Introduction
The health care industry is increasingly focused on customer service, one aspect of which is dealing with complaints. Patient/family dissatisfaction often leads to complaints against emergency medical services (EMS) systems/providers.Reference Colwell, Pons and Pi1-Reference Kuisma, Määttä, Hakala, Sivula and Nousila-Wiik4 The purpose of this study was to assess the prevalence and nature of complaints against prehospital providers in a rural EMS system.
Methods
This retrospective study evaluated logged complaints from May 28, 1999 through September 26, 2008. All complaints registered were closed prior to the beginning of the study. All complaints were investigated by a single trained staff member of the regional EMS office, who interviewed witnesses and reviewed statements and other documentation related to the complaints. There was no standardized complaint submission form. Each complaint was classified as operational, clinical, educational, or customer service-related. In addition, each complaint was classified as founded, unfounded, or insufficient data. Data elements were recorded in a Microsoft Access database (Microsoft Corporation, Redmond, Washington USA) as the elements became available. Criteria for outcomes were based on EMS regional council assessment and affirmation by the Department of Health, Bureau of EMS. Information was collected on the providers who were the subject of complaints, including whether they were paid or volunteer, and what level of training they had attained.
The rural EMS system studied encompasses seven counties, and has a total population of 639,641. County populations ranged from 4,946 to 280, 843. Fifty-seven percent of the region has <100 persons per square mile, 13% has 100-500 persons per square mile, 16% has 501-1,000 persons per square mile, and 14% has >1,000 persons per square mile. The region has both basic and advanced life support providers including 332 first responders, 2,916 EMT-basics, 264 active EMT-paramedics, 18 prehospital registered nurses, and 16 prehospital physicians. The regions’ EMS agencies are comprised of 50 basic life support and 19 advanced life support agencies.
All data were de-identified to assure Health Insurance Portability and Accountability Act (HIPAA) compliance. The UPMC Hamot Institutional Review Board and the Pennsylvania Department of Health Bureau of EMS approvals were obtained.
Results
There were 110 total complaints logged. Thirty complaints were from various agencies, 26 from EMS providers on duty, 15 from family/friends, 12 from EMS providers’ service, 11 from other emergency services, eight from hospital staff, four from training institutions, two from bystanders, and one complaint was self-reported (for not reporting service unavailable for emergency response as per regional protocols). The complaints consisted of 66 allegations against paid providers and 37 against volunteer providers, with the remainder against either the EMS service or a training institute. There were 49 “repeat” complaints against providers who had previously had complaints made against them. Outcomes of investigations validated the complaints in 46 cases, 40 were unfounded, 14 inconclusive, and three were valid with additional infractions noted. In seven cases, the original complaint was unfounded but other infractions were noted. No complaints were related to emergency vehicle collisions. Health care providers filing complaints were all registered nurses. No physicians made any complaints to the regional EMS council.
There were 66 allegations against paid providers and 37 against volunteers, with the remainder against either the EMS agency or a training institute. There were 26 complaints against advanced providers and 33 against basic providers. Of the complaints, 74 were classified as operational including, but not limited to allegations of response or driving issues such as
– self-dispatching;
– driving at excessive speeds;
– inappropriate use of light/siren;
– not completing patient care reports;
– not submitting patient care reports to the regional EMS council;
– functioning after EMS certification had expired;
– failing to report out of service;
– not communicating with the public safety answering point;
– failure to report criminal histories;
– not responding to calls;
– not calling the closest air ambulance;
– confidentiality issues.
Twenty-seven complaints were classified as clinical, involving:
• releasing a minor;
• not transporting a patient with a specific condition (closed head injury in which the patient refused care/transport with subsequent deterioration and complaint made by the family);
• abandonment;
• exceeding scope of practice;
• protocol compliance.
Six were classified as related to education, involving:
• problems with training institutes;
• continuing education sponsors or students.
Three complaints were classified as customer service, involving:
• EMS provider fell asleep during transport, due to illness (one case)
• poor equipment (“dirty” per complainants, two cases).
Discussion
None of the investigated complaints violated the state EMS Act. There are several possibilities for unfounded complaints, none of which would be violations of the state EMS act or treatment protocols. Miscommunication between the EMS provider and the patient/family may result in a complaint. Lack of medical knowledge by a lay patient/family member may also contribute to complaint initiation, such as a registered nurse not trained in prehospital care. This has been addressed at the state level by the Department of Health Bureau of EMS. Emergency Medical Services councils have been given the latitude to explain what their authority is or to explain probable cause, which has reduced the number of registered complaints which would have been determined to be unfounded.
This study appears to be the first to evaluate complaints in a rural EMS system. The fact that this system includes multiple types of EMS agencies, utilizing both paid and volunteer providers in a variety of settings, makes it different from urban systems investigated in previous studies. Curka et al reported the top three causes of complaints in Houston's EMS system were: (1) rude/unprofessional behavior; (2) failure to transport; and (3) problems with medical treatment. In comparison to the Houston study, where complaints were essentially customer-service oriented, the current study predominately showed operational complaints. In contrast, the Houston study found that the top three complaints were failure to provide the patients with information about their injury or illness, failure to explain what the EMS providers were doing, and the perception of extended response times. The most common source of complaints was patients and their families. Only six (1.6%) were related to response time.Reference Parry and Hewage5 There were no complaints related to emergency vehicle collisions. These results should cause EMS agency medical directors to look closely at all complaints, given the substantial number which were either unfounded or had insufficient information to arrive at a conclusion. It is important to note that some complaints may result in changes to formal policy.Reference Montini, Noble and Stelfox6 Just as in the emergency department, patients in the prehospital setting are considered customers; Kuisma et al have demonstrated that customer satisfaction may be accomplished in this setting.Reference Kuisma, Määttä, Hakala, Sivula and Nousila-Wiik4 The evaluation of complaints may provide an opportunity to improve service delivery and patient safety.Reference Griffey and Bohan7
Limitations
Complaints were limited to those brought to the regional level. Many complaints fail to reach the regional level. It is possible that some complainants may not be aware of the components of the EMS system, such as the regional EMS council. It is possible that some complaints may have been directed to medical command facilities and channeled to the service medical director. These complaints may have been addressed through education or other means. Lastly, it is possible that complaints may have been made due to conflicts between EMS agencies and subsequently directed to individual EMS agency administrative staff for corrective action, rather than to the regional EMS council.
Conclusion
The number of complaints averaged 12 per year in this study population. Forty (43%) of the complaints were unfounded. There were 49 “repeat” complaints against providers who had previously had complaints made against them. Types of complaints included operational (74), clinical (27), educational (6), and customer services (3). The types of complaints in this rural EMS system appear to differ from those reported in urban EMS systems.
