Learning from medical errors to prevent their recurrence is an important component of any healthcare system's quality and safety improvement functions. Traditionally, this been achieved principally from review of adverse clinical outcomes. The opportunity to learn systematically and in a system manner from patient complaints and litigation has been less well harnessed. Herein we describe the pathways and processes for both patient complaints and medicolegal claims in Victoria, and Australia more broadly, and assess the potential for these to be used for system improvement. We conclude that both patient complaints and medicolegal claims could afford the potential to additionally inform and direct safety and quality improvement. At present neither patient complaints nor medicolegal claims are used systematically to improve patient safety. We identify how this may be done, particularly through sharing findings across agencies. Patient complaints and medicolegal claims are accepted parts of the healthcare industry. However, using these in a shared and collated manner as part of an improvement agenda has not been widely considered or proposed. This paper provides a summary of the patient complaint and medicolegal landscape in public hospital system in Australia broadly, and Victoria more specifically, identifying the agencies involved and the opportunities for sharing learnings. The paper draws on existing literature and experiences from both Australia and elsewhere to propose a framework whereby complaints and claims data could be shared systematically and strategically to reduce future harm and improve patient care. We offer an approach for practitioners, healthcare managers and policy makers in all Australian jurisdictions to design and implement a statewide capacity to share patient complaints and medicolegal claims as an additional component of system quality and safety.

Background: The Healthcare Complaints Analysis Tool (HCAT) is a coding taxonomy developed to interrogate patient complaints for quality and safety improvement lessons. The reliability of the tool has been tested in whole-of-system and whole-of-service settings. We sought to assess whether the taxonomy is functional at the level of a single hospital department. Objectives: To demonstrate the feasibility of applying HCAT in the setting of a large maternity department with a view to using it to inform quality and safety improvement opportunities. Methods: All 200 de-identified complaints made between 1 April 2011 and 30 April 2016 to a multi-site maternity service were collated. Each complaint entry included a summary of complaint content, complaint report date, complaint closure date and an incident severity rating (ISR). HCAT was applied to the analysis of complaints using a previously validated content analysis framework. A coding flowchart was developed to aid classification. Results: The 200 complaints involved 567 issues, an average of 2.8 issues per complaint. The most common issues were rude behaviour (n ¼ 46), poor communication (n ¼ 38), complaints relating to the quality of medical care (n ¼ 36), nursing care (n ¼ 35), surgical/medical complications (n ¼ 28) and complaints relating to the attitude of staff members (n ¼ 23). Complaints in the clinical domain made up the greatest proportion of both severe (ISR 1-66.7%) and moderate (ISR 2-64.5%) incidents. Conclusions: Using a reliable taxonomy, we were able to successfully interrogate patient complaints, identifying quality improvement targets within a single maternity service. The taxonomy appears suitable for adoption and application across health jurisdictions.

Background: Traditionally, managing patient complaints and medicolegal claims has been largely a reactive process. However, attention has recently turned to systematically learning from complaints and litigation to prevent recurrence. Within a high-volume maternity service, we explored whether developing predictive tools for patient complaints and litigation to support proactive management was feasible. Objectives: To develop and assess two screening tools to predict the likelihood of (i) patient complaints and/or (ii) medicolegal claims arising from maternity care and to assess practitioner awareness of patient risk factors. Methods: Births between 1 April 2011 and 30 April 2016 at a university hospital maternity service in Melbourne, Australia were considered. Univariate binary logistic regression was performed to identify the variables contributing to complaints and claims. Backwards-stepwise logistic regression was applied to develop each screening tool. Clinicians completed a survey to assess awareness of identified risk factors. Results: In the study period, there were 41,443 births, 173 complaints and 19 claims. The complaints tool had only fair predictive capacity (receiver operating characteristic 0.72, p < 0.001) and the claims tool failed. Neither approach afforded sufficient discrimination to be useful in routine predictive modelling. One hundred and one practitioners completed the survey (response rate 15.7%). Practitioners were better at recognising risk factors for legal claims than for patient complaints. Conclusion: Whilst new risk factors for patient complaints and medicolegal claims were identified, we were unable to develop a screening tool that was sufficiently discriminatory to be useful in routine predictive triaging. However, increasing practitioner awareness of key risk factors may afford opportunities to improve care quality.

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Objective To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement.Design Qualitative descriptive study.Setting Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia.Population All obstetric claims and incident notifications occurring within the date range were included for analysis.Methods De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified.Main outcome measures Rate of claims and notifications, relative frequency of issues, a revised taxonomy.Results A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented.Conclusions Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement.

ObjectivesTo determine whether sharing of routinely collected health service performance data could have predicted a critical safety failure at an Australian maternity service.DesignObservational quantitative descriptive study.SettingA public hospital maternity service in Victoria, Australia.Data sourcesA public health service; the Victorian state health quality and safety office—Safer Care Victoria; the Health Complaints Commission; Victorian Managed Insurance Authority; Consultative Council on Obstetric and Paediatric Mortality and Morbidity; Paediatric Infant Perinatal Emergency Retrieval; Australian Health Practitioner Regulation Agency.Main outcome measuresNumbers and rates for events (activity, deaths, complaints, litigation, practitioner notifications). Correlation coefficients.ResultsBetween 2000 and 2014 annual birth numbers at the index hospital more than doubled with no change in bed capacity, to be significantly busier than similar services as determined using an independent samples t-test (p<0.001). There were 36 newborn deaths, 11 of which were considered avoidable. Pearson correlations revealed a weak but significant relationship between number of births per birth suite room birth and perinatal mortality (r2=0.18, p=0.003). Independent samples t-tests demonstrated that the rates of emergency neonatal and perinatal transfer were both significantly lower than similar services (both p<0.001). Direct-to-service patient complaints increased ahead of recognised excess perinatal mortality.ConclusionWhile clinical activity data and direct-to-service patient complaints appear to offer promise as potential predictors of health service stress, complaints to regulators and medicolegal activity are less promising as predictors of system failure. Significant changes to how all data are handled would be required to progress such an approach to predicting health service failure.

Background: To capture the views and experiences of clinical staff following the implementation of a new clinical guideline aimed at reducing stillbirth at term in South Asian women, to identify barriers to implementation. Methods: Cross sectional survey of clinical staff providing maternity care, including midwives, obstetricians and shared-care general practitioner at a Victorian metropolitan university-affiliated teaching hospital caring for about 10,000 women per year at three separate hospital sites. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Two open-ended questions provided opportunities to express concerns and offer suggestions for improvement. Results: 120 staff completed the survey, the majority (n=89, 74%) of which were midwives. The majority of staff thought the guideline was clear with respect to the rationale (n=95, 79%,), the criteria for whom they applied (83%, n=99), and the procedures and instructions within the guideline were clear (74%, n=89). However, staff reported an increase in workload following the implementation of the guideline (72%, n=86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for staff and women, increased workload and insufficient resources, and patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified. Conclusion: This assessment of staff views and experiences of a new clinical practice guideline has identified key barriers to and opportunities for improving implementation. It has also highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse (CALD) women.

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