, Alies. I very much appreciate your insights in this area. I am on the patient advisory council of an academic family health team and am working very closely with a community health centre. Both are doing all they can in the patient engagement area, as is CMHA Ottawa, where I am on the peer engagement advisory council. I am still in my 50s and will keep my eyes and ears open and spend my time supporting organizations that are interested in ensuring healthy transitions. In the end, I believe it will be shown that not only is this a more humane approach, but it will also save the health care system money in the long term and actually help patients to be more informed users of health care and to take charge of their own recovery journey.

Please let me know if the Super Agency opens any discussions in this area, and I will certainly do my best to contribute.

thanks again

Kurtis

[Alies Maybee]

Kurtis, I will let you know about anything I hear. Cheers! Alies

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