ADR: An Early and Mutually Satisfactory Resolution

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By Stuart Foxman

Satisfaction — in processes and outcomes — is such an integral part of medicine. That applies not just to care but also to complaints.

Consider two people who’ve reflected on their recent experiences with the CPSO. Dr. Jonathan Mackenzie, a family physician in Ottawa, says, “The process is fair and more streamlined.” Jill Puffer, a patient in Burlington, says, “I was happy it was handled so quickly.”

Both are talking about Alternative Dispute Resolution (ADR), which the CPSO introduced in the fall of 2018 as part of its right-touch regulation approach. While Ms. Puffer and Dr. Mackenzie’s cases were separate, each were happy with the way the College managed and settled their respective situations.

For certain matters of care and conduct judged to be amenable to a mediated process, ADR may be an option. It’s much quicker than a formal investigation that would go through the College’s Inquiries, Reports and Complaints Committee: often, ADR takes 30 to 60 days instead of 150 or more (sometimes far more). Patients and doctors arrive at an outcome together, with a mediator’s help, rather than relying on a committee decision.

For patients and doctors, it becomes a less stressful and more conciliatory process, leading to an early and mutually satisfactory resolution.

ADR isn’t for every type of complaint. Any involving an allegation of sexual abuse is always investigated. Complaints that raise serious concerns about a doctor’s competence, capacity to practise or conduct also can’t go through ADR.

“We reserve this process, generally, for low-risk matters,” says Denitha Breau, a manager in the College’s Investigations & Resolutions department.

In their professional life, doctors go through this type of process every day. It’s called triage. Think of a hospital emergency room, where people are coming in with life-threatening conditions or minor sprains alike. Some cases obviously require deeper assessments, while others can be fast-tracked in a separate area.

ADR can cover certain communication concerns, consent issues, questions around medical records (access to or transfer of), practice management issues (e.g. wait times, booking appointments), financial issues (e.g. fees), and some clinical issues.

CPSO receives about 3,500 complaints a year. When the College’s new Registrar & CEO, Dr. Nancy Whitmore, arrived in June 2018, she saw that the Inquiries, Complaints, and Reports Committee took no action in 65% of cases. These numbers, she said, suggested an opportunity existed for greater efficiency without compromising fairness or effectiveness. “ADR gave us the opportunity to manage lower-risk complaints differently and more effectively while providing a better experience for complainants and physicians,” she said.

Communication is at the core

ADR falls under Ms. Breau’s umbrella. She notes that communication issues get at the heart of most complaints overall and represent the biggest chunk of ADR cases.

That shouldn’t be surprising. The volume of doctor-patient interactions, their episodic nature, and the often high-stress environments, can lead to communication breakdowns or missteps. That’s not an excuse, says Ms. Breau, it’s just the reality of human contacts on a large scale.

In Ms. Puffer’s case, her doctor (a specialist who she was meeting for the first time) made an ill-advised comment that came across as insensitive. For Dr. Mackenzie, the complainant (the daughter of a patient) was concerned mainly about a perceived attitude and tone.

These complaints were tailor made for ADR. A CPSO investigator acts as a mediator and will ask the patient if he or she agrees to the process to resolve the complaint without a formal investigative process. If the patient and the doctor are on board, and the CPSO Registrar or her delegate approves the use of ADR, the mediator will work with both parties to try to resolve the complaint.

That can involve separate conversations with the parties, an in-person meeting with them, or conference calls. It all depends on the details of the case. The back and forth facilitates a solution and gets the parties more involved.

“The ICRC is a paper-based process, whereas ADR involves more person-to-person engagement,” says Ms. Breau.

Another way to be heard

In some cases, the doctor’s response can satisfy the patient, and no other steps are needed. Other times, the result might be an apology by the doctor. Or the doctor may agree to undertake education. Doctors might also agree to make changes to their practice or talk to CPSO medical advisors about ways to improve their practice.

Both Dr. Mackenzie and Ms. Puffer’s doctor ended up reviewing educational material about communications skills. Ms. Puffer’s doctor also sent a written response that expressed regret for her comment. “I think the doctor was truly sorry,” she says.

“Most people who bring forward a complaint just want a better experience for the next person and are looking to enhance the experience of the communal population,” says Ms. Breau.

Ms. Puffer says that was her goal. ADR provides another vehicle for complainants to be heard.

Both the complainant and physician retain the right to change their mind at any time during ADR and proceed with a formal investigation. And if the mediator can’t find a resolution within the required timeline, the CPSO will transfer the matter to a formal investigation.

Dr. Mackenzie has been through a drawn-out formal investigative process before. In contrast, he was happy that his matter was resolved within weeks, and that everyone could come out feeling good about ADR. He’s also pleased that the process frees up resources to address much higher-risk complaints.

That’s triage in action. The objective — whether for ADR or other investigations — is to arrive at outcomes that serve patient interests and safety.