BMJ Qual Saf: first published as 10.1136/bmjqs-2015-004337 on 14 May 2015. Downloaded from http://qualitysafety.bmj.

com/ on November 12, 2023 at UNICAMP - Universidade Estadual

EDITORIAL

Taking complaints seriously: using

the patient safety lens
Thomas H Gallagher,1 Kathleen M Mazor2

INTRODUCTION
1
Department of Medicine, Spittal and colleagues build on their
University of Washington,
Important progress has been made prior publication that found patient com-
Seattle, Washington, USA
2
Meyers Primary Care Institute, towards reducing adverse events by using plaints against Australian physicians were
University of Massachusetts the modern patient safety framework, highly clustered: half of all complaints
Medical School, Worcester, which assumes that preventable adverse were generated by only 3% of physicians
Massachusetts, USA
events represent the combination of in the study.6 The current paper extends
Correspondence to latent system failures and active human these findings and describes the Predicted
Dr Thomas H Gallagher, errors.1 This systems-oriented approach Risk of a New Event (PRONE) score to
Department of Medicine, UW identifies provider incompetence as the identify physicians at risk of recurrent com-
Medicine Center for Scholarship
in Patient Care Quality and root cause of a problem only after system plaints. The potential utility of the PRONE
Safety, University of Washington, failure and predictable human errors have score is clear: it could move the healthcare
1959 NE Pacific Street, Suite been excluded.2 It relies on concepts of institutions, regulators and liability insurers
BB1240 Seattle, WA 98915, Just Culture and human factors-based who field patient complaints from a react-
USA; [email protected]
analytic techniques to understand the ive to a proactive posture. By identifying
aetiologies of adverse events.3 The

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Accepted 28 April 2015 complaint-prone physicians and providing
patient safety movement prizes transpar- prospective remediation, patient dissatis-
ency, through early event reporting, open faction, quality of care problems and litiga-
discussion of adverse events among col- tion risk associated with complaint-prone
leagues and frank, empathic communica- providers could all be reduced. The ability
tion with the patient when an error has to target at-risk providers, and thereby effi-
occurred.4 ciently use limited and expensive resources
Yet few healthcare institutions see —including provider time—is clearly
patient complaints as adverse events. attractive. Limited self-awareness by provi-
Instead, at most institutions, patient com- ders is a common root cause of recurrent
plaints are handled by patient relations or patient complaints. An empirically derived
risk management departments, with a score indicating the recipient is at high risk
primary goal of mollifying the patient and of recurrent complaints may be hard to
avoiding litigation, missing the opportun- ignore and could motivate an at-risk pro-
ity not only to meet the affected patients’ vider to pursue improvement.7
needs but also to improve the quality of The PRONE score concept and results
care going forward by identifying root also raise important questions. While the
causes and developing prevention plans. authors made efforts to incorporate the
It should come as no surprise that we nature of the complaint into their analysis,
do not take patient complaints as ser- ultimately the PRONE score treats all
iously as we do critical incidents such as complaints equally. In reality, complaints
wrong site surgery. It is easy to dismiss are heterogeneous, stimulated by diverse
complaints as attributable to the provi- events and circumstances, with differing
der’s interpersonal skills or the patient’s degrees and types of harm.8 We learn from
▸ http://dx.doi.org/10.1136/ personality. However, the thoughtful the authors’ analysis that certain specialties
bmjqs-2014-003834 paper by Spittal and colleagues5 reminds are at much greater risk of complaints,
us that like any adverse event, patient with plastic surgeons and dermatologists
complaints have an epidemiology that having a fourfold higher risk of complaints
can yield important lessons for preven- compared with anaesthesiologists and radi-
tion. To optimise learning and prevent ologists. But we do not know what propor-
future complaints, we need to fully apply tion of the complaints against plastic
To cite: Gallagher TH, the patient safety lens and systematically surgeons and dermatologists represented
Mazor KM. BMJ Qual Saf examine the multiple causes contributing patient dissatisfaction with the outcome
2015;24:352–355. to these complaints. of a cosmetic procedure, dissatisfaction

352 Gallagher TH, et al. BMJ Qual Saf 2015;24:352–355. doi:10.1136/bmjqs-2015-004337

 BMJ Qual Saf: first published as 10.1136/bmjqs-2015-004337 on 14 May 2015. Downloaded from http://qualitysafety.bmj.com/ on November 12, 2023 at UNICAMP - Universidade Estadual
Editorial

potentially exacerbated by having paid for the proced- face those situations routinely could be offered tar-
ure out of pocket. The appropriate response to a pro- geted training around listening skills.
vider whose elevated PRONE score is attributable to
expectations about surgical outcomes is likely to differ THE PATIENT SAFETY LENS
from the response to a provider who generates repeated The lens through which a patient complaint is viewed
complaints about serious delays in diagnosis. Clearly, a can reduce or enhance its information value. A risk
‘one size fits all’ approach will not work. As the authors management lens focuses on liability and the potential
note, information such as the details of the actual com- for financial or reputational harm to the organisation
plaints is needed to understand why an individual pro- and the individual provider. Such a focus will neces-
vider is at risk and what steps could prevent recurrences. sarily miss opportunities to learn and improve care.
A more useful lens—one that would favour learning
over protection—is the patient safety lens. A patient
TAKING COMPLAINTS SERIOUSLY safety lens would compel organisations to treat patient
Until recently, the patient perspective has been heavily complaints as adverse events, triggering efforts to
discounted in favour of the provider perspective, mitigate any harm to the patients, as well as systematic
which is largely medical. But patients and family and systemic efforts to prevent recurrences. Such an
members can provide unique and important insights, approach could drive system improvements that
especially around care breakdowns.9 10 When care is would truly matter to patients. Patients who file com-
complex, fragmented or rife with transitions, patients plaints believe that they have been harmed. The harm
and family members may be the only ones aware of may not be physical—it may be emotional distress, life
how care is actually delivered. In many situations, disruption or loss of trust. Regardless, the harm is
patients and family members may be the first to detect experienced as significant and damaging, and the
lapses in safety or quality, identify worsening out- patient wants it to be taken seriously. Healthcare
comes or point out breakdowns in communication systems and providers need to respond accordingly,

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that providers have missed. shifting their focus from efforts to mollify and avert
The fact that complaints are relatively rare contri- publicity to identifying root causes and improving
butes to the tendency to undervalue them. Even for care; the patient safety lens has the potential to help
the most complaint-prone provider, the number of with this shift in focus. Applying this lens to com-
complaints relative to the total number of patients plaints would certainly increase the number and type
seen is extremely small. Small numbers can be inter- of events that would be considered and might also
preted to mean that the ‘complainers’ are unusual, lead to a greater appreciation of the patient’s perspec-
and that their perceptions are wrong or at least sub- tive on harms.
stantively different from other patients’ perceptions, Critical components of applying the patient safety
making it easy for a provider to believe that there is lens to complaints would include:
no need to change. While leaders charged with 1. Using the Just Culture and human factors approach.
improving care quality and patients’ experiences may Understanding complaints as adverse events would reinforce
recognise that a small number of complaints can the importance of applying the same Just Culture and
signal a significant problem, the small number of human factors perspectives to complaints that are used for
events may make it difficult to identify underlying any adverse event.11 In situations where the complaint origi-
problems with confidence. nated from system failure or human error, the provider
Context is always critical when interpreting data, would be consoled. For those complaints that were rooted
but is especially so for understanding complaints. The in at-risk behaviour, coaching would be indicated. And puni-
PRONE score provides one key piece of contextual tive action would be reserved for complaints that repre-
information, that is, whether a given complaint is best sented recklessness or deliberate insensitivity on the part of
interpreted as an isolated event or a sign of future the provider. Implicit in this application of the Just Culture
problems. There is, however, a need to look deeper in and human factors paradigms would be the use of formal
order to identify recurrent problems and patterns event analysis for at least a portion of patient complaints to
within and between providers, specialties and systems. identify the fundamental root causes and develop system-
Complaints could be examined along multiple dimen- based prevention plans, such as communication skills train-
sions, such as provider behaviour (eg, rudeness, insuf- ing or revisions to complaint-prone care delivery
ficient information provision, insensitive delivery of a processes.12
diagnosis), clinical situations (eg, decision making Yet the paper by Spittal and colleagues, which
about surgery, transitioning to palliative care) as well focuses on the issue of recurrent complaints, exposes
as the more obvious dimensions such as patient diag- a potential weak spot in the application of Just
noses. Identification of patterns of complaints would Culture concepts: at what point do recurrent com-
inform interventions. For instance, if complaints plaints, even in the absence of obvious reckless behav-
about providers not listening were particularly iour on the part of the provider, cross over into
common in certain clinical situations, providers who requiring disciplinary action? There is a growing body

Gallagher TH, et al. BMJ Qual Saf 2015;24:352–355. doi:10.1136/bmjqs-2015-004337 353

 BMJ Qual Saf: first published as 10.1136/bmjqs-2015-004337 on 14 May 2015. Downloaded from http://qualitysafety.bmj.com/ on November 12, 2023 at UNICAMP - Universidade Estadual
Editorial

of literature on the predictors of unprofessional and New systems at the institutional and regulatory level
disruptive providers which underscores the need to are needed for monitoring and responding to patient
take a systematic approach to both collecting and complaints. One important challenge will be to iden-
acting on such data.13 If providers are generating mul- tify the most appropriate roles for different stake-
tiple complaints through what could be construed as holders. Healthcare organisations have pertinent local
at-risk behaviour, especially in the face of feedback information about why a provider may be generating
and coaching about how to modify the at-risk behav- complaints but also potentially have the strongest
iour, this pattern itself represents recklessness that incentive to ignore such problems. External regulators
would merit disciplinary action.14 such as state boards of medicine possess the public
2. Better reporting systems for identifying and responding to accountability and ability to respond objectively to
patient complaints are required. Cumbersome, complaints that healthcare institutions may lack and
difficult-to-use reporting systems may discourage complaints also have powerful tools for motivating physicians to
and are suboptimal because they expose only the tip of the change their behaviour such as taking disciplinary
iceberg.10 For every complaint received, an unknown action against physicians’ licences. But these external
number of patients has had similar experiences and suffered regulators often have little access to data about the
similar harm in silence. Proactive surveillance coupled with overall performance of the provider in question, peer
simple, easy to activate reporting systems would provide review information that healthcare institutions guard
more complete information and lead to greater learning, zealously.
much as improved adverse event reporting has been enabled The patient safety movement has taught us that pro-
patient safety efforts. Strategies for rapidly categorising com- gress in reducing adverse events begins with taking
plaints would further enhance the value of increased report- preventable harm seriously, and goes on to stress the
ing.8 Of course, systems which actively encourage value of a systems perspective to understand the con-
complaints will need to include effective strategies for tributing factors and to design innovative error reduc-
tion strategies. Progress in reducing patient complaints

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responding to problems, or dissatisfaction will only be
exacerbated. will require the same approach, and must also begin
3. Transparency and open communication is key. with a change in perspective. The patient safety move-
Transparency in all its forms is critical to detecting and ment challenged the belief that complications were
responding to the care breakdowns that generate patient ‘the cost of doing business’ and highlighted that many
complaints, just as such openness is essential to addressing harms, from adverse drug events and healthcare-
any patient safety problem. Once the care breakdown has associated infections through to procedural complica-
been identified, transparent and open communication with tions and missed diagnoses, could be avoided.
the affected patient, following current recommendations for Similarly, we must overcome the inclination to dis-
disclosure after any adverse event, is critical.15 count patient complaints. Analysing complaints sys-
Post-complaint conversations should include transparency tematically and recognising situations and providers
about what occurred, plans to prevent recurrences, a sincere likely to generate complaints constitute crucial steps in
apology and acknowledgement of the patient’s experience designing strategies to reduce complaints. But the first
of harm.16 And, the profession is going to need to become and most important step entails expanding our per-
more transparent with the public (at least in summary form) spective beyond the technical execution of care to
about patient complaints, including how these concerns are encompass and appreciate patients’ reports of their
being addressed if public trust in the profession’s commit- care experiences.
ment to improving care is to be restored.
Funding Agency for Healthcare Research and Quality Grant
4. Patient safety science is early in its development, and #5R18HS022757-02.
more research is needed. Perhaps the most important ques-
Competing interests None declared.
tion that arises from the findings of Spittal and colleagues is
Provenance and peer review Not commissioned; internally peer
how to intervene when patterns of recurrent complaints are reviewed.
detected. The PRONE score focuses on recurrences for a
specific provider, but complaints could also be evaluated for
recurrence within healthcare systems or clinical situations. REFERENCES
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