When patients need to complain

Healthcare facilities usually have avenues in place for patients to submit their grievances. (This image is human-created, AI-aided)

There has been much public discussion about patients’ grievances with healthcare.

Such grievances may be regarding clinical or non-clinical matters.

The former includes standards of care, doctor(s) and/or nurse(s) conduct and attitude, and communication.

The latter includes approvals by insurance companies/third party administrators (TPAs), billing procedures and administrative deficiencies.

This column seeks to inform the reader of the patient grievance mechanisms currently in place in Malaysia.

Private clinics and hospitals

Private clinics and hospitals are registered or licensed under the Private Health Care Facilities and Services Act (PHFSA), which requires every facility to have a grievance mechanism for patients.

The grievance procedure is spelt out in Regulations 27 (clinics) and 40 (hospitals) of the PHFSA.

The procedures for clinics and hospitals are similar, with specific timeframes for action by the facility, i.e.:

• A complaint is submitted orally or in writing to any member of staff of a clinic, or any health professional or patient relations officer (PRO) of a hospital.
• The recipient of the complaint has to refer it to the person in charge (PIC) of the clinic or the PRO of the hospital by the next working day.
• The PRO has three days to resolve the complaint, failing which it has to be forwarded to the licensee or PIC of the hospital.
• An investigation will be undertaken and a written reply containing the results of the investigation will be furnished to the complainant within 14 working days for clinics or 10 days for hospitals.
• If the complainant is dissatisfied with the reply, they may refer the matter, in writing, to the Health director-general (DG) who will institute an investigation and notify the complainant of the results of the investigation.
• The DG shall inform the complainant and the clinic or hospital in writing of their findings or any recommendations they may have based on their findings.

Sometimes, the patient or a relative may be invited to a meeting with the clinic or hospital where the grievance can be voiced out.

An explanation is usually provided to questions asked.

The patient may be allowed to take written notes of the meeting.

Sometimes, minutes of the meeting will be given to the patient.

As there is no specific expressed provision, the penalty, upon conviction, for contravention of the provisions in the PHFSA on the patient grievance mechanism is the general penalty, i.e.:

• Natural person: A fine not exceeding RM10,000 or imprisonment not exceeding three months, or both.
• Body corporate: A fine not exceeding RM30,000.
• Person responsible for the body corporate, every partner and/or office bearers of a society: A fine not exceeding RM10,000 or imprisonment not exceeding three months, or both.

In addition, there are penalties for continuing offence(s).

Health Ministry facilities

Unlike private clinics and hospitals, the Health Ministry (MOH) has no grievance procedure specified in law.

However, the grievance procedure is typically as follows:

• A complaint is made directly to the healthcare facility or through MOH’s Sistem Pengurusan Aduan Awam (SisPAA).

   

  Apart from complaints, appreciation, inquiries and suggestions can be made on the website.

• An Internal Inquiry will usually be conducted within 30 days of the date of the complaint.

   

  The complainant will be interviewed by the Internal Inquiry committee.

• The Internal Inquiry committee will then inform the complainant of its findings and conclusion.
• If the complainant makes known their dissatisfaction with the outcome of the investigation, an Independent Inquiry, which will not usually involve the complainant, will be undertaken.
• The Independent Inquiry committee will inform the complainant of its findings and conclusion.
• If there is a finding of negligence and the complainant has issued a demand for compensation, an ex-gratia meeting may be held in which the complainant has to attend and to either accept or reject any offer for compensation.

The timeframe for resolving complaints varies, depending on the nature and severity of the complaint.

University hospitals and clinics

University hospitals and clinics are under the jurisdiction of the Higher Education Ministry.

According to section 24B of the University and University Colleges Act, every employee, including healthcare professionals, practising in ­university healthcare facilities are deemed public officers.

Although there are no specified grievance procedures, it is safe to state that university hospitals and clinics do have their grievance mechanisms and that they are not substantially different from the private and MOH settings.

A patient may make a complaint directly to the university healthcare facility.

There have been patients who have been invited to attend grievance meetings at these facilities.

Malaysian Medical Council

The Malaysian Medical Council (MMC) registers doctors and exercises disciplinary jurisdiction over them.

Complaints or information about the (un)professional conduct of doctors can be made to the MMC here.

The Council will then look into the matter.

However, it is not ordinarily concerned with alleged medical negligence unless there is an ethics aspect to the complaint, e.g. a doctor does not attend to an emergency of a patient that the doctor has just operated on.

After the inquiry, the Council makes a finding as to whether the doctor has breached its Code of Professional Conduct, guidelines or directives.

The punishments that the MMC can mete out include reprimand, suspension, deregistration, imposing conditions on the doctor’s practice, or rehabilitative measures.

The doctor has the right to appeal any order made by the MMC in court.

Managed care organisations/TPAs

There have been many complaints about interference with the medical management of patients by managed care organisations (MCOs) or TPAs.

An online portal reported that in a recent survey of MCO/TPA practices involving 855 specialists in private hospitals, nearly 99% perceived interference with clinical decisions and 99% reported that patients encountered health insurance problems in the past year.

The delays, denials and revocations have led to referrals to public hospitals and angst among patients.

It is pertinent to note that section 83 of the PHFSA prohibits any contract with a MCO/TPA that interferes with the medical management of a patient and/or a change in the role of the Medical (and Dental) Advisory Committee and/or contravenes the code of ethics of any professional regulatory body.

The penalties for such offences, upon conviction, include:

• Licensee or holder of a certificate of registration who is the sole proprietor: A fine not exceeding RM100,000 or imprisonment not exceeding two years, or both.
• Licensee or a holder of a certificate of registration that is a body corporate, partnership or society: A fine not exceeding RM300,000.
• MCO: A fine not exceeding RM500,000.
• Person responsible for the body corporate, every partner, office bearers of a society and/or the MCO: A fine not exceeding RM100,000 or imprisonment not exceeding two years, or both.

Complaints can be made here or to the Health DG at [e-mail].

Health insurance

Members of the Financial Markets Ombudsman Service (FMOS) include licensed banks, insurance companies (life and general) and takaful operators.

The FMOS provides recourse for those whose claims for health insurance have been rejected here.

Its website mentions a case study where the FMOS decided in favour of a complainant whose medical and hospitalisation reimbursement claim was rejected by the insurer on the basis of an exclusion clause in the policy.

Going forward

There have been many media statements about unregulated private hospital bills, increased health insurance premiums and the practices of insurance, MCO and TPA companies.

There have also been calls for the establishment of an independent private healthcare commission.

It is very surprising, to say the least, that there has been no mention about the existing patients’ grievance mechanisms.

Surely, knee-jerk reactions cannot guide public policy.

Prior to establishing another regulator, it would be useful if an independent assessment be made of the existing patients’ grievance mechanisms, public awareness of these mechanisms, their usage and whether they are fit for purpose.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.