All EDs receive complaints. Inevitably, some people will voice their dissatisfaction with the quality of care, length of stay, attitude of providers, or cost of care. The approach of the department team and the institution distinguishes the organizations seeking improvement and satisfaction from those destined to repeat mistakes. To develop an effective approach, it is necessary to first understand why people complain.
We all experience dissatisfaction with some interactions because “reasonable” expectations go unmet. The ED is particularly prone to create dissatisfaction among those who use its services. Patients, private physicians, emergency medical services (EMS) providers, and staff all enter the ED with expectations of rapid, quality care by an attentive and kind staff. Unfortunately, it is impossible to always meet these expectations.
Why do people complain? Generally, people are dissatisfied when their expectations go unmet. If, in addition, they perceive that they have been inconvenienced and treated rudely, they are much more likely to voice their dissatisfaction in the form of a complaint.
Although the reasons for patient dissatisfaction are myriad, certain generalizations can be made. The duration of the relationship between the healthcare provider and the patient is positively correlated to patient satisfaction.1,2 The longer the relationship, the more satisfied the patient. The relationship between an emergency care provider and the patient is measured in minutes rather than years. This brief exposure allows little opportunity to develop the bond that may exist between a patient and a private physician.
Patient expectations of healthcare providers go beyond that of clinical competence. Patients expect their practitioners to be friendly, kind, and concerned and to take the time to explain the situation and answer questions.3
In the stressful setting of the ED, the ability to develop a rapid rapport with the patient and family enhances patient satisfaction. The greatest number of complaints lodged against ED workers is related to attitude and poor communication.4 It follows that those healthcare providers who adequately explain the nature of the problem or procedure are found to score higher on patient satisfaction scales than those who do not.1,5,6 More complete explanations create a better understanding and more realistic expectations of the course and outcome. In addition, those who are encouraged to and actually do ask questions about their illness are more satisfied.1,3,6
The Demographics of Complainers
There is substantial literature reviewing the characteristics of the complainer. Considerations of age, sex, and income levels are frequently cited.2,4,7
The relationship between age and complaint behavior is unclear. Although it has been suggested that the elderly are less likely to voice a complaint, this has not been substantiated in several studies. As compared to men, women are more likely to register complaints, which may relate to the fact that women are more likely to be involved in family healthcare decisions. Those with higher incomes voice complaints more often and are more likely to choose another provider as they generally have higher expectations, greater resources, and increased options to obtain alternative providers of care.2
Successful delivery of emergency care entails recognizing the responsibility to address the needs of those using the service. There are many ramifications of dissatisfied and complaining patients, peers, and customers. The ED census may drop, medicolegal cases may increase, and ultimately the ties between the practitioner and the institution may be severed.
People who are dissatisfied with service have 3 choices.8 They may “voice” a complaint, choose another provider (“exit”), or continue to use the service despite being dissatisfied (remain “loyal”). Interestingly, loyal but dissatisfied consumers are considered passive, seeming to “suffer in silence.”
Many dissatisfied people do not complain.5,9-11 They do not express their dissatisfaction because they believe it is not worth their time and effort, they do not know how or where to complain, or they do not believe it will do any good. In fact, fewer than 25% of patients who are dissatisfied voice a complaint to the service provider.
Many of these “noncomplaining” consumers may have a more subtle impact. Although unwilling to complain to the service provider, they may complain to friends and family, influencing their behavior and creating “negative word of mouth”.12 Further, they may seek satisfaction from third parties, such as governmental agencies or the legal system. Finally, they may choose other providers as suggested by the following passage.13
“You know me, I'm a nice person. When I get lousy service, I never complain. I never kick. I never criticize and I wouldn't dream of making a scene. I'm one of those nice customers. And I'll tell you what else I am. I'm the customer who doesn't come back. I take whatever you hand out because I know I'm not coming back. I could tell you off and feel better, but in the long run, it's better to just leave quietly. You see, a nice customer like me, multiplied by others like me, can bring a business to its knees. There are plenty of us. When we get pushed far enough, we go to one of your competitors.”
Changing providers (exit) once a relationship is well established seems difficult and requires substantial effort.2,14 However, literature reveals that up to 63% of patients change physicians when dissatisfied,11,15 which is much higher than previously believed. Those with medical (quality of care) complaints are twice as likely to seek alternative providers as those with nonmedical complaints.2
As the environment becomes increasingly competitive, patients may find the option of changing providers more attractive. This is particularly true in an ED setting because
- The provider-consumer relationship is superficial.
- Interactions occur unpredictably.
- The consumer's absence will go unnoticed.
- Many alternatives are available.
In the ED, a contraction of census will decrease the need for service providers, including nurses, physicians, and support staff. For an emergency physician group that exists within a fee-for-service environment, a dwindling census may be devastating. For employed emergency physicians and emergency nurses, fewer patients may obviate the need for their positions.
Third-party actions are increasingly viewed as an acceptable method of achieving satisfaction. Multiple agencies have created systems to receive and respond to consumer complaints. These include the Office of Consumer Affairs, Better Business Bureau, state medical societies and departments of health. There is an increasing tendency to use the legal system to seek redress.
Consumers have a greater tendency to seek third-party redress when they perceive that more direct interaction, such as voicing a complaint, is unlikely to lead to resolution. There is evidence that consumers perceive healthcare providers to be among the least responsive to complaint resolution among the service industries.14 Only about one-third of the consumers who voiced complaints believed their problems were satisfactorily addressed.9 Consumers dissatisfied with the response to their complaints may readily invoke third parties, including the legal system. Therefore, as a result of not handling complaints, ED leaders may unwittingly encourage third-party actions.
If there is a perception of ineffective problem management, the practitioner's (group's) relationship with the institution may become tenuous. Effective administrators expect problems to be found and solved with the subsequent development of procedures to ensure that the problem does not recur. Emergency care providers are expected to lead this improvement and not allow these problems to continue unabated by avoiding them. Nonparticipation is perceived as an “I don't care” attitude, which is often the reason for the complaint in the first place. Hospital administrators, medical staff leadership, regulatory agencies, and others may react decisively against unresponsive individuals and organizations by looking for alternative contractual relationships.
The Regulatory Imperative
Regulatory agencies look at problems, the systems used to handle those problems, and the methods to prevent their recurrence. The presumption is that if there is an effective system, future problems will be prevented through early recognition and resolution.
The Joint Commission (TJC) looks specifically at the institution's complaint management process. Reviewers often ask for evidence of the system. TJC requires guidelines regarding complaint management be incorporated into the organization's procedures. The 2010 TJC standards require16
The Elements of Performance Standard RI 01.07.01 address the resolution of patients' complaints. The standards require a complaint resolution process and informing individuals about the process. The standards also require response by the organization and the organization informing patients about their right to file complaints with the state authority.
Other regulatory bodies such as the New York State Department of Health further define the process necessary for institutional complaint management. In Code 405.7.23 the regulation states17
“[The hospital shall ensure that all patients…are afforded their rights [to]]: … express complaints about the care and services provided and to have the hospital investigate such complaints. The hospital shall provide the patient or his/her designee with a written response indicating the findings of the investigation. The hospital shall notify the patient or his/her designee if the patient is not satisfied with the hospital's oral or written response, the patient may complain to the New York State Department of Health's Office of Health Systems Management. The hospital shall provide the telephone number of the local area office of the Health Department to the patient.”
Hospitals and their leaders are responsible for developing and implementing mechanisms to promptly receive and respond to patients' and families' complaints. All hospitals provide their patients with a “Bill of Rights.” Most refer to a productive complaint resolution process. The organizations must thoroughly analyze the complaints and when indicated take appropriate corrective actions. The patients or family members making the complaint must receive responses that substantively address the complaints.14
Providing Patient Satisfaction
The job of leaders entails providing high-quality care while satisfying the perceived needs of those around them. It is helpful to look at patients, colleagues, staff, and others who use and interact with the ED and its services as customers. This business philosophy enables ED leadership to look closely at what patients and others want. To do this, it is necessary to first define customer service18:
“Customer service is a series of activities designed to enhance the level of customer satisfaction—that is, the feeling that a product or service has met the customer expectation.”
Therefore, satisfaction can only occur by meeting, surpassing, or modifying expectations.
A critical goal of any ED is to achieve high patient satisfaction. And yet, so often, providers create dissatisfaction by raising expectations, that is
- An emergency physician says, “The nurse will discharge you in a minute.”
- An emergency nurse says, “I'll be right back.”
- A private physician says, “Just go to the ED and get an x-ray.” The inexperienced patient may believe this will be a 10 to 20 minute excursion. If it takes 2 hours and the patient did not plan for it, every little additional delay creates frustration.
Patients are customers and the ED offers a service. If it is not delivered properly, EDs will lose their customers.
Merriam-Webster's defines a customer as “one that purchases a commodity or service.” Unfortunately, some practitioners who work in the ED reject the concept of patients as customers. This disregard is a form of arrogance that essentially communicates: “If the patients don't like what I say or how I say it, they can go somewhere else.”
Patients are not fundamentally different from people who buy computers, gas, or food. A person who comes for treatment of a broken toe and one who orders food in a restaurant both want service delivered quickly, courteously, with quality, and at a fair cost.
Patients want the same things that all customers want—the 4 Cs (Box 66-1)19:
- Convenience: When patients have a choice about emergency care, they tend to choose the institution that will get them in and out most quickly. Interestingly, healthcare providers rarely have the patience to wait in the waiting room of their own EDs when they or their family members are ill.
- Caring: Emergency care providers must develop rapport quickly. The success of the treatment approach once the patient is discharged depends on the trust developed. Patients judge providers most often based on the level of caring rather than the level of care.5,10 Caring goes beyond giving a high standard of care. The classic response, “I did everything correctly; just look at the chart,” just is not good enough. When dealing with people and complaints, the complaint manager (CM) initially must focus on how the process did not work for the patient (complainer) rather than trying to provide education and defend the process.
- Care: Generally, the lay public cannot judge the quality of care provided. Consider how difficult it is for an unsophisticated consumer to assess whether the examination was complete, the testing was appropriate, or the antibiotic was correct. It is only when the outcome is poor and unexpected that questions arise, perhaps even leading to questions of competence. Therefore, it is critical to recognize the patients' expectations and meet, surpass, or modify them. It is often prudent to both say and document: “You should improve with this treatment. If you are not better in __ days or you get worse, I would like you to immediately see your doctor or come back here.”
- Cost: Value is an important issue for those who use the ED. If a patient waited for hours, was treated rudely, or got worse in spite of treatment, the cost of care may seem inappropriate no matter how inexpensive. Conversely, patients who perceive that they received value—treated quickly, courteously, and correctly—are much more willing to pay a reasonable bill.
Box 66-1 The 4 Cs of Patient Satisfaction
Complaint Prevention Techniques
Though it is not always possible to meet patients' initial expectations, ED providers have many opportunities to modify or reset patients' expectations. In other words, unrealistically high expectations can be lowered and then met or surpassed (Box 66-2).
Box 66-2 Complaint Prevention Techniques |Favorite Table|Download (.pdf)
Box 66-2 Complaint Prevention Techniques
- Realistic triage
- Triage ordering
- Reset expectations
- Theory of “Yes”
- Questionably necessary test
- Closing questions
Triage provides the first opportunity to recognize and influence the patient's expectations. The most common patient complaint is related to duration of stay, perhaps based on patients' unrealistic expectations or a poor understanding of the process. The triage nurse may positively modify the patient's expectations by spending a few extra seconds to explain what will happen to the patient. For example, to a patient requiring an x-ray, the nurse could explain
“From here you will be registered and then wait in the waiting room until a room is available. I'll order an x-ray now so that once you're in the examining room you will receive a more in-depth evaluation by both the RN and the MD who will review your x-ray. The physician will determine your treatment and follow-up and then your nurse will give you discharge instructions. Generally, the entire process takes 90 minutes. Do you have any questions?”
It is appropriate to add a few minutes to the estimate of the patient's duration of stay to allow for the interruptions that typically occur in an ED. If the evaluation is completed sooner, the patient is thrilled because the lowered expectation will have been surpassed.
Operational protocols that empower the nursing staff to order necessary tests and begin treatments on patients can dramatically reduce the duration of stay. As in the example earlier, an x-ray or lab test that has been completed by the time the patient arrives in the examining room will reduce unnecessary waits.
While patients expect rapid care, it is not always possible to meet this expectation. There are several appropriate opportunities to modify the patients' expectations during the wait. After a particularly busy time, such as a resuscitation, the nurse or physician may go out to the waiting room with 2 or 3 charts in hand. An apology for and explanation of the delay, displaying respect and providing a legitimate reason, are usually very much appreciated. Then bringing 2 or 3 patients into the ED proper will confirm that the situation is improving. Once a patient is in an examining room, the same outcome can be achieved on an individual basis.
“Hello, Mrs Jones. I am Dr Smith. I am sorry that you have been waiting a while. I am taking care of a very unstable patient and expect to be back with you in about 20 minutes. In the meantime, I will ask the nurse to make sure we get your evaluation started and to keep me informed.”
The caveat is that if providing a specific time resets the expectation, the promising provider must be there at or before the promised time. If the provider gets “tied up,” he or she must send someone in to say it will be a little longer.
It is often helpful to begin the response to a request or inquiry with a form of “YES!” The “yes” is only meant to affirm that point of view of the other person, not to agree to the request. Consider the following response to a patient asking for something unreasonable: “No, you don't need that.” The message is, “I am the trained specialist and I know what you need better than you do.” Once the response begins with “No,” the communication and therapeutic relationship may deteriorate. Alternatively, according to the “Yes” theory, one might respond by saying, “Yes (sure), I can see that this is bothering you. Let me take a closer look so that we can figure out exactly what is wrong.” The communication now is one of acceptance—affirmation that the patient has a reasonable perspective. The practitioner has agreed to work with the patient to further elucidate the problem without actually agreeing to meet the unreasonable request.
The Questionably Necessary Test
The patient requests a questionably necessary test, convinced that the test is essential. When practical, a successful strategy is to involve the trusted private practitioner in the discussion. On other occasions, it may be appropriate to provide the desired test. The patient will leave satisfied and believe that the practitioner cared enough to make sure that the patient is okay. This is not substantially different from the practice of most practitioners who obtain ankle, knee, or cervical spine films that are of questionable necessity. Alternatively, if the practitioner successfully convinces the patient not to get the test and eventually pathology is found, the vindicated patient may be very resentful, or as Marshall Segal says20:
“When things go wrong, nobody ever thanks you for having saved them money.”
It is a good practice for each practitioner who participates in the discharge of the patient to routinely ask the closing question to ensure that nothing has been overlooked from the patient's perspective (Box 66-3). When given the opportunity, occasionally patients divulge their true concern only at the end of the visit, such as “Will I be okay?” or “Is it cancer?” Without that final opportunity to ask the question, the patient may leave dissatisfied. Other patients may notice or describe an additional complaint, such as “What about my…?” that may have been previously overlooked. Most often, the patient will respond with a “No, but thanks.” Some practitioners ask a closing question to obtain feedback on their own and the staff's performance. The closing question allows the patient and the practitioner to come to a definitive closure.
Box 66-3 Closing Questions |Favorite Table|Download (.pdf)
Box 66-3 Closing Questions
Is there anything else that I can do for you?
Have I fully addressed your medical problem?
Have you and your family been kept fully informed?
Have we provided you with excellent care?
Providing Satisfaction to Other Stakeholders
The hospital administration runs a service business that to be effective must listen to its customers and user groups. Included among the most influential are the patients and their insurers, who use the service and pay the bills; the primary care physicians and proceduralists, who control which of the paying patients will use the hospital's service; and the hospital board of trustees, the institution's governing body, which directly oversees the administrator. The emergency care providers are not among the most influential groups.
Administrators typically want ED staffs that are problem solvers, do not generate a lot of complaints, and keep the influential customers—the patients, physicians, and the board—happy.
The appropriate management of complaints, including trend analysis, cannot be overemphasized as one of the key tasks of ED leadership. When an effective emergency complaint management system exists, the process of handling a complaint proceeds down the following well-worn path:
- The administrator receives a complaint about the ED.
- The complaint is immediately and confidently forwarded to the ED CM for rapid resolution (because complaints have always been resolved quickly and effectively in the past).
- The complaint is resolved quickly and effectively.
- The ED CM communicates the resolution to the administrator (in writing).
- Processes are put in place to limit the recurrence of a similar complaint in the future.
The emergency staff requires leadership that solves problems. For instance, if a nurse or physician comes to the ED leader and states that there is a problem with another person or a process, it is incumbent upon the leader to investigate and attempt to resolve the problem. Staff issues generally do not go away and if ignored erode the confidence of the staff in the department leaders. Leaders who do not address the problem become part of the problem.
ED complaints from non-ED medical staff generally involve effectiveness of communication and quality of care.21 ED leaders should seek out these complaints and those who make them. Once made aware of the complaints, the CM should rapidly investigate them and communicate the results of those investigations. By moving quickly to resolve the concerns of the medical staff, ED leaders demonstrate that the greatest interest of the ED staff is to provide the best care possible to the patients and those who care for the patients. To achieve success, the ED leaders should articulate and promote a philosophy of partnership with the members of the medical staff.