Novel patient complaint management strategies can improve care
December 1, 1998
Novel patient complaint management strategies can improve care
Effective complaint management can bolster patient satisfaction and reduce liability risks
The way you manage patient complaints has a major effect on satisfaction and quality of care delivered, says Michelle Regan-Donovan, RN, BSN, CEN, principal of Millennium Strategies, based in Charlottesville, VA and Ambulatory Care Advisory Group, based in Chicago, IL. "Frequently, letters of complaint may be the only way a hospital may identify trends within the ED [emergency department] environment, such as inappropriate treatment, staff attitudes, or turnaround times," she stresses.
All complaints must be taken seriously, emphasizes Joel A. Stettner, MD, FACEP, assistant chairman of the department of emergency medicine at Summit Medical Center in Oakland, CA, and chairman of the emergency medicine group management section of American College of Emergency Physicians (ACEP). "There always will be some frivolous complaints, but you can’t dismiss any complaint as unimportant. Patients will tell lots of people if they are unhappy," he adds.
Instead of getting defensive, use complaints as a tool, recommends Charles Zeller, MD, FACEP, president of Southwestern Michigan Emergency Services in Kalamazoo. "Many times, people try to circle the wagons and react to negative comments by trying to support the actions of the ED staff. This mindset can be counterproductive," he says. "By doing that, you may lose the real value of the complaint. There is a learning experience from almost every complaint you will receive in your ED."
Document the type of complaint
Complaints should be carefully tracked by category and outcome, says Regan-Donovan. "Document the type of complaint, such as attitude of staff, poor quality care by their perception, inappropriate medical treatment, misdiagnosis, issues with follow-up, etc.," she advises.
A form should be used to track complaints (see ED complaint management form in this issue), Regan-Donovan recommends. "However, the result will depend on the resources available and the credibility given to the system of complaint management," she adds.
Tracking of complaints gives ED managers insight into the perception of patients with regard to staff attitudes, quality of care, timeliness, and other issues, says Regan-Donovan. "It also allows management to track bogus complaints for defense to hospital administration and the board as required," she explains.
The form may also reveal the inappropriate management of various high-risk patients, notes Regan-Donovan. "One hospital noted that a particular physician was removing collar and boards of all patients, and had, in fact, cleared (without C-spine films) several cervical spine fractures," she says. "One was actually discharged."
Another incident involved a diagnosis of hypoglycemia and a patient complaint letter that stated the patient, in fact, had a carotid occlusion and was hospitalized the following day for a carotid endartarectomy, says Regan-Donovan. "The patient did not sue, however, the complaint led to other charts and peer review for a physician who was eventually allowed to retire," she reports.
At Glen Oaks, every ED complaint is logged by a secretary and categorized in the following areas: finances, timeliness of service, quality of care, and communication. "We openly share these complaints with the appropriate people, so we aren’t just getting the patient’s perception about what happened," says Joseph Shanahan, Esq., MD, director of emergency medicine at Glen Oaks Hospital in Glendale Heights, IL. "If it involves other people, we get their input within two or three days."
Complaints about individual staff members were also tracked. "If a complaint involves a physician, it gets logged in by a physician number, so we can track problem areas," Shanahan explains. "If someone is seeing 20% of patients and accounts for 45% of our complaints, we have to sit down with that person and come up with a plan to address it."
For example, several patients may raise the same issue about a nurse or physician. "In one case, the majority of complaints about a particular physician said that it didn’t seem like he spent enough time with patients. Now he sits down on a chair when he talks to the patient. After making that one change, we haven’t had another complaint about that physician in two years," Shanahan explains. "But if we didn’t have the system to track these things, we never would have known it was an issue."
By tracking complaints, meaningful changes can be made. "In one month, we had two similar complaints," Phyllis T. Doerger, MD, FACEP, chair of ED at Miami Valley Hospital and regional director for Premier Health Care Services, Inc. "Both gentleman had catheters put in and felt like nobody explained how to take care of it, or how long it was going to be in. When we investigated, we found that both the physician and nurse assumed the other one would teach the patient, and it ended up that nobody told them." The physicians and nurses created a discharge instruction sheet for catheter care, she reports.
Meticulous tracking of complaints has contributed to a lower complaint rate, Doerger notes. "We were at 2.4 per 1000, and it’s now down to 1.9 per 1000, which includes billing errors," she says. "At the end of each quarter, we sit down and review whether complaints were accurately categorized."
Here are categories of complaints and ways to address each:
Billing. "Financial complaints have been exacerbated over the years because there are so many independent bills. A patient may receive separate bills from the radiologist, pathologist, and the facility, which is confusing," says Stettner. "It’s helpful to have someone at the billing company who can help patients understand the different bills they have received. That individual can also act as an ombudsman to resubmit a bill to the insurance company which might have been rejected."
At Glen Oaks, it was noted that a significant number of complaints concerned charges for minor injuries or illnesses, says Shanahan. "Ninety percent of our financial complaints involved 10% of our charges. We found that by reducing the cost by 20%, it did away with a significant percentage of our complaints," he reports.
Wait times. A significant number of complaints are due to wait times, often with patients expressing frustration over another person being seen first. "Often, all it takes is better communication as opposed to leaving them in the dark," says Zeller. "Most people are very understanding about the priorities of care when there is a seriously injured person, but if no one makes the effort to explain that, it doesn’t help.’
Giving patients an accurate estimate of wait time is key, says Doerger. "The patient should not be sitting, waiting, without knowing why. Someone needs to explain that: now the film will be developed and the physician will need to review it, and it will be another half hour before they’ll get back," she explains.
Attitudes. Complaints about rudeness call for training, says Doerger. "We have had several patient satisfaction seminars for the entire staff, but still we all have bad days or say things that are wrongly perceived by the patient," she notes. "If a particular individual is getting more complaints than average, there is intensive work done with them on retraining their interpersonal skills."
One nurse was the focus of 22 patient complaints in one year, notes Doerger. "Obviously, there was a problem with the way she was interacting. When she left, the complaints dropped considerably. But even the best nurses will get one or two a year," she says. "Even if they provided good medical care, it may not be what the patient wants. For example, if the patient has chronic back pain, [he or she] may want you to prescribe narcotics."
Focus groups allow staff to hear complaints and public perception firsthand so that they can empathize with patient issues, says Regan-Donovan. "Staff members and patients can talk about misconceptions such as perceived neglect by staff or delays in treatment, and defuse ongoing attitudes of staff that patients perceive as negative," she explains.
Any complaint that is attributed to a trend in a single individual, a shift, or an ongoing problem should be addressed as a quality or human resource issue, documented, and appropriate disciplinary action [should be] taken, says Regan-Donovan. "Sometimes focus groups with staff and patients can be helpful at assisting staff in realizing the patient’s perception of the ED and the care received there," she says.
Individual staff members. If a complaint is about an individual nurse or physician, he or should not be kept in the dark, says Doerger. "If the patient’s perception was that [the] physician was rude or didn’t communicate, you need to let them know about that," she stresses. "It’s not that you believe that the facts are what the patient relates, but, in essence, what they perceive is true, [what] is their reality. You don’t necessarily have to believe the patient, but in essence what they think is true, is true."
Complaints should be tracked by staff members, says Stettner. "There might be physicians who get more complaints than others. If there is an internal management problem, you absolutely need to know about it," he explains. "The earlier one knows about that, the more effectively an intervention can be designed."
Medical management. These may or may not have some merit. "A patient may believe you gave them the wrong antibiotic or think you missed a fracture, but it may be they are mistaken or misunderstood what you told them," says Doerger.
Regardless, complaints about clinical issues require an explanation and some empathy, says Stettner. "I don’t believe it’s an admission of guilt to say, I am sorry it didn’t come out as well as you expected,’" he notes.
Any patient who has a complaint about his or her medical management should be contacted immediately, Doerger says. "Usually it turns out to be a communication problem, but it is our job to explain what we are doing," she notes.
Contact can be in the form of a letter, phone call, or even a meeting, says Doerger. "I invited one man to come in and look at his x-ray because another doctor had told him they were misinterpreted. We looked at the film and discussed the findings and he understood everything perfectly when he left," she recalls. "And if there has been a serious outcome like a death, that is also a situation when you may need to sit down face to face."
If there is an issue between a family doctor and an ED physician, you may need to all sit down in the same room as a group, says Doerger. "If the family calls and complains that their family doctor made comments about the ability of [the] ED physician, it is helpful to call that practitioner and talk about the issue," she says. "Most of the time, the patient has misunderstood, but sometimes the doctor does feel something wasn’t done correctly. That needs to be addressed so it’s not a he said, she said’ situation."
Follow up with complaints
Return every complaint with at least a phone call, advises Regan-Donovan. "Express thanks for making you (director, nurse manager, guest relations guru, etc.) aware of the issue (whatever it is), and express concern that they were dissatisfied and let them know that you are making every effort to address their problem," she says.
Send patients a thank-you note for complaining, suggests Stettner. "Send a note explaining that you will pursue the matter, stressing that your goal is to give high quality care," he says. "You are not admitting anything," but you are acknowledging that the patient has a complaint. "Even if you don’t solve the problem, you’ve sent a message that you think the complaint is important enough to respond to it."
Follow up on patient care when appropriate. "A classic example is abdominal pain when the diagnosis is not clear," says Stettner. "You have done everything you can in the ED, but should follow up to make sure the patient is OK," he notes. "Likewise, with an injury you are a little worried about, you might routinely tell patients to come back in 24 hours, but sometimes patients don’t follow instructions."
At Summit’s ED, a random sampling of patients are also called back to check on their perception of the care they received. "We call back 5% of patients at random, and ask them what their experience was like," says Stettner.
However, it’s a challenge to make these resources available. "It’s good PR, but the resources to do that are not always there. Today, all of us are working harder with greater acuity, so there is not a lot of time to do that," says Stettner. "Clerks can make many of these calls, but if it’s a more serious situation you might want to have a nurse or physician make the call."
Careful following up with complaints reduces liability risks (see related story on risk management aspects of complaints). "We feel strongly as a physician group that managing complaints appropriately has decreased our risks," says Doerger. "People tend to sue when they are angry, especially if they feel you are not listening to them. If you can defuse the anger, they may not want to go through legal maneuvering. Otherwise, they may feel they have no other recourse than to turn to a lawyer."
Achieve consistency with scripts
At Miami Valley, inconsistent application of ED policies had resulted in a significant number of patient complaints. "For instance, our policy is to allow two visitors at the bedside, and family members can trade off by exchanging ID badges. That keeps the number down to a reasonable amount, but allows patients to have their family members with them, and the family is kept in the loop," says Doerger. "But some nurses were making sure no one was [in the room without a badge], while others were letting everyone back there."
The inconsistent enforcement of the policy resulted in complaints, says Doerger. "Patients tended to take it personally, feeling it was because they didn’t have insurance, or thinking it was a race issue, when it was really just the different personality of the nurses," she explains.
Patient "scripts" were written by the patient representative, nursing staff, and chair (see the ED’s scripts in this issue) with standardized answers to explain policies on visitors, food, and communicating with private physicians. "We gave them out to everyone and asked for comments. When everyone agreed they liked the wording, we trained everyone in how to use them," says Doerger. "Occasionally, we’ll have a resurgence of complaints in a particular area, and we then review how to use the scripts during staff meetings."
The scripts had a dramatic effect on reduction of complaints, Doerger reports. "We had over 100 complaints related to policy issues, and this dropped those complaints down to almost none," she says.
The scripts enable staff to clarify policies for patients. "A frequent complaint from women is, they did a pregnancy test even though I told them I wasn’t pregnant,’" Doerger notes. "Some physicians have trouble phrasing the need for this test, so they don’t mention the test, and the patient sees ii on the bill and is furious. Scripts can help physicians and nurses explain why we need to rule out pregnancy. Then, if the patient refuses it, you can at least document that and explain the risks and benefits."
Here are some ways to improve management of complaints:
Implement a formal complaint management process. "There should be a formal review of complaints every month," Stettner recommends. "At staff meetings, review complaints by category and the most recent Press Ganey survey results." (see policy for complaint management in the ED, in this issue.)
Empathize with the patient. "Presume and intimate to the patient or complainant that they are right and thank them for letting you know that there is a problem," advises Regan-Donovan. "This allows you to empathize with their perception’ of the issue. Many complaints only need an ear and confirmation that you will provide some resolution so that it does not occur again."
If patients feel they are being taken seriously, their frustration usually lessens, says Shanahan. "Ninety percent of the time, if you just listen to them, that is all they really want," he explains. "Seldom do we have to adjust bills or drop charges. People just want to know their concerns were acknowledged. Maybe the patient didn’t realize you had four other patients waiting or just had the death of an infant."
Get feedback from staff involved in patient’s care. "To every extent possible, determine the staff members who were involved, even if it means pulling the patient’s record," says Regan-Donovan. "No corrections will be made if the parties involved are not aware of the issues at hand. Always listen to the other side of the story.’"
Maximize the value of complaints by asking staff for feedback, says Zeller. "There should be some very candid discussions with the parties involved. The idea is not to question the validity of the complaint, but rather to explore what could we have honestly done better to have avoided this complaint," he explains.
Ferret out underlying problems that led to the patient’s complaint, says Zeller. "Sometimes the details of a complaint don’t give you that information. It may be focused on one aspect of care, when in fact the event that triggered it was an inappropriate comment," he notes.
Interview staff members who were directly involved with the patient’s care, Zeller suggests. "If you look at a chart of any given patient, you can identify a whole lot of people involved," he says. "The complaint may be directed at the physician, but there may also be a nurse or a security guard who encountered the patient, who may give you some insight about what was going on that night. Maybe it was a terribly busy night, or clerks were shortstaffed."
Have one person handle complaints. At Miami Valley, all physician complaints except billing errors are handled by a single individual. "There is a school of thought that individual doctors can handle their own complaints, but I like the philosophy of one central person handling all complaints," says Doerger.
It’s not a good idea to allow clinicians to manage patient complaint directed at them, says Doerger. "They may get the patient on the phone and become defensive or argue, which makes the problem worse," she explains. "Also, the patient usually doesn’t feel comfortable talking to the doctor they’re complaining about."
The individual charged with managing complaints should be personally involved, says Shanahan. "I have no problems giving patients my home number or calling them at night when they are home from work," he explains. "If you can take a bad experience and turn it around to a good experience, that is well worth the investment of time."
Ask for feedback from the patient. "Ask for the complainant’s assistance and get them involved," says Zeller. "Tell them, We are not a perfect ED. Please give us your honest opinion as to how we might make this better.’ It is amazing how many people, if they sense you are serious, will make every effort to help you with that."
One patient’s family felt as if their questions about the patient at discharge were not adequately answered, recalls Zeller. "They told us it would have meant a lot if somebody had just given us some closure, and asked if we had any other questions." he says. "It’s now standard practice that the last inquiry prior to discharge is, Do you have any other questions or concern about your care or family member’s care?’ We ask the staff to document that."
Summarize complaints on a regular basis. "On a periodic basis, there should be some generic summary of all complaints that come to the ED, shared with the entire department," says Zeller. "That way, people have a sense of the nature of the complaints and can better identify trends."
Don’t minimize complaints. "There is a tendency to sugarcoat complaints when presenting them to individuals," Zeller notes. "The motivation is to spare them bad feelings, but it’s better off to be straightforward. Otherwise, you don’t tend to get honest thinking and constructive responses."
Complaints should not be presented as criticism, notes Zeller. "To eliminate defensiveness, that attitude has to come from the top down, and be intrinsic to [the] culture of the department. It must be practiced and not preached," he says. "Complaints should not be used in a negative fashion to unduly chastise employees with the threat of termination. The vast majority of complaints do not merit that."
Staff may still feel the need to defend themselves. "On a busy, high acuity night, a patient with a minor problem may complain because they had to wait. The employee then feels unduly criticized because they were doing what they were supposed to do," says Zeller. "But it really doesn’t matter, because it’s what experience the patient is having that counts."
Notify the ED chairman when appropriate. The ED chairman should always be involved when there is an allegation made against a physician such as a misdiagnosis or potential for a bad outcome, Regan-Donovan stresses. "Any report of an adverse event that comes in the form of a patient complaint deserves immediate notification of the director," she adds.
Similarly, system complaints or notable trends that involve nursing staff, timeliness of care, or general satisfaction issues should involve the nursing manager and/or director, Regan-Donovan says.
Involve EMS. EMS is a valuable source of complaints and may help identify issues regarding care delivery in the ED, says Regan-Donovan. "These frequently may involve attitudes and bad or potentially bad outcomes," she explains. "Addressing these in a special forum with representatives from this group may also improve relationships between EMS and ED staff."
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