We live in a world that increasingly encourages the provision of feedback about services and experiences. From Tripadvisor to Google reviews, providing feedback has become easier and more common. In this environment it is perhaps unsurprising that patients increasingly want to provide feedback on the quality of healthcare they receive. Even if this feedback comes in the form of a complaint, having a system to accept and deal with such feedback can be beneficial for patients and practices.
Data from the Australian Health Practitioner Regulation Agency (Ahpra) indicate patient complaints to regulators are increasing.1 These complaints are broad in scope and encompass both clinical and non-clinical elements, suggesting they can arise from any point in a patient’s journey through the practice.
Correspondence from the regulator might be the first indication for a doctor that a patient had any concerns. However, research indicates that relatively few patients who later go on to make a complaint felt able to raise concerns or dissatisfaction with their care at the time, with some waiting years to complain.2
There are multiple benefits in knowing about complaints, and hopefully managing them at an earlier stage within the practice. By understanding these potential benefits and exploring barriers to patients speaking up, practices have an opportunity to implement strategies to encourage patients to express dissatisfaction and to respond effectively.
Potential advantages from directly addressing complaints
Beyond the professional obligation under the Medical Board of Australia’s good medical practice code of conduct to enable patients to complain about their care,3 there are some important benefits in hearing patients’ perspectives on and concerns about their care. Practices are expected to have processes for managing complaints as part of The Royal Australian College of General Practitioners (RACGP) Standards for general practices.4
Studies suggest a majority of complaints can be fully resolved at the point of service,5,6 and there is growing recognition that patient complaints provide an important insight into potential patient safety risks.7–12
Addressing complaints can avoid escalation
Research indicates patient complaints often stem from poor communication or lack of information.5,13
For example, Avant’s analysis of complaints involving general practitioners found that 23% were related to practitioner behaviours such as perceived rudeness or failure to communicate information.14 The most common issues in complaints and claims against practices involved staff behaviours, including issues such as patient communication, long waiting times or difficulty accessing care.15
Complaints can often be resolved directly by the healthcare practitioner or team simply by acknowledging the patient’s dissatisfaction and providing an explanation or apology.13
However, if patients feel unable to raise concerns or have them addressed at the time, some report finding themselves resorting to a ‘trial-and-error’ approach, working through the system and speaking to anyone who will listen.2 They might go on to complain elsewhere, including to a complaints body, the media or online.2,16
Potential to identify safety and quality concerns
Patient complaints data can help expose patterns and identify risks to care, as well as providing insights into potential patient safety ‘hotspots’ and ‘blind spots’, including systemic issues and areas that are traditionally hard to monitor.8–12 Complaints about issues such as waiting times might also provide opportunities to review procedures or offer more information to pre-empt concerns.
Patients are the constant in an increasingly fragmented care journey and can see issues that healthcare providers might be unaware of (eg failures in handover of care).12 Their complaints can point to failures to listen or take patient concerns seriously, missed warning signals or clinical omissions that led to significant patient harm.11,17
Improved communication and restoring trust
Effective doctor–patient communication has been shown to correlate with improved health outcomes.18,19 Poor communication might make patients more likely to complain if they experience a complication or if their expectations of treatment are not met.20,21
Strong open communication between doctor and patient requires patients being able to voice concerns,22 and to have those concerns addressed with respect.23
Complaints about manner or communication can often be resolved by an apology or explanation.13 There is evidence that the doctor–patient relationship can also be restored even after an error, adverse event or unpleasant experience.24 In these cases patients look for their doctor to show empathy, take their concerns seriously, accept responsibility for errors, provide reassurance and plan for their ongoing treatment.24
Practice staff also play a crucial role in communicating with patients and supporting the doctor–patient relationship. Practice staff often represent or communicate on behalf of the doctor, and their actions can be interpreted as those of the doctor. If practice staff are not involved in the planning and execution of customer service, their behaviours might lead to patient grievances against doctors.25
What gets in the way: Barriers to direct complaints
Patients might feel unable or unwilling to speak up at the time if they feel that something is wrong or unsatisfactory.2 UK research has suggested that fewer than half of those experiencing poor care report it.16
It is important for practices to understand the barriers preventing patients from directly raising their concerns. These barriers include unclear complaint pathways, a power imbalance between the patient and doctor and fear of damaging the treating relationship. Once these barriers have been identified, practices can implement strategies to encourage patients to express feedback in a more direct and timely manner.
Patients might lack confidence that their concerns will be addressed.16,23 They often report difficulty knowing who to raise concerns with, or finding someone to speak to.5
Feeling anxious or vulnerable is also likely to be an inhibitor. Patients might be concerned about being seen as a ‘complainer’ or ‘troublemaker’ and that this will affect their ongoing or future care,2,5,23 particularly if they feel their choice of healthcare provider is limited.8
There is limited evidence indicating any characteristics that make a patient more likely to complain.26 However, some studies indicate patients experiencing disadvantage might feel even less able to complain.5,9,23
Strategies for practices to improve feedback
Complaints are rarely welcome in a busy practice. They are often dealt with on a case-by-case basis,9 and the priority for staff can be to remove the disruption as quickly as possible, rather than exploring the patient’s underlying concern. It can be easy to assume the problem is with the patient themselves or what might appear to be unreasonable expectations.
Practices can adopt a number of strategies to help them better understand patient concerns and use feedback, including complaints.
Have a clear and accessible feedback process
Having a simple and clear complaints process and communicating that to patients through multiple communication channels can help ensure patients bring their concerns directly to the practice.9 The process could be outlined on the practice website, or notices could be placed in the waiting room encouraging patient feedback.
Everyone in the practice needs to know the process and their role in it, and how to respond if they are the patient’s first point of contact.9
An effective complaints process can help prevent complaints becoming more time-consuming and tying up multiple staff in the practice. It is also likely to avoid patients becoming more frustrated and might keep them from taking complaints elsewhere.
Welcome patient feedback
Patients generally say they want to be treated with respect and understanding if they make a complaint.27
They are more likely to share their experiences if they feel welcome and encouraged to do so, particularly if their care provider encourages them to raise any concerns.23
Create an effective resolution mechanism
Studies consistently point to patient lack of trust in the complaints mechanism as a reason for failing to provide feedback.9,23
Patients who complain generally want reassurance their concerns have been heard and understood. They want an apology for any harm or hurt suffered and an explanation of what went wrong.9,27
To encourage patients to invest their time and energy providing feedback, practices need to have an effective process to track and investigate complaints and communicate clearly and promptly about the process and outcomes. Practices should always adopt culturally sensitive approaches when dealing with complaints.
It can be helpful to involve an appropriate senior staff member to help with the resolution of a complaint.
Use complaints to improve care
Patients and families who complain often say they are motivated by a desire to see change as a result of their experience.5,9,24 Most patients want to know something has been done to address their concerns.27
It might not always be possible to make the changes a patient is requesting. Although it might appear that some complaints are unreasonable or unrealistic, it is important to consider them objectively and consider whether any change is possible. Even seemingly trivial or vexatious complaints should be taken seriously and responded to, and they might provide learnings to improve care.
Complaints might involve several elements, often including poor communication.5 Improving communication with patients, about processes, delays or adverse events, might be enough to address their concerns and resolve the complaint.
Regularly reviewing complaints collectively (eg at a monthly practice meeting) might uncover trends or systems issues that require further attention.
Support staff during and after a complaint process
Using patient feedback to improve patient care might require a cultural shift towards a ‘just culture’ where everyone, including patients, is encouraged to speak up if they see an issue and where those making mistakes are supported rather than blamed.27
There is considerable evidence of the devastating impact a complaint or claim can have on doctors, as well as the protective value of a supportive practice culture.28
Responding to complaints might be difficult for many staff in the practice. Training staff in what to say and how to respond effectively to a dissatisfied patient can help them feel prepared and reduce their stress, as well as reducing the likelihood the complaint will escalate. It is also important to have clear pathways for providing ongoing care for patients who do make a complaint.29 Ideally, practices should try to resolve the complaint so that the therapeutic relationship is preserved, and preferably improved. If, however, the relationship has broken down to the extent that it is no longer in the patient’s best interests for the patient to be seen at the practice, it might be appropriate to end the relationship.
Focusing on structural issues rather than individual blame can be a helpful approach.9 Staff members who are the subject of a complaint, as well as those who need to hear the patient’s distress or respond to their anger and those who need to try to resolve the complaint might also experience distress and need support.
Conclusion
Although the word ‘complaint’ might raise feelings of dread, and it might never really be possible to welcome complaints, there are some important benefits for practices if they can encourage patients to express their dissatisfaction and respond to it appropriately.
Listening to patient complaints and viewing them as a learning opportunity rather than a nuisance can assist in improving patient satisfaction, maintaining the therapeutic relationship where possible and appropriate, and reduce the risk of complaints escalating to a formal process. If there is uncertainty about how to manage a complaint, or if a complaint escalates to a regulator or complaints body, doctors are encouraged to seek the assistance of their medical indemnity provider.
It is important the entire practice team perceives complaints and feedback as valuable opportunities for improvement and that they are trained in the process of handling feedback and complaints.
Key points
- There is an increasing need for practices to have clear systems in place to manage and address patient concerns.
- There is evidence that having systems to deal with complaints is in the best interest of patients, doctors and practices.
- Managing patients’ feedback within a practice can help prevent complaints escalating to regulators.
- Patient feedback might also provide an opportunity to review and improve practice performance.
- Effective strategies to manage patient complaints include process improvements, cultural changes and providing support for those involved in any complaint process.