Unfortunately, you don’t have to be a doctor for very long to be involved in a patient complaint. It happens to every one of us and it can be a cause of great stress and self-doubt when a patient is unhappy with the care we have given.
Here I want to outline the most common cause of patient complaints and secondly how we resolve them so that everyone can move on positively. I’ll also touch on how adverse outcomes might be investigated and dealt with.
When you are in the midst of an adverse patient outcome or complaint, it can be difficult to see that it is rarely about you as doctor, or individual. None of us come to work with the intention of making people upset or causing harm. When it happens, I can't emphasise enough the importance of a supportive mentor or senior colleague to help keep things in perspective and guide you through the process. How we deal with complaints and adverse events is intended to be aligned with strong support for our staff; this is not a witch-hunt or a punitive process.
If you don't feel your immediate senior is being supportive or offering the help you need to negotiate this, find someone who can help you get access to the assistance you need. If you are a junior doctor, then it might be your College training supervisor if you are on a specialist pathway. The Director of Clinical Training is another resource for anyone who isn't sure where to turn for help.
Why patients complain
The most common cause of patient complaints are:
- Treatment - 35%
- Communication - 22%
- Access to services - 15%
- Issues with the hospital environment - 13%
- Medication - 5%
Treatment complaints are usually about perceived inadequate, incorrect or poorly coordinated treatment. Poor staff attitude or communication skills are a consistent complaint that occurs across all areas of the hospital. Patients not only expect to get the right care at the right time, they expect staff who take care of them to be kind, empathic, open and honest – qualities that we would all look for in professionals caring for ourselves or our own family.
Access complaints relate to waiting times and service availability. The single most common issue with the hospital environment is about car parking and medication complaints relate to prescription errors, dispensing and drug administration on the ward.
Healthcare will always have adverse outcomes – we can never remove the risk completely. In practice, half of these are not preventable and very few are due to negligence.
The aviation industry has reduced avoidable errors, by:
- Expecting human error
- Challenging the blame & shame culture
- Identify the ultimate cause of errors to prevent recurrence
- Normalise respectful assertiveness among staff
- Hold people accountable for non-compliance with policy, not for errors
- Openly share, analyse and learn from incidents and near misses
Many of these are appropriate to health care and have been adopted into our risk management processes.
Once you know someone has had an adverse outcome or is unhappy with an aspect of their care, there is often an opportunity for front-line doctors to ‘nip it in the bud’ and resolve the patient dissatisfaction.
There is a natural tendency to not want to be around people who are unhappy, especially if we have been involved in what might have been the cause of their pain – such as a complication of our care.
It is important to know that this is the time your patient needs you to be there. When an adverse event occurs, we need to increase the attention they receive. Firstly, to ensure that care from here onwards is optimal and secondly, so they know that you acknowledge what has happened.
This isn’t easy, but it’s good medicine and will result in fewer formal complaints and litigation. Always involve seniors if you have a sense that someone is unhappy and document everything well. Litigation is fortunately rare, but defending yourself is much easier when you have documented your practice and any steps to remedy the situation.
If your patient has any degree of cognitive impairment, is elderly or has heavy family involvement, help your team arrange a family meeting to ensure everyone understands what has happened and what is being done from here. They can nominate a representative to receive regular updates on progress. Beware the unhappy daughter!
It’s important to enter adverse events into the local risk management database, e.g. RiskMan or PRIME. This will allow the clinical governance team of the hospital to seek patterns of adverse outcomes with an underlying cause that might not be obvious to individual teams. It will also ensure that the appropriate response is made and staff are supported.
Where a major event has taken place, teams should come together for debriefing. This should be facilitated by a senior clinician, and is about running through what happened, people’s experiences since the event, emotional and personal responses they may wish to share and have acknowledged. The initial debrief isn’t about an investigation or chain of events – it’s about supporting staff and making sure they have access to the resources they need.
When formal complaints occur, the department Director will go through the following:
- If it can be solved quickly with a telephone call and immediate rectification, that is often the easiest way forward – e.g. complaints about waiting list or if the patient is seeking a second clinical opinion.
- Where possible, we contact the patient as soon as possible so they know it is being dealt with. Even if it’s something complex that will eventually be a face-to-face discussion, the sooner the patient is contacted, understands that it is being looked into and given an idea of a time line, the better. This can also give us a chance to understand which area of the complaint is particularly important to the patient and what they’re actually looking for (acknowledgment, apology, rectification, compensation, legal redress, etc.). You cannot over-communicate when dealing with a complainant and often a swift initial contact defuses anger.
- Understand what happened: review the case notes. Talk with, and support, those involved to consider whether the complaint has highlighted an area where we might consider changing practice to prevent recurrence. Is the complaint unreasonable or does the complainant have unrealistic expectations?
- Decide on how to proceed. Is a telephone call/explanation enough? Should the patient come back to see their clinical team to resolve misunderstanding? Is this a clinical incident that needs entry into RiskMan/PRIME reporting system? Do we need to do an Open Disclosure and if so, who needs to be there?
- Written response or face-to-face? A written response is often appropriate, but for complex cases, a letter cannot convey the nuances of judgments that were made without being long and cumbersome. In these situations, a face-to-face debrief is better. Often this involves both medical and nursing teams.
Some people want a letter in response to their complaint: see this post for full details of an approach to this.
A face-to-face meeting after a complaint might be a conversation to hear their complaint and to outline how the we are going to respond to the issues they have brought up.
Formal Open Disclosure is a framework that describes how clinicians communicate with and support patients, families and carers, who have experienced actual harm during health care. The 8 guiding principles of OD are as follows:
- Open and timely communication
- Acknowledgement that an adverse event has occurred
- Apology or expression of regret
- Supporting, and meeting the needs and expectations of patients, their family and carers
- Supporting, and meeting the needs and expectations of those providing health care
- Integrated clinical risk management and systems improvement
- Good governance – system accountability at a senior level to ensure appropriate changes are implemented.
Litigation is a stressful occurrence for all involved. It is hard on health care staff and locks patients and their family in the angry phase of a grief reaction. Why do they do it? The reasons aren’t as simple as the obvious answer of ‘for the money’. They do it:
- To find out what happened and why. It can be a sign that they aren’t getting their concerns addressed elsewhere.
- Acknowledgement, acceptance of responsibility and an apology
- To enforce accountability
- To correct deficient standards of care
- Financial compensation – for accrued and future costs
There is good evidence that high quality communication with our patients from the outset – including formal open disclosure if appropriate – will reduce the risk of litigation.
Hospital investigation process
Briefly, adverse events that are entered into a risk management system are allocated a Severity Assessment Code or Incident Severity Rating (SAC/ISR 1-3). Minor adverse events will be investigated and dealt with by the department Director or Nurse Unit Manager through clinical review and actioned as above. More serious adverse events are formally investigated by clinicians and Patient Safety teams that use formal review processes such as Root Cause Analysis (RCA). This is a non-punitive way to assess if there are any system issues responsible, and how similar events can be avoided in the future.
So what can I do to avoid all this?
How do we as individual doctors reduce the risk of patient complaints and adverse outcomes? Going back to the list of reasons that I started with:
1. Provide high quality care: involve the right doctors (and the correct seniority), consider the appropriate differentials, refer to other teams as needed, order the indicated tests, follow up the results and ensure they are acted upon. Attention to detail. Communicate well with GP’s.
2. High quality communication skills and emapthy – patients are looking for your humanity, a genuine connection that shows they are more than a hospital number, test result or the NSTEMI in bed 14. Put simply, treat them how you would like yourself or your mother or sister to be treated. As an individual with individual concerns to be addressed. The health care environment is often a disempowering or even frightening place for people - help them navigate it with compassion.
3. Facilitate the access to the services they need. It can be challenging to look at the bigger picture of a complex patient’s health needs in a system that's organised around organ-based specialisation. Acknowledge this and try to take it into account when planning your patient’s care.
Finally, some health care challenges seem to be absolutely insurmountable. Could anyone possibly fix the problem of car parking?