Rae Lamb, a former journalist and deputy health and disability commissioner in New Zealand, is now in her second term as Australia’s Aged Care Commissioner. She talks to Linda Belardi about her new determinative powers, best practice complaints handling and why providers should say sorry more often.
As a health correspondent for New Zealand public radio, Rae Lamb covered some of the country’s major health inquiries.
Among them was an inquiry in 2001 that uncovered major problems in New Zealand’s national cervical screening program.
It was this interest into what can go wrong in healthcare that led to a Harkness Fellowship at the Institute for Healthcare Improvement and the Harvard School for Public Health in the United States and her later appointment as Deputy Health and Disability Commissioner in New Zealand in 2005.
As part of her fellowship she researched the disclosure of medical error to patients. In her writing, Lamb argued for open, honest, and timely disclosure of medical error.
The experience as deputy commissioner and her academic work on open disclosure in the health arena has influenced much of her current thinking on complaints handling as Australia’s Aged Care Commissioner, a position she has held since January 2011.
Reflecting on her decade of experience in complaints management, Lamb says she is convinced it is best to resolve a complaint early, and to do so directly between the parties involved.
“By the time a complaint in aged care, health or disability comes to a complaints scheme, and certainly by the time it gets to an office of review… It’s becoming too late to get a satisfactory outcome for the people involved.”
Lamb says this puts the onus on providers to respond well to complaints and facilitate early and direct resolution as much as possible.
“Service providers also need to realise that doing a good job of complaints is the quid pro quo of a resolution-based complaints scheme. You have a system now where the focus, when something goes wrong, is on fixing deficiencies and addressing what has gone wrong. It is very seldom there will be a punitive outcome for the service provider.”
However, for the public to have faith in that kind of system, they need to see their complaints will make a difference, that their concerns will be resolved appropriately, where necessary, and that there is improvement to care, Lamb says.
A good apology
Offering an apology where deficiencies have been established is an important part of good practice, and can provide the acknowledgment and individual resolution a complainant may be looking for, Lamb says.
An apology can be just as important as receiving an explanation of what happened and an assurance that the necessary steps have been taken to correct the matter and improve care, she says.
Open discussion about complaints is also critical to promoting a culture that encourages organisations to learn from mistakes. “Complaints are so rare that they need to be valued,” she says.
In a recent change, the Aged Care Commissioner was granted determinative powers as part of the Living Longer Living Better reforms to strengthen public confidence in the complaints review process.
Since 1 August 2013, the Commissioner has been able to direct the Aged Care Complaints Scheme to re-examine a complaint and to take particular matters into account.
Previously the Commissioner could only recommend a new resolution process be undertaken if she found fault with the scheme’s decision, drawing criticisms from some in the sector that the Commissioner was a “toothless tiger”.
As a result of the changes, the Department of Social Services must now also provide its draft findings to the Commissioner following a new process, and take into account any further comments she makes. If the Commissioner is unhappy with the final outcome, she can submit a report to the minister.
Since her new powers came into effect, Lamb says she has been satisfied with the way in which the scheme has responded to the directions from her office and its reconsideration of complaints.
As a result of her powers, she says action has been taken to improve aged care services and providers have been encouraged to apologise where it is due.
Last financial year, Lamb directed the scheme to re-examine 11 complaints, which represented 48 per cent of appeals to her office since 1 August 2013. In four of the 11 cases, the Commissioner’s direction resulted in the aged care service having to apologise and acknowledge failings to the care recipient.
Lamb says her new powers are rare and significant for a Commissioner.
“To have the power to be able to direct the Department of Social Services … is quite significant and perhaps addresses the concerns that people may have about the degree to which there is independence and oversight over what happens in the complaints scheme.”
Lamb says any complaints scheme will never get it right all the time and having an independent commissioner examine and direct the scheme to revisit a complaint, where appropriate, will make a difference to outcomes and improve confidence in the system.
While the legislative change to her role is important, she says that in practice her recommendations to the department have been followed in close to 100 per cent of cases.
Lamb’s experience is a significant improvement from past years when the 2009 Walton Review reported that in 2007-08 the department disagreed with approximately 12 per cent of the Commissioner’s recommendations and 10 per cent of recommendations in 2008-09. The inaugural Aged Care Commissioner Rhonda Parker told Professor Merrilyn Walton during the review that her capacity to effect change and drive quality was limited and her recommendations to improve the scheme’s processes were not well received.
An independent scheme
When I ask for her views on a key recommendation of the Walton Review – the structural separation of aged care complaints from the department – Lamb acknowledges there are benefits and disadvantages in both models. However, she says demand for change may have receded somewhat since the height of the Walton Review.
“I’m not convinced at the moment there is a huge groundswell of concern about the need for there to be further change to the Aged Care Complaints Scheme,” she says. “I know there is, and continues to be, some concern from consumers around the scheme and the extent to which it meets their expectations but I’m not convinced that that is absolutely to do with the fact that it is based in the department.
“I have noted since the complaints scheme changed to a resolution-based model rather than an investigation-based one that service providers are certainly not coming to my office and complaining about the scheme. In fact, they have just about disappeared.”
This silence from providers is noteworthy and suggests a level of acceptance or contentment by service providers with the scheme, she says.
Having the complaints body inside the department also allows for compliance action to be taken easily where complaints have highlighted risks that require urgent action by the regulator, she says.
Following the shift from the Complaints Investigation Scheme to local resolution in 2011, Lamb has also observed an overall and sustained drop in the number of providers and consumers making an appeal to the Commissioner’s office.
To further improve complaints handling and public confidence in her oversight role, Lamb has also instigated her own initiatives.
In 2013, she requested that the scheme provide a twice-yearly update on its progress in implementing her recommendations to its processes. This system of follow-up has since been introduced for recommendations to the Quality Agency.
In the first year of the initiative, the Commissioner found that while action on many recommendations was underway, most had yet to be completed by the scheme. In the 2013-14 financial year the Commissioner reported timelier implementation of her recommendations.
The intersection between complaints and accreditation is also on Lamb’s agenda.
Following concerns raised by complaints to her office and in the media, Lamb introduced an initiative in May 2014 to examine the referral of information that may raise systemic issues from the complaints scheme to the Quality Agency.
* * * * *
Rae Lamb on:
The influence of her journalism background: “It has given me a pretty general view of the world, and as a health correspondent a strong understanding of the consumer point of view. Journalists learn to look at things from all sides and understand the need for accuracy and impartiality. That has helped a lot in this role. Also, most journalists are generalists rather than experts and have to learn to quickly identify the real issues and come up to speed on complex matters.”
Her watchdog function: “I don’t have particular concerns around my independence. I feel I am providing independent oversight and people can have confidence that I am outside the department. I’m appointed by the minister and I certainly cast an independent eye over complaints to me about what the department has been doing. It is extremely rare for someone in a position like mine to have the ability to direct the department to do something and I can do that.”
Approaching complaints: “There are three things that service providers need to think about – resolution, protection and learning. Start thinking about what it will take to resolve this complaint and settle the concerns for the person involved. You also need to think about from the protection point of view; does this complaint highlight any risks or safety issues that need to be addressed straight away, and making sure opportunities to improve care highlighted from the complaint are identified and acted on. I also urge providers to be aware there may be a power imbalance and consumers should be encouraged to use advocacy services for support.”