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Patient Ombudsman
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Patient Ombudsman 2021/22

Making connections

Supporting a better health system for everyone

Patient Ombudsman’s message

Resilience, reassurance and change. Those are the three driving factors behind the work we do.

Read Craig Thompson’s message

What Patient Ombudsman does

We champion fairness for everyone, and work to ensure more positive health care experiences for all Ontarians.

Read our vision and mission

Evolution of the Office

The Changing Nature of Complaints

Patient Ombudsman’s sixth year of operation was a time of growth, change and new challenges.

As we grow and evolve as an office, Patient Ombudsman has started to collect a body of work – including data, reports, and recommendations – of patient and caregiver experiences that allows us to better shine a light on issues that continue to challenge and strain our health care system.

Complaints that included concerns related to COVID-19

Bar graph showing complaints by month from March 2020 to March 2022. Complaints related to COVID are highlighted. COVID complaints peaked in June 2020 and March 2021 but still occur in the last month of the graph, May 2022.

The COVID-19 pandemic had a dramatic effect on both the volume and focus of the complaints Patient Ombudsman received in 2020/21. While the number of new complaints remained high in 2021/22 – and continues to grow – the nature of the complaints changed. Patient Ombudsman continued to receive complaints about challenges with restrictions on visiting in hospitals and long-term care homes, vaccination, testing and infection control but in lower volumes.

The pandemic, however, continued to be an important factor, exposing and aggravating long-standing stresses on the health care system that affect patients’ and caregivers’ experiences.

Special reports

In addition to our complaints work, our second and third special COVID-19 reports were released in August and December 2021, respectively, and provided important context to patient, caregiver, and long-term care home residents’ experiences due to the pandemic.

Putting patient and resident experiences at the centre of these reports helped highlight the ways in which the pandemic affected care and increased loneliness, depression, and decline. In those reports, our office made recommendations regarding the essential role of caregivers, the need for clear communication in a crisis, necessary supports for the health care workforce, and considerations that health organizations should make when implementing restrictions to visitation.

Patient Ombudsman also finalized an investigation into fair billing practices, which included recommendations to protect patients from financial abuse.

Spotlight issues

Lessons We Can Learn

Patient Ombudsman monitors the complaints we receive to identify emerging issues. Our “Spotlight” stories shine a light on the kinds of cases we receive, how we achieve resolutions, and where health sector organizations can look for opportunities to improve patient and caregiver experiences.

Spotlight 1/4: Hospital security protocols

Patient Ombudsman has seen an increase in the number of complaints describing negative interactions between health care providers, patients and their caregivers.

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Spotlight 2/4: Discharging vulnerable patients safely

Complaints about premature or uncoordinated discharges from hospital to home or other care settings have consistently been in the top three complaints to Patient Ombudsman since the office opened.

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A silhouetted figure looks to the distance, highlighted by the backdrop of a puzzle piece shape

Spotlight 3/4: Care in emergency departments

In addition to frustration with wait times, complaints about emergency departments touched on poor communication, being prematurely discharged, and lack of caring, sensitivity, courtesy and respect.

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A silhouetted figure highlighted by the backdrop of a puzzle piece shape clasps their head in their hands and looks down in distress and turmoil

Spotlight 4/4: Resolving complaints by rebuilding relationships

Patient Ombudsman’s resolution process varies based on the nature of the complaint, the patient or caregiver’s expectations, and the willingness of all parties to engage actively in the resolution process.

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Follow-up on issues spotlighted in past reports

Illustration of a person in silhouette gazing downwards, surrounded by shapes and lines creating a sense of sadness or distress.

Complaints about Sexual Assaults

In its last annual report, Patient Ombudsman highlighted a cluster of complaints involving reports of sexual assault and insensitive care for patients with past sexual trauma.

Where this issue is today
Illustration of a pair of glasses in silhouette

Complaints about lost or damaged personal property

In 2018, Patient Ombudsman reported on an investigation into a complaint about an elderly patient whose dentures were lost while they were a patient in a public hospital.

Where this issue is today

Complaint Details

Complaints: By the Numbers

Patient Ombudsman received 3,306 complaints in 2021/22, including 2,456 received through the call centre and 850 written complaints. Six per cent of the complaints described concerns with more than one health care organization or provider, and complaints frequently involved multiple issues. Some people submitted multiple complaints over the year, including 184 who initially contacted the call centre and later followed up with a written complaint.

3,306 total complaints to Patient Ombudsman in 2021/22

Pie graph shows distribution of complaints by type of Health Sector Organization. 61% are for hospitals, 10% are for long-term care homes, 7% are for home and community care, and 22% are for other health care.

Complaints by Health Sector 2021/22

As shown in this chart, most of the complaints (61%) involved concerns about patients’ and caregivers’ experiences with public hospitals. Since significantly more people receive care from hospitals than from the other health sector organizations, this is not surprising nor is it a reflection on the relative quality of care in hospitals.

Pie graph highlights the 61% of complaints that are for Hospitals.

Hospitals: 61% of complaints

Top complaints
  • # 1 Quality of care : 17%
  • # 2 Diagnosis/Treatment : 13%
  • # 3 Discharge/Transfer/Transition : 11%
  • # 4 Visitation : 10%
  • # 5 Access or delay : 8%
Complaints about sensitivity, caring, courtesy and respect increased by 43% over 2020/21.

For hospital-based complaints: patients and caregivers most frequently complained about overall quality of care, diagnosis and treatment. In 2021/22, there was a 43% increase in the number of patients and caregivers who reported that they were treated with a lack of sensitivity, caring, courtesy or respect at hospitals, particularly in emergency departments.

Pie graph highlights the 10% of complaints that are for long-term care homes

Long-term care homes: 10% of complaints

Top complaints
  • # 1 Quality of care : 24%
  • # 2 Visitation : 19%
  • # 3 Communication : 12%
  • # 4 Personal security/safety : 6%
  • # 5 Finance/cost : 6%

As in past years, overall quality of care was the most frequent concern raised about long-term care homes. Complaints about visitor restrictions continued through 2021/22 despite provincial policy guidance that encouraged homes to consider residents’ emotional well-being and the negative impact of social isolation.

Pie graph highlights the 7% of complaints that are for home and community care.

Home and Community Care: 7% of complaints

Top complaints
  • # 1 Access or delay : 25%
  • # 2 Staffing/resources : 20%
  • # 3 Coordination/continuity of care : 16%
  • # 4 Quality of care : 12%
  • # 5 Communication : 10%
19% of complaints about home and community care were about long-term care home placement processes, which is managed by Home and Community Care Support Services.

Complaints about home and community care most frequently involved concerns about delays and access, specifically that the level of service provided was insufficient. Patients and caregivers often noted that home and community care was unable to fulfill all the approved hours of care, visits were missed, or there were frequent changes in care providers.

Complaint Decisions

Patient Ombudsman closed 3,291 complaints in 2021/22, including 206 complaints that were open at the end of 2020/21. At the end of the fiscal year, 379 complaints remained open, some pending assignment because of the rapid growth in complaints over the past two years. The outcomes achieved in the written complaints resolved in 2021/22 are described below. A single complaint can have multiple outcomes.

How the 3,291 complaints were closed

Flow chart shows how 3,291 complaints were closed. Some complaints were referred to other oversight bodies or received help in reaching certain contacts, while 329 of the closed complaints were ready for our involvement. The outcomes achieved among the 329 complaints include 127 health sector organizations met expectations, 53 provided service, 49 acknowledged a negative experience, 29 provided an apology, 34 acted on Patient Ombudsman’s suggestions, 29 provided staff education/training, 18 revised policies/procedures, and 5 waived or adjusted fees. (A single complaint may have multiple outcomes).
Flow chart shows how 3,291 complaints were closed. Some complaints were referred to other oversight bodies or received help in reaching certain contacts, while 329 of the closed complaints were ready for our involvement.
The outcomes achieved among the 329 complaints ready for our involvement include 127 health sector organizations met expectations, 53 provided service, 49 acknowledged a negative experience, 29 provided an apology, 34 acted on Patient Ombudsman’s suggestions, 29 provided staff education/training, 18 revised policies/procedures, and 5 waived or adjusted fees. (A single complaint may have multiple outcomes).

Summary

From Pressure to Perspective

As shown throughout this report, the COVID-19 pandemic continues to place stresses on the health care system and has widened the cracks exposing long-standing vulnerabilities.

Rather than a rapid return to “normal,” it’s likely that these stresses will continue for some time while efforts are made to address human resource shortages, wait times, access issues and backlogs in surgeries and other procedures. Perhaps of most concern is the evidence of fatigue and frustration that has increased reports of violence against health care providers and insensitive care for patients and caregivers. As noted in previous reports, the importance of listening and clear, sensitive communication cannot be underestimated.

Patient Ombudsman continues to advance a formal investigation into the impact of COVID-19 on the care and health care experiences of long-term care residents, as well as completing new investigations based on complex, unresolved complaints.

In March 2022, the Government of Ontario passed a regulation under the Excellent Care for All Act, 2010 that expands the definition of home and community care services within Patient Ombudsman’s jurisdiction to include Ontario Health Teams and other service providers that offer professional home care services, personal support services and related homemaking. The new regulation came into force on September 1, 2022. Patient Ombudsman has been preparing for this expansion of its mandate and communicating the changes to patients, caregivers and health sector organizations.

Looking ahead, Patient Ombudsman is also planning to complete a refresh of its strategic plan and continue progress on reducing delays in our service. Patient Ombudsman is also planning to expand outreach and engagement with Indigenous and other communities that experience discrimination and challenges accessing health care.