Aim To determine whether analysis of unsolicited healthcare complaints specifically focusing on unprofessional behaviour can provide additional information from the patients' perspective.
Methods A qualitative study with content analysis of healthcare complaints and associated judgements using complaints filed from 2004 to 2009 at the complaints committee of a tertiary-referral centre. Subsequent comparison of the resulting categories of poor professionalism to categories perceived relevant by physicians in a previous study was performed.
Results 137 complaints (98%) yielded 46 different unprofessional behaviours grouped into 18 categories. The element ‘perceived medical complications and error’ occurred most commonly (n=77), followed by ‘having to wait for care’ and ‘insufficient or unclear clarification’ (n=52, n=48, respectively). The combined non-cognitive elements of professionalism (especially aspects of communication) were far more prominently discussed than cognitive issues (knowledge/skills) related to medical error. Most categories of professionalism elements were considered important by physicians but, nevertheless, were identified in patient complaints analysis. Some issues (eg, ‘altruism’, ‘appearance’, ‘keeping distance/respecting boundaries with patients’) were not perceived as problematic by patients and/or relatives, while mentioned by physicians. Conversely, eight categories of poor professionalism revealed from complaint analysis (eg, ‘having to wait for care’, ‘lack of continuity of care’ and ‘lack of shared decision making’) were not considered essential by physicians.
Conclusions The vast majority of unprofessional behaviour identified related to non-cognitive, professionalism aspects of care. Complaints pertaining to unsatisfactory communication were especially noticeable. Incongruence is noted between the physicians' and the patients' perception of actual care.
- Professional behaviour
- quality improvement
- quality in healthcare
- medical education training
- adult intensive critical care
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- Professional behaviour
- quality improvement
- quality in healthcare
- medical education training
- adult intensive critical care
The importance of both development of professionalism and addressing unprofessional behaviour are increasingly underscored in both scientific and public domains. As with any subject, different perspectives, for example, the students', teachers', physicians', and patients' perspective, result in different views on the matter. Recently a study among physicians determined which elements of professionalism are considered important from their perspective.1
It is estimated that approximately 15% of physicians will be ‘impaired’ in the sense of being unable to fulfil their professional responsibilities, for example, due to substance abuse or psychiatric illness at some points in their careers.2 Apart from diagnostic and treatment errors, impairment may result in inappropriate professional behaviour, such as ineffective communication, failure to attend to patients' psychological needs, an uncaring or disrespectful manner, not relating appropriately to patients and boundary violations.3 ,4 These violations of standards of professionalism are associated with poor adherence to guidelines, impeded collaboration, information transfer, workplace relationships, low staff morale and turnover, and also to medical errors, adverse outcomes and malpractice suits.5–15
Unsolicited patient complaints can also be predictive of malpractice risk,16 ,17 and they ‘connect dimensions of medical care that are unsatisfying to patients in dimensions that may be injurious to them’.18 Although both quality of care and professionalism are considered as part of the core business of contemporary healthcare, data on patient satisfaction and complaints have only recently been recognised as a valuable source of information.19–28 Patient satisfaction surveys are commonly invitational and distributed by hospitals to patients after discharge, whereas voluntary complaint processes are initiated by patients.28 Patient satisfaction survey ratings of inpatient physicians' performance are associated with complaints from patients and with risk management episodes (defined as incidents that can lead to legal action or for which a compensation request is filed).29 Wofford et al reported that at least one-third of US patients experienced some degree of dissatisfaction with their hospital care,27 but only a minority of patients actually talked about their experiences with physicians, while even fewer lodged a formal complaint.27 ,30 Earlier studies reported that 20% of patient complaints were due to communication problems between patients and healthcare providers and 10% were based on perceived disrespect.31 A recent content analysis study reported that at least 35% of unsolicited complaints were related to professionalism issues.28 It thus appears that episodes of disruptive, unprofessional behaviour are neither common nor rare.5
Wofford et al used the business adage ‘A complaint is a gift’ to underscore that ‘complaints may offer valuable feedback to business organisations from which they can learn to better serve their customers’.27 Healthcare organisations may likewise benefit from systematic monitoring of patient (dis)satisfaction and analysis of patient complaint data to enhance quality assurance and improvement.27 An analysis of complaints specifically relating to professionalism could thus provide valuable additional information about professional lapses in healthcare from the patients' perspective.
Aim of the study
To investigate whether systematic analysis of complaint letters and judgement letters can provide additional valuable information on unprofessional behaviour in healthcare from yet another perspective: that of the patients.
Purpose of the study
In this study we therefore:
Performed content analysis of unsolicited healthcare complaints to determine the presence, extent and nature of elements of poor professionalism.
Performed comparable content analysis of the judgements from the hospital Complaints Committee regarding these complaints, after which the results from the complaints letters and judgements were compared.
Compared the resulting categories of poor professionalism with categories of professionalism perceived important by physicians (intensivists-in-training), as determined in a previous study.1
Between 2004 and 2009 the Patient Information Centre, the Complaints Officer's Office and the Complaints Committee received 368, 2199 and 140 complaints, respectively (for the study context, see box 1). This study involved analysis of only those complaints that reached the stage of being lodged with the Complaints Committee during the period of 5 years that was studied and of the related judgements, 140 in total (5% of the total), over this period. The study period was selected since the hospital complaints database contains detailed records of complaints filed at, and the judgements of the Complaints Committee in this period. All complaints were retrieved from storage and anonymised by the Complaints Committee before analysis by the authors.
Maastricht University Medical Centre is an academic tertiary care referral medical centre in Maastricht, The Netherlands. Its annual activities comprise approximately 30 000 inpatient admissions, 400 000 outpatient visits, 26 000 emergency department visits and 18 000 day-case visits. Patients' dissatisfactions and/or complaints can be voiced and handled on different levels. The Patient Information Centre provides easily accessible support for patients that are dissatisfied with their care. When initial efforts to resolve reported issues are not effective, the Complaints Officers provide further support and impartial mediation. When the Complaints Officer and/or the patient deems it necessary, the patient can request the Complaints Committee to pronounce a formal judgement in accordance with a law enacted in 1995 defining patients' rights to lodge complaints with healthcare providers. The patients must submit their complaint in writing, and after a formal hearing, the Committee pronounces a judgement. The Complaints Committee can advise the board of directors to make improvements in the organisation of care.
We subsequently conducted content analysis of complaint letters and judgements using qualitative data analysis software (Atlas.ti.V. 5.2.0).32 This involved systematic collection and analysis of qualitative data33 using standardised coding principles.34 Elements of professionalism which we had established in prior research were the starting point for coding.1 Apart from elements of professionalism, more general aspects of the complaints were also documented (the nature of this previous study is outlined in box 2). When we came across elements of professionalism that did not fit the previous coding scheme we assigned new codes.1 Multiple units of comments contained in one linguistic clause but covering different topics were coded as different units of comments. WvM analysed all the transcripts and SG cross-checked the coding scheme. Disagreements between the researchers were resolved through iterative discussions. After consensus was established, the unprofessional behaviours were restructured into more abstract categories. Descriptive statistics were obtained from quantitative analysis of the codes and categories using SPSS V. 188.8.131.52 The categories of poor professionalism identified in this study (the order of which was determined by the number of codes assigned to unprofessional behaviours within each category) were used as a starting point for comparison with professionalism categories identified as relevant in the previous study among physicians.1
The physicians' study
A nationwide qualitative study was performed using focus group interviews. The moderator asked participants to clarify the terms professionalism and professional behaviour, and the ways these are learnt. Qualitative data analysis using an inductive coding approach was performed. Thirty-five (out of 90) fellows across eight groups participated. The emerging themes considered most relevant for intensivists were adequate communication skills, and keeping boundaries with patients and relatives.
Ethical committee approval
The Maastricht University Medical Centre's board of directors, the medical director and the Complaints Committee approved the research protocol of this study.
In the next paragraph, we consecutively report the general characteristics of the complaints and the judgements and the unprofessional behaviour identified therein, and compare the categories of poor professionalism derived from the complaint letters with the categories identified as relevant in a previous study among physicians (intensivists-in-training).1
Two complaints were withdrawn before judgement was pronounced and one complaint file was in use in the adversarial process and was therefore not available for analysis. Thus, 137 complaints and the related Complaints Committee judgements were analysed.
General characteristics of the complaints and judgements
The majority of complaints were from patients (84/137 (61%)) or their partners (21/137 (15%)), children (13/137 (10%)) and parents (10/137 (7%)). Of the complaints 81/137 (59%), 7/137 (5%) and 3/137 (2%) were about physicians, nurses and other healthcare professionals, respectively. Twenty-one per cent of the complaints (29/137) involved multiple categories of healthcare providers, such as physicians and nurses, while 17/137 (12%) of complaints were directed at a more general, organisational or departmental level. Thirty-seven per cent of the complaints (51/137) resulted in 67 recommendations to the board of directors relating to organisational issues (20/67 (30%)), provision and transfer of information to patients and other care providers (19/67 (28.5%)), need for adequate protocols (8/67 (12%)), responsibility for coordination and continuity of care (8/67 (12%)) and collaboration with regional hospitals and family physicians (5/67 (7%)). Other suggested areas of improvement were transfers/handovers (1/67 (1.5%)), record keeping and documentation (3/67 (4.5%)) and patient-centeredness (3/67 (4.5%)).
Unprofessional behaviour identified in formal complaints and judgements
Forty-six different unprofessional behaviours were identified in the complaint letters and judgements of the Complaints Committee, 29 of which occurred more than five times in the total 137 complaints (table 1). Unprofessional behaviours in the remaining group of 17 items were language issues (eg, being addressed in the local dialect), noisy clinical environment and care providers not introducing themselves properly to patients. The unprofessional behaviours were categorised into 18 different categories (table 2).
Comparison of types of unprofessional behaviour in the complaints and judgements
Comparison of the occurrence of the 46 types of unprofessional behaviour in the complaint letters and the related judgements yielded between one and four additional types of unprofessional behaviour in 50% (69/137) of the complaints. The elements ‘medical error’, ‘insufficient clarification’, ‘organisational issues’, ‘lack of leadership’ and ‘lack of respect for patients' and relatives' opinions’ were mentioned 8 to 26 times more often in the judgements than in the patients' letters.
Comparison of the categories of poor professionalism derived from the complaint letters with the categories identified as relevant by physicians (intensivists-in-training)
The categories of poor professionalism established in this study were compared with the categories of professionalism elements, which a prior study had shown to be considered relevant by physicians (intensivists-in-training) (table 2).1 Many categories were identified in both studies, that is, were mentioned both by physicians and by patients or their family members, but some categories mentioned by the physicians were more abstract, less specific and less concrete than those identified in the present study. Categories like ‘norms and values’, ‘attitude’ and ‘altruism’ did not occur in the letters. Three categories that were considered important by the physicians were not mentioned by the patients and relatives in their complaint letters: ‘keeping distance and respecting boundaries with patients’, ‘technical skills’ and ‘appearance’. Eight categories of poor professionalism that emerged in the present study were not considered essential from the physicians' point of view: ‘waiting for care’, ‘continuity of care’, ‘documentation and record keeping’, ‘shared decision making’, ‘accessibility and approachability’, ‘problems around discharge’, ‘financial issues and billing problems’, and ‘privacy of the patient-doctor relationship’.
The first part of the discussion consecutively discusses the objectives of the study. Subsequently some general lessons to be drawn from the results and the study's limitations are discussed.
Characteristics of the general complaints and judgements
The results confirm that patients are quite tolerant about the received unsatisfactory healthcare,27 ,30 with only a minority of patients and relatives (5%) making a formal complaint to the Complaints Committee. In our study, the majority of complaints were about physicians and one-fifth concerned other healthcare staff. The general literature on complaint analysis includes reports of similar findings, such as those of a nationwide Finnish study,36 but an Australian study of complaints lodged with the Office of Patient and Family Relations found that 78% of complaints were not about physicians.28 This notable difference with our results may be, at least partly, due to the fact that complaints filed at the Patient Information Centre and the Complaints Officer's Office were not included in our analysis.
Unprofessional behaviour identified in complaints and judgements
Perceived medical errors and complications are at the top of the list of unprofessional behaviours generated by our content analysis (table 1). That unintended medical harm due to adverse events is indeed a major issue reflected by their reported occurrence in 5.7% of 1.3 million hospital admissions in The Netherlands in 2004. Of these cases 2.3% involved preventable harm.37
Although professionalism was initially defined as ‘a body of knowledge (cognition) and skills (expertise) put into the service for the welfare of society’, the largest share of the currently prevailing concept of professionalism is grounded in the non-cognitive domain.20 Our results show that although medical issues still play an important part in unsolicited healthcare complaints, complaints pertaining to the (more generic) aspects of professionalism by far outnumber the specifically medical elements (tables 1 and 2). Complaints about unsatisfactory communication were particularly conspicuous in our results. The unprofessional behaviour reported most frequently in this category was ‘insufficient clarification/unclear information’, which comprised unclear information about diagnosis and treatment due to the use of too much medical jargon and failure to provide written information (brochures) to the patient. No or insufficient information about reasons for delay in medical care, such as expected time of surgery, was another source of anxiety and frustration. Other authors have pointed to the benefits to patients and staff that can be achieved by improving information and communication.38
Comparison of the categories of poor professionalism derived from the complaint letters with those categories of professionalism aspects identified as relevant by physicians (intensivists-in-training)
The complaint letters provided more specific and concrete descriptions of unprofessional behaviours, compared with the more abstract formulations, such as ‘attitude’ and ‘altruism’ by physicians.1 Comparably, physicians' concerns regarding ‘keeping distance and respecting boundaries with patients’ and ‘appearance’ were never cited as a cause for complaint.
Despite these differences, many categories of poor professionalism derived from the complaint letters were nevertheless perceived to be important by the physicians too. It seems that although physicians and patients share a common denominator of aspects of professionalism that are important, the practical implementation by physicians requires further attention. Physicians' practice is not yet optimally congruent with their rhetoric (table 2). An example is lack of teamwork, with complaints focusing on poor communication between individual staff members and within and between specialties. This suggests that additional courses on leadership, team development, teamwork training and team communication might be useful in improving patient satisfaction.
More disturbingly, eight categories of poor professionalism derived from the complaint letters analysis were not considered essential from the physicians' point of view. This may be explained by the fact that physicians, unlike their patients, do not experience the negative effects of, for example, ‘having to wait for care’, the category of poor professionalism that showed a very high frequency rate in the complaint letters and includes, for example, repeatedly hearing that all theatres are occupied and (again) having to wait for surgery. Waiting for care had almost equal prominence in the complaints, as did ‘medical error and complications’!
A second important patient grievance that was not recognised by physicians was ‘lack of continuity of care’, which was perceived as suboptimal due to ever changing doctors and nurses. Increased workload and part time work and the recent restriction of duty hours may partly explain this problem.20 In the literature time pressure is also identified as a barrier to incorporating professionalism in daily practice,39–41 although it has also been suggested that reduced working hours can promote fellows' well-being, personal development, reflection and teamwork.39 ,40 This apparent contradiction between demands of contemporary medical practice and the striving for excellence in professionalism is increasingly noted,1 and may even contribute to burnout and premature retirement from clinical practice.42
The concept of professionalism does encompass the entire continuum from the individual (attributes, capacities and behaviours), via the interpersonal (interactions of patients and healthcare professionals) to the macro-social level (eg, institutional and social responsibility and economic imperatives). In the same way, our results appear to identify potential areas of improvement on all three levels, with beneficiaries extending from the individual healthcare professional to the institution and society as a whole. It has indeed been suggested that in order to make any sustainable quality improvement, hospitals should be more proactive and not be content to (only) respond to patient complaints in a reactive way on an individual, case-by-case basis.43 Complaint data should preferably be systematically documented in a complaint management system that can support analysis of individual (case-to-case) complaint data, and provide information about structural systemic problems.43 We found that 140 isolated complaints resulted in 67 recommendations to the board of directors for system improvements. In line with the abovementioned findings, a sizeable proportion of these recommendations pertained to organisational aspects of the provision and transfer of information to patients. Signalling of unprofessional behaviour leading to patient complaints thus can and should be succeeded by focused intervention and remediation strategies. In the authors' opinion, recurrence of unprofessional behaviour on an individual, departmental or institutional level despite adequate remediation strategies should be followed by additional interventions, including eventual cessation of training or occupation if necessary. Development of frameworks fit for this purpose is in its infancy in The Netherlands.
The general lessons pertaining to the individual and interpersonal domains that can be drawn from the results of this study are summarised in box 3. Although they are derived from patients' perceptions of what transpired during their hospital stay, some of the findings are confirmed by prior studies comparing video-taped communication behaviours of physicians who had and those who had not been involved in malpractice suits.44 ,45 Many aspects mentioned in the table are not markedly new, and are also touched upon in recommendations and guidance in the UK's General Medical Council's ‘Tomorrow's doctors’ report.46
Lessons regarding adequate patient-physician communication: dos and don'ts in communication (adapted from studies on the relationship between malpractice suits and patient-physician communication (with permission), and the study herein presented).44
Prepare for the meeting, make sure a well-equipped room is available, with sufficient chairs for all participants and preferably have a nurse present.
Before seeing patients, take time to prepare by reviewing their charts. Knowing about patients' situations before you meet is one of the indications of your respect.
Introduce yourself properly to your patients and, if circumstances permit, shake hands with them. This gesture shows concretely that you acknowledge patients as people in their own right and thus helps establish good rapport. Communicate in the national language, and not in a local or regional dialect.
Acknowledge patients as individuals with their own stories to tell; let them describe what symptoms or problems mean to them personally. Acknowledge the individual human behind the patient, lack of sympathy and/or empathy is noticed by patients. Offer reassurance where possible.
Pay close attention to and regard for remarks and observations/views made by the patient and relatives, and if the related request seems reasonable and achievable, agree with them.
Show patients they have your full attention, and avoid interruptions during interviews. Interruptions influence how patients perceive the duration and quality of consultations, particularly when the visit is short.
If you do not have much time or feel rushed for any reason, it is better to tell patients how much time you have rather than risk their interpreting your behaviour as a sign of indifference. Adjust the amount of time allotted if you are delivering bad news. Remember that bad news has to be considered from patients' perspectives, not your own.
The more meaningful the content of the interview or conversation to patients, the greater the chance your interventions will succeed, and the more satisfied patients will be. Make sure to provide clear information, avoid medical jargon. Appropriate humour is appreciated, cynicism and arrogance is misplaced.
Discuss the diagnostic or treatment plan with the patient and/or his relatives in a process of shared decision making, rather than simply conveying your own opinion, or leaving the decision completely to the patient. Exerting pressure, intimidating or threatening patients or relatives is extremely unprofessional.
Take time to make sure your patients understand you. Never take it for granted that they do! Despite your best efforts to explain situations, patients' understanding is often fragmentary. And, if they do not understand, they will think you explained matters badly.
Take time to ask patients if they have any questions. Provide patients with sufficient time to think about the information they received.
Never make promises you cannot keep: “I'll come and see you at the end of day”, or “I will perform the necessary surgery myself”, for example. To patients, a broken promise is a sign of negligence, lack of regard, perceived lack of commitment and responsibility.
Never expect patients to voice dissatisfaction or give their opinions spontaneously; the traditional asymmetry in roles dictates that physicians ‘run’ interviews.
Admit mistakes and errors to the patient, report them to the responsible authorities, and make sure these reports are dealt with in a professional manner.
Patients should be informed about the process and the outcome of their complaints and reports.
Schedule structurally planned meetings with patients and relatives to discuss progress regarding diagnosis and treatment, preferably with the same central contact.
Make sure there is clarity for the patient who is the physician in charge of care and cure: who is coordinating the process of care, who is responsible, who is the central person to address and schedule appointments with. The latter will prevent the patient being confronted with incorrect views and information, as well as information varying from one physician or nurse to the other.
Try and avoid too much variation in treating physicians and nurses. Try to approach the patient and his medical problems with objectivity, and to resist the influences of (a sometimes pressing) environment: maintain you own professional values despite for example, less optimal approaches due to time/work pressure or other contextual circumstances.
Adequately and timely communication with all colleagues within the same and other specialties about the diagnostic and treatment plan. Make sure all information is correct, not too limited nor superfluous or irrelevant in nature. However, do not discuss a patient's medical problems without the patient's consent.
Make sure accessibility for ad-hoc communication and making appointments is optimal; calls should be answered rapidly, and returned if an immediate solution is not within reach.
If information provided to the patient may prove incorrect against the odds, inform the patient or his relatives about the reasons for the unexpected change on time, for example, in clinical condition, scheduled surgery.
Attempt to prevent delays in care as much as possible; they form a serious grievance for patients. Pay sufficient attention to the patient's pain medication.
Adequately document all relevant issues, such as reasons for important medical decisions, and outcome of communication with the patient, relatives and/or co-treating physicians.
Unavoidable patient transport to other healthcare facilities should be carefully planned, adequately guided if necessary, and with all necessary documentation accompanying the patient.
Limitations of the study
This single-centre study included only local unsolicited complaints. However, it is known that complaint-related safety systems integrated in provider organisations such as hospitals are well positioned to receive and respond to patient complaints.18 ,47 Some of the identified issues may have resulted from unique local or (EU)regional factors (eg, language issues and issues related to methicillin-resistant Staphylococcus aureus). This may limit the generalisation of the results. Moreover, if our analysis was not limited to unsolicited complaints but included actively solicited pre-discharge patient interviews, more elements may have been found.48 However, an effect on patient satisfaction remains to be established for both approaches.48
Unsolicited patient complaints about perceived medical errors and complications are common, but the vast majority of complaints relate to professional aspects of care. Complaints about unsatisfactory communication predominate. Incongruence is noted between unprofessional behaviour revealed by the analysis of patients' (and relatives') complaints and professional behaviour as perceived important by physicians. Thus, there seems to be a discrepancy between physicians' contemporary practices and their rhetoric.
Complaints [no final apostrophe] analysis provides insight into unprofessional behaviour from the patients' perspective.
Areas of unprofessional behaviour identified by patients are not always recognised as relevant by physicians.
Complaints regarding unprofessional behaviour outnumber those regarding medical errors and complications.
Complaints on unsatisfactory communication predominate.
Physician's contemporary practice and rhetoric regarding professional behaviour are not always congruent.
Current research questions
This study suggests that systematic analysis of unsolicited healthcare complaints has the potential to provide insight into patient care-related professionalism aspects on an individual, interpersonal and institutional level. Further intervention studies followed by studies of potential improvement of physicians' behaviour and reduced occurrence of disciplinary actions and lawsuits are recommended.
▶ Irvine D. Patients, professionalism, and revalidation. BMJ 2005;330:1265–8.
▶ Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007;82:1040–8.
▶ Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med 2006;144:107–15.
▶ Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008;34:464–71.
▶ Rosenstein AH, O'Daniel M. Invited article: Managing disruptive physician behavior: impact on staff relationships and patient care. Neurology 2008;70:1564–70.
The authors thank Ms Mereke Gorsira, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, for critically reviewing the manuscript regarding use of the English language, and Ms N. Verleng, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, for assistance regarding digital data preparation. Finally, the authors are indebted to Dr A Muijtjens, statistician and methodologist, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, University of Maastricht, The Netherlands, for his advice regarding the study's statistical data analysis.
Competing interests None.
Patient consent Detail has been removed from these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.