Reclamos por atención en salud: experiencia en un centro privado / Analysis of healthcare claims received at an audit unit of a clinical hospital

ABSTRACT

Background: The resolution of claims at healthcare institutions is an important issue for administrators. Aim: To analyze the causes of healthcare-related claims in a private, clinical health center. Material and Methods: All claims processed at the audit unit of a clinical hospital between 2016 and 2019 were analyzed. Results: In the study period, 602 complaints were recorded, representing a rate of one claim for every 1,000 services provided. The two main causes of complaints were sub-standard interaction with the doctor such as communication or lack of empathy, corresponding to 21% of cases, and complaints related to care costs, quotes, and insurance coverage (21%). The highest number of complaints originated in emergency care, but the highest rate by number of healthcare services provided occurred in hospitalization in the Mental Health and the Adult Critical Care units. Roughly, 75% of the complaints were settled with a phone call to the patient, which allowed to explain what happened and to apologize accordingly. In 21% of the cases, one or more meetings were held with the patient, a family member, or his/her legal representative to settle an agreement. In 3.5% of cases a mediation process through an independent third party was required. Only 1% of the claims resulted in a legal action. Conclusions: The importance of cultivating an adequate physician-patient relationship for the prevention of complaints and eventual litigations associated with the provision of healthcare services, is emphasized. Quality control policies and processes within healthcare organizations should be strengthened.