What to Do if You Have a Concern About the Quality of Care from a California Doctor

Advice and resources for dealing with quality concerns

For many of us, our doctor is one of the most important people in our lives. We trust him or her to help keep us well or care for us when we're sick. There are about 100,000 actively practicing doctors in California, and most provide high-quality care to their patients. There are times, however, when people have concerns about the quality of care they or a loved one receive from a doctor. If this happens to you, this tip sheet can help. It gives you:

• Practical advice about what to do and who to talk with, including phone numbers and addresses
• Links to resources that can help

This tip sheet explains steps you can take in your doctor's office to deal with your concerns about quality. It tells you how to contact places that regulate or oversee doctors. You can also consider filing a lawsuit, but that is not the focus of this tip sheet.

Is it worth it to pursue a concern about quality?

For many of us, it's not easy to act on a concern about the quality of doctor care that we or loved ones receive. It's even harder if we try to talk with a doctor or their staff about our concerns, but don't feel we're getting anywhere. The process can be stressful, frustrating and take a long time. And in the end, it's possible that others may not agree with the way we see the situation.

Is it worth the time and energy to take action about the quality of a doctor? Only you or your loved one can decide. In making the decision, think about the continued harm that might take place if you do nothing. And think about how the actions you take might lead to better care for future patients and their families.

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What is quality of care?

Quality health care is doing the right thing, at the right time, in the right way, for the right person and with the best possible results. Generally, care delivered by doctors and other health professionals must meet a “standard of care.” That standard is the expected level and type of care provided by the average competent health professional in a given situation. A standard of care is based on good scientific studies or agreement amongst experts.

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What can you expect as a patient regarding the quality of doctor care?

To become a doctor, students have to go through a long training process. This includes hands-on learning in hospitals and other health settings. When they finish training, doctors promise to "do no harm" to their patients. As professionals, doctors voluntarily follow codes of ethics that lay out the way they are to behave. For example, the American Medical Association Code of Ethics notes some patient rights in the patient-physician relationship:

• The patient has the right to receive information from physicians and to discuss the benefits, risks and costs of treatment options.
• The patient has the right to make decisions regarding health care recommended by his or her physician and may refuse any recommended treatment.
• The patient has the right to courtesy, respect, dignity, and timely attention to his or her needs.

The American Board of Internal Medicine Foundation and other partners has published a new physician code or charter. The Foundation works with an organization that certifies physicians caring for adults. This document specifically addresses quality and competence in what is expected of doctors:

• Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care.
• Physicians must be dedicated to continuous improvement in the quality of health care. This commitment means not only keeping their skills up-to-date, but also working with other professionals to reduce medical error, increase patient safety, keep an eye on costs and make sure patients are getting the best possible care.
• Physicians are required to provide care that is based on the wise and cost-effective management of limited resources. This includes avoiding unneeded tests and procedures that expose patients to avoidable harm and expense.

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What types of quality concerns might you experience?

Health care quality concerns could arise for a variety of reasons while you are under a doctor's care. Some concerns are the result of a specific action a doctor or staff member takes (or doesn't take) as they treat you or a family member. This includes misdiagnosing a condition or prescribing a drug that you shouldn't take.

Other quality concerns result from how well the doctor's staff work together to safely care for you—for example, making sure that the right medical chart goes with the right patient or that patient messages are delivered on time.

Some of these actions in a doctor's office may not affect your health at all; some may cause inconvenience or pain; others may cause serious harm.

The most common complaints received by organizations that oversee or regulate doctors nationwide are:

• Over-prescribing or prescribing the wrong medication
• Failure to diagnose a medical problem that is found later
• Misreading X-rays to identify a medical problem
• Failure to get back to a patient with medical results in a timely manner, which leads to harm to that patient
• Failure to provide appropriate care after a surgical procedure

What should concern patients the most—and what concerns organizations that oversee doctors—is when there is a pattern of problems with a doctor. If something happens once, it is usually a mistake. If it happens again and again, it may indicate a larger problem of competence or quality that could hurt any patient.

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What steps should you take if you have a concern about quality?

Depending on what kind of problem you have and your relationship with your doctor, you might talk directly to him or her or to another office staff member about your concern. For example, if your concern relates to the way the doctor's office is organized, the doctor and staff may not know how it feels to be a patient in their office. They might be particularly interested if you thought mistakes could result from what you see. Speaking honestly about your concerns gives your doctor or another staff member the opportunity to explain why things happen the way they do. It may also lead to changes in the office.

If your concern is more medical in nature—for example, getting the wrong prescription, the wrong dose, or the wrong referral—you should speak with the doctor directly to correct the problem. Then think about whether this has happened before and be alert to whether it happens again.

If your concern is with a doctor that you've been referred to for specialty care, share your concerns about that physician with your personal doctor. It will help your doctor decide whether to refer other patients to that physician. Or, if your concern is with a doctor you're seeing while in the hospital or another health organization, again, let your personal doctor know. He or she may be able to tell you who in the facility can help you.

If you continue to have concerns about the quality of a doctor and their staff, you have the option to leave the practice and go to another doctor. Remember to check with your health insurance plan to see which doctors work with your plan and which are taking new patients.

You do not need to tell your doctor why you are leaving, but you might consider writing a note with your concerns. The more specific you are, the more he or she might be able to understand your views and possibly take action on them.

If you leave the practice, you should request copies of your medical records to take with you. Under California law, you have the right to view and have a copy of your medical records, though doctors may charge a fee to cover their costs for copying. Your doctor may transfer your records to your new doctor, though they aren't legally required to do so. The Medical Board of California has more information on accessing your medical records:

http://www.mbc.ca.gov/Consumers/Access_Records.aspx

If you feel you should take action to protect yourself and/or other patients from a doctor who you think poses a public safety threat, you can file a complaint with the Medical Board of California. The Board oversees physicians as well as podiatrists, physician assistants, and midwives. Working with the California Office of the Attorney General, the Medical Board ultimately has the power to discipline a doctor—to decide whether and how a doctor can practice medicine in California. It should be noted up front that if your case is pursued by the Medical Board, the process can take a long time, involves many steps and requires a high standard of proof before the Medical Board can take action against a doctor. There were over 7,000 complaints filed during fiscal year 2010-2011 and 317 doctors had some type of action taken against their license.

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Filing the Complaint: The Medical Board of California has a consumer complaint form that you should use to file your complaint. It is available online to print out, fill out and mail in, or you can call the Board and have them mail you a copy: 800-633-2322. You must also complete and sign an authorization to release your medical information so the Board can request your medical records as part of their investigation.

Medical Board of California Complaint Form:

http://www.mbc.ca.gov/forms/07i-61.pdf

Complaint form in Spanish:

http://www.mbc.ca.gov/forms/07i-61_spanish.pdf

 

The information should be sent to:
Medical Board of California
Central Complaint Unit
2005 Evergreen St. Suite 1200
Sacramento, CA 95815

The investigation:  When your complaint is received, a staff member will review it and gather the information needed to review your case—including whether the doctor has a history of issues with his or her license.

If the case doesn't involve medical care—for example, if the doctor won't provide your medical records—the staff person may call the doctor, explain the law and persuade him or her to turn them over to you.

If the complaint involves medical care and treatment and you’ve said that your medical records can be reviewed, the Board will request your records from your doctor’s office. An expert consulting doctor will review your records to see whether the care in question met the “standard of care.” The Board will notify you when your case goes out for review to a medical consultant.

The medical consultant will evaluate whether there’s any evidence in your medical record to indicate:

• Gross negligence — An "extreme" departure from the standard of practice such as failing to do basic diagnostic tests, not recognizing or acting on common symptoms, not using accepted or effective treatments or diagnostic procedures, or not referring a patient to a specialist when appropriate.
• Negligence — A "simple" departure from the standard of practice. One act of simple negligence usually is not enough to take formal action against a doctor's license.
• Repeated Negligent Acts — An initial negligent act followed by a separate and distinct departure from the standard of care.
• Incompetence — A doctor who is unable to recognize and act appropriately on a patient’s symptoms.

If no violation is found, the case will be closed and maintained on file for one year. If a violation is found, but does not warrant action against the doctor's license, the case is closed and maintained on file for 5 years. That means if others complain about this doctor, there will be evidence of your concerns for some period of time. You have the right to appeal the findings only if you have new information that was not previously submitted.

If the medical consultant determines that there is enough evidence of a serious violation to begin a full investigation, the complaint will be forwarded to one of the Board's district offices. It will be assigned to an investigator and prosecutor (a government lawyer) for further investigation. Under the law, all of the Medical Board's investigative files are exempt from public disclosure, so you won't be able to receive a copy of the medical consultant's report.

Next steps: If the investigative office finds evidence of a violation, then the prosecutor files a formal charge or “accusation” against the doctor and a hearing is scheduled. At that point, the doctor and the state may decide to settle the case, subject to review by the Medical Board.

If there is no settlement, the case is heard by an Administrative Law Judge (ALJ) who drafts a proposed decision. That decision is then reviewed by the Medical Board. The Board can adopt the decision of the ALJ, reduce the penalty given to the doctor, or increase the penalty. Penalties range from taking away a doctor's license to practice in the state or putting them on some type of probation (such as random drug screenings or required coursework). Doctors have the ability to appeal and, if they lose their license, can petition to practice again after meeting certain requirements and timelines of the Medical Board. They can also appeal to the California court system.

How long does this process take? There are no specific timelines for how long the Medical Board complaint process takes. Normally, it takes 4-6 weeks to initially review the complaint. A complicated case that goes through the entire disciplinary process can take up to 3 years.

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Can I remain anonymous when I file a complaint? A complaint can be filed anonymously, but the Board has a difficult time investigating such complaints and may not be able to pursue them. If the Board can’t obtain medical records for a specific person, the complaint may not move forward. The Board does accept complaints from individuals who wish to designate themselves as “confidential informants.” In that case a code name can be used which allows investigators to discuss the complaint with the doctor without disclosing the patient’s name. However, if the case goes to a hearing, the confidential informant’s name may become public.

Additional information about the Medical Board of California complaint process: Other information about filing a complaint with the Medical Board of California:

http://www.mbc.ca.gov/Consumers/Complaints/
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Where else can you complain about the quality of a California doctor?

Medicare: If Medicare (the federal health insurance program for people over age 65 or people under 65 who are disabled) pays for the care you're receiving from a doctor, you have an additional place to go with a quality concern. Medicare pays a Quality Improvement Organization (QIO) to take complaints from Medicare patients. Be advised up front, however, that these organizations primarily help doctors improve the care they provide. They do not punish doctors.

In California, the QIO is called Livanta. You can call Livanta at the following number: 877-588-1123

Explain to the person who answers the phone what your concerns are. Depending on the type of problem you are having, they may be able to help you right away. For example, with your permission, they may be able to call the doctor's office to see if they can help solve your problem. In other cases, they may ask you to send your complaint in writing using a complaint form.

After you file a complaint with Livanta and allow release of your medical records, a doctor will review your records. After the review, you will get a letter indicating whether the standard of care was met in your case or not—that is, whether the expected level and type of care was provided.

For more information about the Livanta complaint system and to access an online complaint form: http://www.bfccqioarea5.com/

Other health organizations

Doctors often practice as part of larger organizations such as a medical group, hospital or managed care plan or HMO. Each of these organizations might have a process that patients can use to express concern about the quality of a doctor. Generally, these organizations will review a concern about a particular doctor’s quality through a process called “peer review.” This means that other doctors in the same field review the practices of a doctor in question.

If the health organization confirms that there’s a quality concern with your doctor, they can limit the doctor’s ability to practice in a hospital or HMO. Under certain circumstances, the organization must report its actions to the Medical Board of California. As noted above, that office can then conduct an investigation.

A health organization may also be required to report its actions against a doctor to the federal National Practitioner Data Bank. The Data Bank includes information on doctors who have a record of unprofessional behavior or malpractice. The public does not have access to the Data Bank, though it should be checked by any hospital or health plan in the country where that doctor might try to work.

If you’re a patient of a large medical group: Look on the website of your medical group for any information about voicing a complaint. It might be in a section on "Member Rights," or "Customer Service" or in the "Contact Us" section. You can also ask a staff member if there is a number to call or a process to follow.

Your health insurance plan or HMO: Doctors are usually affiliated with a health insurance plan or HMO. Call your health plan, explain the problem to them and ask whether you can file a complaint about the care provided by a doctor affiliated with their health plan. A list of phone numbers and websites of health plans in California is available at the Department of Managed Care website:

http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_contact.aspx

or you can call the Department of Managed Care’s Help Center:
1-888-466-2219
TDD: 1-877-688-9891

Physician Organizations

The physician's specialty society: A few physician specialty societies (the professional association affiliated with the physician’s type of practice, for example, pediatrics or orthopedics) accept and have a process to review complaints against their members. For example, the American College of Physicians (ACP), an association of internal medicine doctors who generally treat adult patients, has a process for addressing “ethical complaints” against their physician members that come from laypeople. For more information about the ACP process:

http://www.acponline.org/running_practice/ethics/complaints

Local medical societies: In some California counties, local medical societies receive patient complaints and attempt to resolve them by mediating between a doctor and a concerned patient. Call the California Medical Association (CMA)  (916-444-5532) and see if the doctor you’re concerned about is a member and lives in an area where this service is available.  If it is, you’ll be directed to that local medical society for further information.

 

Consumer Organization

The Safe Patient Project (SPP) is a project of Consumers Union (publishers of Consumer Reports magazine) that seeks to eliminate medical harm in the health system.  The Project is collecting stories about patients’ experiences and concerns with their care in hospitals and from physicians across the nation, including California.  While they can't help with your specific complaint, the collective power of stories from patients and families can help pass laws and seek other changes to make the health care system safer.

http://safepatientproject.org/

In a joint effort with the Empowered Patient Coalition, the Safe Patient Project is conducting a survey about medical events from the perspective of the patient. For more information about the survey:

http://empoweredpatientcoalition.org/report-a-medical-event
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Where can you find out information about doctors in California?

Physician License Lookup – A site maintained by the Medical Board of California that tells whether a physician has been disciplined in California or by a Medical Board in another state.  The site also includes some information about malpractice settlements.  Information about complaints against a physician is NOT available.

http://www.mbc.ca.gov/lookup.html

Quality Report Card on Doctors and Medical Groups – A site of the California Office of the Patient Advocate that provides information on whether a medical group's care met national standards in areas such as preventive services and diabetes care.  Includes patients’ ratings of care and service.  The site doesn’t provide information on individual doctors.

http://www.opa.ca.gov/report_card/doctors.aspx

Other useful information:

If you’re concerned about the quality of care in a California hospital, managed care plan or HMO, or nursing home, or the care provided by registered nurses, here’s information about what to do:

What To Do If You Have Concern About Quality of Care from a California Hospital:
http://www.informedpatientinstitute.org/HOSQuality-CA.php

What To Do If You Have Concern About Quality in a California Nursing Home: http://www.informedpatientinstitute.org/NUHQuality-CA.php

Managed Care
California Department of Managed Health Care, Problems and Complaints: http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_default.aspx

Registered Nurses
California Department of Consumer Affairs: http://www.dca.ca.gov/online_services/complaints/complain_rn.shtml

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