• Walang Nahanap Na Mga Resulta

Alvin B. Caballes, Ivy D. Patdu and Joel U. Macalino

College of Medicine

University of the Philippines Manila

This study evaluated complaints against health personnel filed with the Professional Regulation Commission (PRC), in order to describe the complaint patterns; identify providers’ lapses in professionalism;

compare the administrative outcomes between patient care-related and other cases; and infer the critical areas in health personnel regulation.

Data was collected from a retrospective records review of complaints involving health professionals filed with the PRC from January 2013 to December 2016. Case summaries were written based on the submitted complaints and other documents. The anonymous summaries of all the cases were reviewed by the authors, and attribution of errors and causes were made. Specialists were consulted to review selected cases.

Only 358 case files were retrieved, nearly equally divided between those concerning patient care and those which did not. Among the former, deaths occurred in 30% of cases. Physicians, dentists, nurses and midwives had the most complaints. Clinical management lapses were the most commonly identified errors for professionals. For some, the adverse events were perceived as due to system deficiencies and even the patients’ severity of illness. Most of the reviewed cases which had corresponding PRC Board decisions were either dismissed or settled. There were more and harsher penalties among the non-patient care cases.

Keywords: professionalism, health personnel, patient safety, quality of health care, government regulation

INTRODUCTION

P

rofessionalism, as it applies to health personnel, has been variably defined as consistency with aspired attributes or codes of conduct as well as the attainment of specified competencies.1-4 Due to increasing complexities in the health field, the conferment of professional status has shifted beyond peer recognition to official certification by publicly designated organizations.5-7 Lapses in professionalism among health personnel can diminish the health care experience and even harm patients. Complaints, aside from other means for redress, may then be brought against health professionals by the offended parties. Being a crystallization of patients’ appreciation of apparent service provision oversights, such complaints have been shown to provide important insights on the interrelated concerns of professionalism, patient safety, and quality of care.8-10 Among other concerns, a comprehensive review of these complaints can define the extent by which professional standards of health practitioners are met and how these affect the provision of health services. The nature and handling of these complaints vary across settings.

This is apparent even among Asian countries, given the differences in the prevailing legal or ethical norms, socioeconomic milieu, and even cultural preferences.11-15

In Southeast Asia, the Philippines is noteworthy for its health workforce.

It has the largest number of physicians, nurses and midwives, sizable even on a per capita basis, among the countries in the region.16 From a global standpoint, the Philippines is a dominant supplier of health professionals, particularly nurses, for many receiving countries.17 The Philippines has also been described as having a health regulatory system that has a middle-of-the-road maturity, when compared to other Asia-Pacific countries.18 The statutory regulation of health workers is centered on the Professional Regulation Commission (PRC).

It is an autonomous government agency that is authorized to set training standards and grant licenses to qualified professionals, including health care providers.19 The licenses are prerequisites for local clinical practice and even for foreign work placements. Private professional organizations, notably those established by medical specialties, have independent self-regulation arrangements for their members. The Department of Health (DOH) sets manpower standards for hospitals and clinics and administers personnel

under its direct employ but does not have any general health professional regulatory responsibility.

The PRC has several constituent Boards which oversee respective professions, including the following health-related occupations: Dentistry, Medical Technology, Medicine, Midwifery, Nursing, Nutrition and Dietetics, Optometry, Pharmacy, Physical and Occupational Therapy, Psychology, Radiologic and X-Ray Technology, and Respiratory Therapy. As the agency also has quasi-judicial functions, its Boards receive, process, and adjudge complaints from the public against health personnel who are either in the process of seeking licenses or are already registered professionals, as well as non-qualified persons who illegally render health services. Complaints lodged with PRC against professionals may relate to adverse patient events or incidents involving supposed inappropriate or immoral behavior in non-health care situations. In the Philippines, complaints concerning the former may be legally considered as negligence cases. These may be pursued with the PRC as administrative cases, or, separately, for civil damages or criminal penalties in regular courts.20 The PRC only metes out administrative penalties, with license revocation being the harshest. Still, with proceedings in regular courts deemed to be more expensive and protracted, the PRC would be the most convenient route for filing charges against health professionals. Nonetheless, the PRC has procedures similar to those of regular courts.21 If no conciliation is achieved, hearings proceed and are conducted by a Board member of the same profession as the implicated providers. Complainants and respondents need not be represented by legal counsel although they have a choice to be represented by one.

There is no national registry for ongoing legal cases in regular courts, including those concerning medical negligence or malpractice. There is likewise no central database for complaints against health workers filed in individual health facilities or other venues. The PRC is therefore the default national repository of complaints against licensed professionals and thus provides a unique yet untapped source for obtaining data and insights on what patients or other parties consider to be lapses in professionalism among health workers and determine the implications of these on overall health service quality and safety.

A study was therefore undertaken to assess the status of professionalism and the related concerns of patient safety and quality of care in the country

from the inverse context—from patients’ complaints with the PRC that are supposed to document lack or absence of professionalism. This report has the following specific objectives: 1) describe the patterns of PRC complaints against health personnel, with emphasis on those directly related to patient care; 2) identify the correspondingly common or important lapses in professionalism among the involved health care providers or professionals;

3) compare the administrative outcomes between cases which were directly related to patient care and those which were not, and; 4) infer the critical areas in the regulation of health professionals in the Philippines.

METHODS

The study involved a retrospective records review, specifically of the files of complaints against health professionals kept at the PRC. The research protocol was developed in coordination with the PRC, primarily to work out confidentiality and security arrangements, and was reviewed and subsequently approved by the research ethics board of the authors’ university. Only those cases implicating health professionals that were accepted by the legal unit at the main PRC office from 1 January 2013 to 31 December 2016, and which could be made available by the same office during the 2 May to 29 September 2017 review period, were included. A supposedly small number of cases which were with the regional PRC offices were excluded from the study.

Using the PRC electronic master list of received complaints as reference, the corresponding case files were requested from the legal staff. Based on the written complaints as well as any supporting documents (including those submitted by the respondents), the research assistants wrote case summaries.

For patient care-related cases, additional details were obtained and entered in registry forms, with items loosely based on a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) framework.22 There were several encoding rules which were adopted, such as case registration being based on individual events (rather than, for example, multiple case entries for different providers but involving the same incident); limiting the listed facility to that which was primarily related to the event (and not the subsequent referral sites); and denoting a single count for providers under the same profession or physician specialization (thus, if several physicians and nurses were implicated in a particular event, only one count would be tallied for each provider type).

The case files were reviewed and the registry forms were accomplished only at a designated secure room within the PRC premises.

The registry data, expunged of all personal and institutional identifying information, were encoded in a secure online spreadsheet. Microsoft Excel and Epi Info 7 software were used to generate frequency distributions and summary figures. The case entries were individually reviewed, details were verified, and the corresponding causes for the patient-related events were deliberated on by the investigators. Cases requiring more nuanced assessments were referred to clinical specialists. Investigators and specialists were inhibited from reviewing any cases which they had been directly or implicitly involved in. Though the cases were evaluated objectively, there was partiality for the patient’s perspective in contradictory instances.

RESULTS

Based on the PRC master list, there were 597 filed complaints that implicated health professionals from 2013 to 2016. Of these, only 60%, or 358 cases, could be made available for review. The highest yield was in 2015, at 100%, and the lowest was in 2016, with only 35% of the complaints retrieved. There was nearly an equal number of the compiled cases which were directly concerned with patient care events and those which were not (see Figure 1).

Figure 1.Collection of cases from complaints filed with the PRC against health care providers

Patient Care Events

Most of the complaints which concerned patient care involved adults, with a slight preponderance of females. A large majority of the patients required therapeutic interventions, which also included those for cosmetic and rejuvenation purposes (see Table 1). Deaths as well as resultant moderate or severe physical incapacitation were reported in the majority of the patient care-related complaints. Psychological harm was less often alluded to (see Table 2). A few of the unfortunate outcomes occurred under seemingly disconcerting circumstances. These included the following illustrative cases:

maternal deaths from uterine rupture or massive post-partum haemorrhage;

unattended recovery room mortalities; post-procedural blindness; severe reactions to non-conventional therapies; and offensive sexual behavior.

Most of the incidents occurred in hospitals, particularly in tertiary centers.

Table 1

Distribution of allegedly harmed patients, by selected characteristics, PRC Health Board complaints, 2013-2016

Category Group Frequency %

Age Group (n=180) Minor (0-17 years old) 33 18%

Adult (18-59 years old) 108 60%

Elderly (≥ 60 years old) 35 19%

Not Specified 4 2%

Gender (n=180) Female 93 52%

Male 84 47%

Not Specified 3 2%

Care Requirement (n=197)* Therapeutic 163 91%

Diagnostic 16 9%

Cosmetic 14 8%

Rehabilitative 2 1%

Not specified 2 1%

* category assignments are non-exclusive, with some cases having more than one care requirement

Table 2

Distribution of patient care-related events, by alleged harm, PRC Health Board complaints, 2013-2016

Alleged Harm Frequency %

Physical Harm

(n=180) Death of a complainant’s family member 58 32.22

Moderate to Severe, Permanent 35 19.44

Moderate to Severe, Temporary 26 14.44

Moderate to Severe, Unknown Duration 18 10.00

Minimal, Temporary 12 6.67

Not Specified 6 3.33

Minimal, Permanent 3 1.67

Minimal, Unknown Duration 2 1.11

None 20 11.11

Psychological Harm

(n=180) Present, Unknown Duration 41 22.78

Present, Temporary 5 2.78

Present, Permanent 4 2.22

Not Applicable or Not Specified 130 72.22

Dental and lying-in clinics were also relatively common sites for adverse events. There were, in cumulative terms, an ample number of cases involving smaller facilities, such as stem cell clinics. Patients’ homes, with health workers in attendance, were the sites of untoward events in some cases (see Table 3).

Table 3

Distribution of patient care-related events, by reported location, PRC Health Board complaints, 2013-2016

Health Care institution Frequency %

Hospital (n=128) Level III 54 30.00

Level II 35 19.44

Level I 37 20.56

Unspecified hospital 2 1.11

Other Health Service

Facility (n=42) Dental clinic 17 9.44

Lying-in clinic 10 5.56

Cosmetic surgery/ Dermatology clinic 3 1.67

Mall clinic 3 1.67

Private clinic 3 1.67

Eye clinic 2 1.11

Stem cell clinic 2 1.11

Pharmacy 1 0.56

Work place clinic 1 0.56

Other Venues (n=7) Home 5 2.78

Hospice 1 0.56

Medical Mission 1 0.56

Not specified 3 1.67

Physicians were the object of complaints for most patient care cases.

Dentists, nurses, and midwives accounted for smaller but still substantial number of incidents. There were only very few complaints against other health professionals (see Table 4). The respondents were specifically identified as students or trainees in eleven cases. A handful of complaints also referred to physicians in their capacity as facility administrators. There was, in accordance with the JCAHO framework, an extensive listing of apparent errors by health professionals. A summary of the leading types of errors committed by selected professionals is provided in Table 5. While intervention-related problems were more common among physicians and dentists, communication errors were foremost for nurses and midwives.

Table 4

Distribution of patient care-related events, by type of allegedly involved health professional, PRC Health Board complaints, 2013-2016*

Health Professional Frequency %

Physician 143 72.59

Surgery 31

Obstetrics Gynecology 26

Internal Medicine 21

Pediatrics 15

Anesthesiology 11

Ophthalmology 7

Orthopedics 6

Radiology 5

Emergency Medicine 4

Primary Care 3

Otorhinolaryngology 3

Dermatology 2

Pathology 2

Psychiatry 2

Family Medicine 1

Neurology 1

Rehabilitation Medicine 1

Not Specified 2

Dentist 19 9.64

Nurse 17 8.63

Midwife 10 5.08

Radiation Technologist 2 1.02

Pharmacist 2 1.02

Medical Technologist 2 1.02

Physical Therapist 2 1.02

Optometrist 0 0.00

Total 197 100.00

* more than one type of professional in some cases Table 5

Percentage frequency distribution of patient care-related events, by leading inferred error types and selected professions, PRC Health Boards, 2013- 2016

Physician Dentist Nurse Mid-

wife Error Type % Freq Error

Type % Freq Error Type %

Freq Error

Type %

Freq Correct

Intervention, with Complication

12%

Correct Intervention,

Incorrectly Performed

15%

Inappropriate Disrespectful or Comments

15% Questionable Advise or Interpretation 15%

Questionable Advise or

Interpretation 9% Questionable Advise or

Interpretation 10% Questionable Advise or Interpretation 10%

Correct Intervention,

with Complication

12%

Questionable Tracking or Follow-Up;

Omission of Essential Procedure

6%*

Questionable Disclosure;

Correct Intervention,

with Complication

10%* Questionable Tracking or

Follow-Up 10%

Inappropriate Disrespectful or Comments;

Insufficient or Questionable

Use of Resources;

Inaccurate Diagnosis

9%*

* percentage value applies equally to the error types listed for the third tier of the category

Even as the actual complaints were against professionals, the investigators figured that many of the adverse events were attributable, concurrently or independently, to systems deficiencies (see Table 6).

Foremost among these were the apparent absence or inadequacy of clinical or administrative protocols in the health facilities. Instances occured wherein health staff were deemed to be indifferent to patients’ needs, epitomizing attitudinal deficiencies from defective organizational cultures. Physical inadequacies, such as the lack of equipment in smaller facilities, were also found to be contributory to adverse patient events. There were a few cases wherein external factors, such as facility incapacitation due to typhoons, were also at play.

Table 6

Distribution of patient care-related events, by attributed causes, PRC Health Boards, 2013-2016*

Attributed

Cause Frequency % for Group Systems Organizational

Service Protocols/ Processes 71 39.01 Administrative Procedures 41 22.53

Organizational Culture 40 21.98

Technical

Facility 27 14.84

External 3 1.65

Human Health

Professional 171 74.35

Rule-based 109

Knowledge-based 71

Skill-based 59

Patient 48 20.87

Other Person 11 4.78

* more than one cause attributed in some cases

Nevertheless, specific persons were identified by the investigators as either being primarily responsible for or contributory to the supposed incidents. The actions of the practitioners accounted for the vast majority of these cases. Their apparent errors were further attributed to non-observance or lapses related to the applicable rules, knowledge, or skills. Patients themselves accounted for the next tier. In the respective cases, the investigators surmised that the severity of the patients’ medical conditions was a primary factor that had caused the reported adverse outcome. A few of the supposedly untoward cases were deemed to be contentious mostly due to the divergent perceptions or expectations of the patient’s relatives and other parties who considered the actions of the health professionals as inappropriate or detrimental, but these claims could not be substantiated by the investigators.

Non-Patient Care Events

For the 178 cases which were not directly related to patient care, only the alleged offenses of the professionals were tallied. As classified in general terms, and ranked in decreasing frequency of cases, the leading infractions were as follows: marital infidelity (29%), swindling (19%), misrepresentation/

falsification (15%), inter-professional conflict (7%), and sexual harassment/

violence (4%). Among the complaints were those lodged by the Philippine Health Insurance Corporation (PhilHealth), the country’s social health insurance agency, and pertained mostly to supposedly bogus procedures.

Regulatory Outcomes

Most of the cases which were included in this study were ostensibly still undergoing hearings, or had not yet otherwise been decided upon by the

respective PRC Boards (see Table 7). A majority of the resolved cases did not beget any regulatory sanction, having been dismissed by the Boards or because the contending parties had apparently reached amicable settlements.

In only a few cases were penalties meted out against health workers. There were fewer providers penalized, and the disciplinary actions were also much less severe among the adjudged patient-related cases.

Table 7

Distribution of patient care-related events, by outcomes and main event types, PRC Health Boards, 2013-2016

Case Status

Patient care events

Non-patient care events

n % n %

Ongoing 91 51% 83 47%

Dismissed/

Settled 86 48% 74 42%

Penalty for

Professional Reprimand 3 2% 1 1%

Suspension 6 3%

Revocation

of license 6 3%

Other/

Unspecified 8 4%

DISCUSSION

A premise of the study is that the PRC provides a comprehensive patient complaints resource, providing a bellwether of health care professionalism, safety, and quality. But while the PRC may be the least expensive route, the process can still be financially burdensome particularly for poor families.

This would have deterred them from filing complaints, especially for less serious incidents. Some events may, for various reasons, including non- recognition, have not been pursued at all. Studies in other Asian countries have shown how cultural preferences and social gradients deterred complaints from filing, a phenomenon which could just as well apply to the Philippine context.23-25 Many untoward events could have also been

addressed in other venues, such as within the concerned hospitals. Civil and criminal suits could have also been filed in regular courts, even among those who had already filed complaints with the PRC. There may have been divergent case details and outcomes for these venues, but these were beyond the study’s scope. These issues could have contributed to the total number of PRC-tendered complaints, being low relative to the figures reported for other countries, considering the overall count of the country’s health professionals.11,15, 26

The study had additional intrinsic limitations. A good number of complaints could not be provided by the PRC, affecting the quantity and quality of the available data. For the complaints which were included, the findings and inferences were gleaned from abstracted files. Relevant but undocumented details would have therefore been missed. The practitioners cited in the complaints were aggregated and not individually counted, leading to lower tallies of implicated professionals. In compliance with privacy and confidentiality restrictions, not only were the identities of specific persons or institutions withheld, but relationships between surmised lapses and Board decisions could also not be delved into. These logistical and methodological factors would have affected the study’s findings, leading to, among others, differences in attributions of accountability and due sanctions with those decided upon by PRC Boards.

The large number of mortalities, and severe morbidities, that were collated among the care-related events are consistent with a “tip of the iceberg” complaints-filing bias. It would have been expected that the more serious cases were to have been complained about. It was in anticipation of this occurring that the JCAHO framework, with its added focus on the safety and quality dimensions of health services, was utilized in data collection and processing.22 The identified errors and their inferred causes were thus not only attributed to individual professionals, but also to systems lapses that undermined the quality and safety of patient care.8,9,26 Some adjustments in the framework were adopted, such as additional error categories (e.g., inappropriate statements), to also reflect local quality of care concerns. The non-patient care cases were not segregated to the same extent as, while providers’ professionalism may have been questioned, the events would not have as direct a bearing on patient safety and quality of care. These would,