PA P E R S

The use of patient complaints to drive quality

improvement: an exploratory study in Taiwan
Sophie Y Hsieh
Department of Healthcare Information and Management, Ming-Chuan University, 5 De-Ming Road, Gui-Shan, Taoyuan,
Taiwan, ROC
E-mail: [email protected]

Summary
This study aims to investigate the nature and resolutions of patient complaints and further to explore the
use of complaints to drive quality improvement in a selected hospital in Taiwan. A teaching hospital (i.e.
the Case Hospital) in Taiwan was purposefully chosen for a case study. The author conducted the critical
incident technique (CIT) using questionnaires to obtain information about the complaints and the
process of their resolutions. To enhance the reliability of the study, the author also conducted non-par-
ticipant observations as an outsider at the Case Hospital. In this study, 59 complainants registered 87
complaints. The CIT found that care/treatment, humaneness and communication were the most
common causes of complaints. The response time of patient complaints averaged 1.76 days, except for
five cases in which response time was not reported. The majority of complaints were resolved within
three days. Moreover, this study found that of 149 resolutions, 105 taken by the hospital involved an
explanation of the facts to complainants (n ¼ 41), investigation of events (n ¼ 33) and empathy with
complainants (n ¼ 31). The lack of any systematic use of complaints data was one of the most crucial
failures of the Case Hospital. Instead of attempting to use such data as the basis for initiating quality
improvement measures, complaints were consigned to a ‘black hole’ where their existence was con-
veniently forgotten. Based on this study, the author suggests ways to strengthen the capacity of the
hospital in terms of using patient feedback and complaints to improve the quality.

Introduction complaints can affect the focal areas of quality improve-

ment activities in health care in which preventive or
Traditionally, patients have not had a direct impact on the proactive mechanisms can be set up, for example risk man-
choice of services they received and did not know what stan-
agement and a patient safety mechanism to provide safer
dards they should expect.1,2 The health-care system often and sound quality of care for patients.6 – 11
neglects patients’ rights and their complaints.3 In those cir- The searches used the electronic databases PubMed
cumstances, patients are simply expected to follow the rules and ProQuest, which in turn expanded access to further
and regulations of the health-care organization and to obey literature. Of the 43 studies published between 1983 and
the ‘commands’ of the health professionals. However, it is 2006, only four addressed organizational behaviour
increasingly recognized that as customers, patients can often
and strategy concerning patient complaints, those of
identify problem areas that management is not aware of and Carmel12 in Israel, Gilly et al. 13 in the USA, Van der
can offer health-care managers innovative ideas for improve- Wal and Lens14 in the Netherlands, and Douglas and
ment. A well functioning patients’ complaints system enables Harrison15 in Australia. It is still not clear, however, how
patients to contribute to the improvement of services and to patient complaints could be used to improve quality of care
participate more actively in their own care and treatment. in health-care services. This represents a gap in knowledge
The rationale of quality improvement is to create an which this study aims to address by examining how patient
environment where it is possible to understand and be
complaints can be used to drive quality improvement in
responsive to patient needs. There is a growing body of lit- practice in a selected hospital in Taiwan.
erature which suggests that complaints can provide good
opportunities for developing risk management or quality
improvement programmes.4,5 The nature of patient Methods
A teaching hospital (i.e. the Case Hospital) in Taiwan was
Sophie Y Hsieh PhD, Assistant Professor, Department of Healthcare purposefully selected as the site for the fieldwork for three
Information and Management, Ming-Chuan University, 5 De-Ming main reasons. Firstly, the Case Hospital is an exemplary
Road, Gui-Shan, Taoyuan, Taiwan, ROC. organization, one which has gained visibility and respect

Health Services Management Research 2010; 23: 5 –11. DOI: 10.1258/hsmr.2009.009011

6 Hsieh

nationally in Taiwan with regard to managing quality of Data analysis

care. Secondly, the Case Hospital has a good national This study adopted the techniques of the thematic analysis
reputation for providing quality patient services. Thirdly, with an interpretivist approach to investigate and interpret
the Case Hospital agreed to allow the researcher to the meanings of empirical data. The study looked at the
conduct this study in situ as much as possible. occurrence of certain terms/concepts (e.g. complaint
The critical incident technique (CIT) is an innovative types) within texts. The approach in analysing data was
research strategy for studying ‘moments of truth’ and to systematically search text for categories and themes.
involves gathering self-reported data about subjects’ most The researcher then quantified and analysed the presence,
memorable experiences, positive or negative, within a meanings and relationships of such terms and concepts.
specific context.16 It is a systematic qualitative research Finally, the researcher made inferences about the messages
strategy17 – 19 as well as an appropriate tool to reflect within the texts.
patient-perceived quality or patient dissatisfaction based
on negative critical incidents.20,21
Ethics consideration
With the hospital’s permission, the researcher visited
Data collection the Case Hospital to meet with the manager assigned to
The author conducted CIT using questionnaires to obtain coordinate this project. This organizational study was
information about the nature and resolutions of complaints conducted in a natural setting without performing any
from 1 May to 31 July 2002. Social workers within the experiments on participants. The role of the researcher
Social Work Department at the Case Hospital were was that of an outsider. All participants in this study
trained to fill out this critical incident questionnaire, were employees and managers. Each participant was free
taking into consideration the sensitivity and confidential- to withdraw or discontinue his or her participation in
ity of the data, the education level of the complainants this study at any time.
and the consistency of the study. To enhance the
reliability of the study, the author also conducted non- Results
participant observations as an outsider at the Case
Hospital. Being a non-participant observer enabled the General background
researcher to collect the necessary data without being A total of 59 cases were collected by conducting the CIT.
involved in the management of the organizational Of these, 17 cases were lodged in May 2002, 20 cases in
system. Any other quality improvement activities were June and 22 cases in July. In terms of the units that were
noted as well. Some informal interviews were also con- being complained about, 48 complaints concerned the
ducted if the situation was of interest to the study and per- clinical unit, in which the main complaints related to
mission was granted. The themes observed/interviewed humaneness (n ¼ 16), care/treatment (n ¼ 15) and com-
primarily included methods of contacting complainants, munication (n ¼ 13) (Table 1). Of 87 complaints, 16%
how the hospital staff handled complaints, the interaction (n ¼ 14) were related to the administrative unit and
between departments and units, complainants’ satisfaction most of them were about billing/payment problems
in the way their complaints were handled and severity or (n ¼ 4; 28.6%) or environment/equipment problems
failure magnitude of complaints. (n ¼ 4; 28.6%). In addition, 15% (n ¼ 13) were about

Table 1 Number and percentage of complaints by category for four unit types

Unit types/complaint types Clinical unit Allied health unit Nursing unit Administrative unit Total

Care/treatment No. 15 5 4 0 24
% 31.3 41.7 30.8 0 27.6
Communication No. 13 1 1 2 17
% 27.1 8.3 7.7 14.3 19.5
Humaneness No. 16 2 5 1 24
% 33.3 16.7 38.5 7.1 27.6
Business practice No. 2 3 1 1 7
% 4.2 25.0 7.7 7.1 8.0
Access/availability No. 1 0 0 2 3
% 2.1 0 0 14.3 3.4
Billing/payment No. 0 1 0 4 5
% 0 8.3 0 28.6 5.7
Environment/equipment No. 0 0 1 4 5
% 0 0 7.7 28.6 5.7
Suggestions No. 1 0 1 0 2
% 2.1 0 7.7 0 2.3
Total No. 48 12 13 14 87
% 55.2 13.8 14.9 16.1 100

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Use of patient complaints to drive quality improvement 7

the nursing unit and mainly concerned humaneness ‘environment/equipment’ (n ¼ 4), ‘billing/payment’
(n ¼ 5; 38.5%) and care/treatment (n ¼ 4; 30.8%). (n ¼ 3) (all three cases were about the level of parking
Of a total of 59 cases, 43 cases were categorized as fees) and ‘access/availability’ (n ¼ 2). Despite this, some
none (i.e. no obvious harm, no injuries or low financial cases related to more than one subcategory of complaints.
loss) in terms of severity; nine were catastrophic; four For example, one case was mainly concerned with ‘care/
were major; and three were minor. Personal visit treatment’, and this was related to an incorrect diagnosis,
(n ¼ 26) and telephone (n ¼ 22) were ranked as the dissatisfaction with treatment outcome and inadequate
most popular methods of staff contact with complainants treatment, thus reflecting different subcategories.
after the complaint was made. Others were letter Furthermore, there were 23 cases where more than one
(n ¼ 3), email (n ¼ 2), phone and personal visit complaint was made. Of the 23 cases, 18 contained two
(n ¼ 5), and personal visit and letter (n ¼ 1). In most complaints. There were six combinations in which
cases (n ¼ 29), complainants accepted the results of the two complaints were made in a single case, two of which
complaint handling by the hospital. While complainants were more frequent. Firstly, most of these were related to
in 24 cases did not state their satisfaction in terms of the ‘care/treatment’ and ‘humaneness’ (n ¼ 6). Half of them
complaint handling; 15 cases were considered by them to (3 of 6 cases) were associated with ‘inadequate treatment’
be fair; and they were dissatisfied in six cases. and ‘staff who were unconcerned, rude or disrespectful
to patients’. The second most frequent combination of
The nature of complaints patient complaints was ‘communication’ and ‘humaneness’
(n ¼ 5). Specifically, four of five cases were associated with
In this study, 59 complainants registered 87 complaints. The
‘incorrect or misleading communication’ and ‘staff who
CIT found that care/treatment (n ¼ 24), humaneness
were unconcerned, rude or disrespectful to patients’. For
(n ¼ 24) and communication (n ¼ 17) were the most
example, the social worker’s case-notes stated:
common causes of complaints (Figure 1). That is, three-
quarters of patient complaints (n ¼ 65) were related to The patient was told by his general practitioner (GP) that
‘care/treatment’, ‘humaneness’ and ‘communication’ in . . .were problematic and needed to be operated on. The
the Case Hospital. These results are generally consistent GP suggested that the patient go to the hospital for an exam-
with Webb’s study in the UK,22, that inadequate care and ination. Therefore, when the patient came to the hospital,
poor staff attitudes were the most common causes. he asked the doctor to arrange an MRI examination. The
Furthermore, other studies show that care/treatment and doctor was unhappy with this request and said ‘you cannot
the quality of communication are the most common subjects just order whatever examination you want’. The doctor then
turned over the medical record. The doctor did not make an exam-
of complaints, for instance, Pichert et al.’s23 study in the
ination and wrote out a prescription for the patient.
USA and Anderson et al.’s10,24 study in Australia.
However, the groupings of complaints in both studies were Another five of 23 cases involved combinations in which
not clearly identified and it is therefore difficult to make three complaints were made by a single complainant.
comparisons between the two. Of these, the main complaints (i.e. four of five cases)
Specifically, 36 out of 59 cases involved one complaint. were about ‘care/treatment’, ‘communication’ and ‘huma-
Most of these 36 cases related to ‘care/treatment’ (n ¼ 8) neness’. For example, one case involved ‘inadequate treat-
and ‘humaneness’ (n ¼ 8). In terms of humaneness, seven ment’, ‘unconcerned attitude of medical staff’ and
of eight cases were about staff who were regarded as being ‘inadequate communication’. Another case involved a
unconcerned, rude or disrespectful to patients. Others combination of three complaints by a single case which
were ‘business practice’ (n ¼ 6), ‘communication’ (n ¼ 5), related to ‘humaneness’, ‘business practice’ and

Figure 1 Complaint types by frequency (May– July 2002)

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8 Hsieh

‘environment/equipment’ (n ¼ 1). In the case-notes of (n ¼ 41), investigation of events (n ¼ 33) and empathy
the social worker: with complainants (n ¼ 31). In other cases, as can be seen
The patient’s bed faced the entrance of the toilet. The move-
in Figure 2, these were:
ment of other patients and beds affected the patient’s
sleep. The relative originally sought a transfer for the patient (1) Social workers referring the complaint to other units
to another bed when the patient in the next bed was dis- to deal with (n ¼ 15);
charged. But a new patient was admitted when the next (2) Replacement (n ¼ 8) indicates that the hospital
bed’s patient was discharged. Moreover, the relative was offered substantial services to complainants, for
dissatisfied with the ward environment and thought the example alternative exam, bed arrangement and
nurse did not deal with their request seriously. substitution of meals;
(3) Apology (n ¼ 7) means the doctor expressed their
The resolution of complaints apology to the complainants;
The response time of patient complaints averaged 1.76 (4) The intervention of the Medical Disputes Team
days, except for five cases in which response time was (MDT) (n ¼ 4);
not reported. Of 59 cases, 38 cases were resolved within (5) Social workers making suggestions to unit managers
one day; six cases within two days; three cases within (n ¼ 4);
four days; two cases within three days; two cases (6) Correction (n ¼ 2) refers to the hospital taking action
within seven days; one case within five days; one case to correct wrong procedures or processes, for example,
within six days; and one case within 11 days. That is, modification of computer programs;
the majority of complaints (46 of 59 cases) were resolved (7) Social workers making suggestions to complainants
within three days. However, 80– 90% of complaints in (n ¼ 2);
21 hospitals in Netherlands were dealt with within two (8) Compensation (n ¼ 1) means that the hospital reim-
months.14 This was a result of various complaints manage- bursed its fee to complainants;
ment systems being used in different countries. (9) Using continuous quality improvement technique
Additionally, of the 59 cases described, if the complaints (Plan-Do-Check-Act, PDCA) to solve the complaint
involved no obvious harm, no injuries or low financial problem (n ¼ 1).
loss (n ¼ 43), most were resolved within four days and
36 of 43 within one day. However, if complaints involved These results show that the resolutions taken by the
a major or catastrophic consequence, it took a longer time Case Hospital were more complex than in Hunt and
to resolve, though exactly how long was not known. Glucksman’s study. One reason is that the current study
Over a three-month period, the study found that of a conducted the CIT to observe the actual scenario as
total of 59 cases, in terms of frequency, 149 resolutions complaints took place.
were taken by the hospital. Hunt and Glucksman25 con- In terms of the strategies of complaints resolution taken
ducted a case study in an accident and emergency depart- by the hospital, the study found that the hospital intended to
ment in the UK and found that complainants tend to seek conduct the PDCA technique (n ¼ 1) to improve nursing
an explanation, an apology and compensation for unsatis- care (i.e. clinical quality) when complaints involved care/
factory services. However, this current study found that of treatment. However, at the time of the study, the Nursing
149 resolutions, 70.4% (n ¼ 105) taken by the hospital Department coordinated relevant staff/units to work out a
involved an explanation of the facts to complainants quality improvement project and it was unclear whether

Figure 2 Resolution of complaints by frequency for May– July 2002

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Use of patient complaints to drive quality improvement 9

the hospital actually used the PDCA to improve its clinical way in which work was currently performed. In terms of
care. On the other hand, methods of explanation (n ¼ 41), organizational learning, ‘single-loop’ learning26,27 occurred
empathy (n ¼ 31), replacement (n ¼ 8), compensation in the Case Hospital when handling complaints. On the
(n ¼ 1), apology (n ¼ 7), correction (n ¼ 2) and sugges- other hand, the hospital did plan to conduct the PDCA
tions to complainants (n ¼ 4) were likely to have contribu- technique to improve nursing care. There is no empirical
ted to satisfying the expectations of patients/complainants, evidence, however, that sustainable quality improvement
whether they were tangible or intangible. However, there occurred within the hospital.
was no empirical evidence for sustainable improvement It is difficult for the researcher to follow up actions or
within the hospital. improvement activities taken by the MDT due to the con-
The study revealed that the response pathway of fidentiality and sensitivity of some cases; this has led to the
empathy with complainants, investigation of complaints development of a ‘black hole’ syndrome within the organ-
and explanation of the facts to complainants was an effec- ization. The chief characteristic of a ‘black hole’ is its
tive approach when resolving individual patient com- non-transparency. In other words, it is impossible for the
plaints that involved ‘communication’ and ‘humaneness’ researcher as an outsider to know what happens to data
occurring simultaneously in a single case. Two-thirds of or information that goes into the ‘black hole’. Therefore,
complainants were satisfied with the response of the hospi- it is unclear whether complaints drive quality improve-
tal when they used strategies of empathy, explanation, ment when strategies of resolutions involved (1) the
apology or replacement, when complaints involved ‘care/ intervention of the MDT (all 4 complaints involved
treatment and humaneness’ or ‘care/treatment and com- care/treatment), (2) social workers referring complaint
munication’ simultaneously occurring in a single case. problems to the relevant units (7 of 15 complaints
However, while these strategies tended to satisfy complai- involved care/treatment), and (3) social workers making
nants’ needs, they did not contribute to any systematic suggestions to unit managers (2 of 4 complaints involved
quality improvement. care/treatment).
In addition, multiple actions were taken to handle Based on observations made in this study, only one
patient complaints by social workers. Generally, the hospi- critical incident was used to enhance clinical quality.
tal empathized with complainants, investigated events, A review of the nature of the complaints reveals that,
explained the facts to complainants and referred complaint of the 59 cases observed, 24 related to the quality of
problems to the relevant unit(s). While the researcher ‘care/treatment’. Thus, the hospital responded at least par-
looked at how frequent specific resolutions appeared in tially to patient complaints related to clinical issues.
sets of data, ‘investigation and explanation’ occurred It appears, however, that many complaints disappeared
simultaneously to resolve 29 of 59 (49.2%) cases. into a ‘black hole’ due to lack of transparency in handling
‘Explanation and empathy’ (n ¼ 19) occurred as the complaints. The inadequate handling of patient com-
second most frequent resolution. Furthermore, ‘investi- plaints was most likely to occur when managerial interven-
gation and empathy’ (n ¼ 11), ‘investigation, explanation, tion by the MDT was required, when social workers
and empathy’ (n ¼ 11), and ‘empathy and refer to relevant referred complaint problems to relevant units, and when
units’ (n ¼ 11) were ranked as third most common actions social workers made suggestions to unit managers concern-
taken conjointly. ing complaints associated with ‘care/treatment’ (e.g.
inadequate treatment) (n ¼ 13). These findings reinforce
the notion that if the hospital intends to use patient com-
Discussion plaints to improve its quality of clinical care, it needs to
In terms of the strategies of resolutions taken by the hospi- eliminate the aforementioned ‘black hole’ to act as a
tal, approaches of explanation, empathy, replacement, ‘double-loop’ learning organization,27,28 i.e. do the right
compensation, apology, correction and suggestions to com- things and to question why errors happened and problems
plainants were more likely to have contributed to satisfy occurred. This may require modification of the hospital’s
patients’ needs. When handling complaints, the Case underlying norms and policies.28
Hospital tended to investigate and correct the problem
on hand without examining the appropriateness of the
current ways of doing work within the organization. The Conclusions and implications
hospital attempted to correct administrative errors (e.g. No matter how good the complaints management system
business practice and billing/payment), as well as to is, complaints are a small part of patient voices and are
satisfy the needs of complainants, by offering replacement passive. Many dissatisfied patients and their relatives do
and compensation, making suggestions to complainants not lodge a complaint. For achieving a ‘double-loop’ learn-
and giving an apology. While the hospital followed ing organization, the findings of this study suggest a
correct procedures, it appears that it did not make systema- number of implications with regard to a best practice
tic effort to learn from these complaints. In other words, system for using patient complaints as a trigger to
the hospital proceeded with the detection and correction improve quality of care (Figure 3).
of problems/errors without any serious interruption to This study has suggested that the lack of any systematic
the organization’s business, and focused on resolving pro- use of complaints data was one of the most crucial failures
blems without examining assumptions underlying the of the Case Hospital. Instead of attempting to use such

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10 Hsieh

The hospital could also institute, either internally or exter-

nally, a system (such as an ombudsperson) that would
enable patients to lodge their grievances if they were not
satisfied with complaints resolution procedures or when
they felt they had been discriminated against. Such a grie-
vance system could enhance the hospital’s accountability
for the way it dealt with complaints.

Management and analysis of complaints

The second phase of complaints management would
involve appointing designated personnel (e.g. a quality
improvement coordinator) to collect, analyse and commu-
nicate complaints data. Such personnel would have direct
or ready access to the senior management of the hospital
and would be able to initiate and monitor any quality
improvement activities resulting from complaints manage-
ment. In addition, the senior management of the hospital
would be responsible for designing and providing quality
services in the hospital such as the establishment of the
complaints management policy and its relevant organiza-
tional structure. The involvement of the senior manage-
ment is important as they can review the hospital-wide
complaints handling and management system, and also
examine the effectiveness of using complaints to improve
quality of care. Based on this information, they would,
if necessary, provide support resources with regard to com-
plaints management.

General pathways
Generally, the hospital should systematically document all
complaints for auditing and improvement purposes. One
way of avoiding systems overload would be to triage all com-
Figure 3 The ideal model for using complaints to help drive plaints separating the more serious from the trivial. That is,
quality improvement complaints registered can be classified as major or minor
problems. Having this classification, the designated person-
nel responsible for receiving and resolving complaints
data as the basis for initiating quality improvement
would be able to judge whether to take immediate or reme-
measures, complaints were instead consigned to a ‘black
dial action. If complaints have been recognized as severe or
hole’ where their existence was conveniently forgotten.
major (e.g. the transfusion of a wrong blood type), the
In order to remedy this situation, it is suggested that a
organization would provide an urgent response by immedi-
basic requirement would be the implementation of a two-
ately reporting to the authority for quick resolution of the
phase system in which (1) the investigation and resolution
problem. If complaints are minor (e.g. cold food), the hos-
of complaints was separated from (2) the process of data
pital could provide initial responses to complainants such as
management and its secondary analysis. The ideal system
giving support or solving problems.
for using patient complaints to drive quality improvement
Following these actions, the nature of complaints, the
would work as follows:
investigation process, the causes of complaints and the
outcome of complaints would be documented in a formal
Investigation and resolution of complaints report as either a minor or major problem. It would be
It is suggested that, first of all, patient complaints at the important to maintain the confidentiality of the com-
frontline be resolved on a case-by-case basis either by plaints data by, for instance, keeping it in a lockable
social workers or other staff (e.g. nurses). The hospital filing system. The documented complaints would then be
may have designated personnel (e.g. social workers) or a reviewed on a monthly, or at least periodical, basis,
unit (e.g. a standing committee, a department) responsible by undertaking secondary analysis of accumulated com-
for helping patients register their complaints, resolving the plaints to identify any common or special causes of com-
immediate difficulty they are facing and then documenting plaints, as well as to review which location, category of
every complaint. Such personnel or unit may also give staff, procedure or particular set of patients are the cause
support to complainants, investigating their problems of the most frequently lodged complaints. It is important
and explaining the facts to them where necessary. to note that minor problems might lead to major problems

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Use of patient complaints to drive quality improvement 11

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