One-year audit of complaints made against a University Hospital Surgical Department
- C. D. Mann MRCS, BSc; J. A. Howes MBChB; A. Buchanan MBChB, MRCS; D. J. Bowrey MBBCh, MD, FRCS (Gen Surg).
- This paper was presented at the Association of Surgeons of Great Britain and Ireland Annual Meeting, Bournemouth, UK, 2011.
Mr David J. Bowrey, Department of Surgery, Level 6 Balmoral Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK. Email: email@example.com
There is relatively little in the medical literature relating to complaints about the healthcare process. The aim of this study was to report the frequency and content of patient complaints against a University Hospital Surgical Department. In particular, the study aimed to relate the number of complaints to the number of health-care episodes and to determine the frequency of patient safety incidents and subsequent medico-legal action.
Retrospective interrogation of a prospectively maintained Complaints Department database at a University Hospital for the calendar year 2009.
Complaints relating to 360 aspects of the health-care journey in 113 patients were made. This translated into one complaint per 400 health-care episodes. Concerns about clinical care were cited in 31%, delays in the health-care process in 30%, communication issues in 19%, the institutional environment in 8% and poor discharge planning in 6%. Overall, 16 complaints (4%) were raised as patient safety incidents. Eighty-three per cent of complaints were addressed by a telephone conversation or a single letter response, 13% by a face-to-face meeting. Two per cent resulted in subsequent medico-legal action.
Although perceived in a negative way by health-care professionals, only 1 in 400 health-care episodes resulted in a complaint. Only a small number related to patient safety incidents or resulted in medico-legal instructions. Attention should focus on developing effective strategies to improve patient satisfaction with all aspects of the patient journey.
Over the past decade, there has been a shift towards recording and evaluating more meaningful information about the quality of health care. The most tangible of these are outcome measures, such as survival and length of hospital stay. The second domain is a record of patient safety incidents. A patient safety incident is defined by the National Patient Safety Agency (NPSA) as any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving National Health Service (NHS) care and is a standard process within the NHS framework. A third surrogate marker of health-care quality is a record of complaints against both individuals, departments and organizations.[1, 2] Complaints have an immediacy about them, in that feedback is rapid and has very much a ‘local’ dimension to it, although it may be difficult to make comparisons between centres. Outcome measures and patient safety incidents tend to require information gathering over longer periods of time to allow trends to be observed, and for benchmarking and comparison between institutions to occur.
By virtue of their local dimension often naming health-care professionals, complaints are perceived as an adverse judgement on an individual's clinical competency. In the UK, complaints against individual clinicians are reviewed as part of the annual faculty appraisal system. There is surprisingly little information in the literature relating to complaints, but a Google search identifies a plethora of sites where complaints can be lodged against health-care organizations.
Surgical disciplines, by their nature, tend to generate more complaints than other specialties because of the tangible nature of operative intervention, perioperative care and surgical outcomes.
The NHS complaints procedure comprises two stages: the first being local resolution and the second referral to the Health Service Ombudsman. Complaints can be made by the patient themselves or nominated legal or parliamentary representatives. Locally, complaints are initially managed by the Complaints Department. Acknowledgement of receipt of a written complaint must be made within three working days. Simple complaints are dealt with verbally within 10 days by a member of the Surgical management team who clarify the areas of concern and, where possible, respond immediately. Those that require a report are responded to within 25 days, and those that require multiple reports or independent review are responded to within 60 days. The Complaints Department coordinate reports from staff members involved, including responsible the consultant. A collated response is then made to the complaint by the General Surgical manager. This communication lists those members of staff from whom reports were obtained, summarizes the case, lists the issues raised by the complainant, and responds to these either with explanations or apologizes where necessary. Following this, they outline any action plan to be implemented to rectify any problems in the future, and contact details should the complainant be unhappy with the response and wish to arrange a meeting. Any subsequent meetings must then be arranged and the whole process completed within 6 months. Meetings are chaired by the General Surgical manager and provide an opportunity to resolve any issues outstanding from the written response. Learning from complaints is fed back to staff members involved and any serious incidents were discussed at multidisciplinary departmental meetings. Complainants have the right to take the matter to the Health Service Ombudsman within 12 months if they are dissatisfied with their response. The Ombudsman has powers to compel disclosure of documents and attendance of witnesses in investigating a complaint.
The aim of the current study was to retrospectively audit all complaints made against the General Surgical Department of a large university hospital over a 12-month period. In particular, the study aimed to identify the frequency of complaints, the number that give rise to medico-legal claims and the number that relate to patient safety events.
The study was a retrospective audit of all complaints received against the Department of General Surgery at University Hospitals of Leicester NHS Trust during the time period 1 January 2009–31 December 2009. Information was extracted from the prospectively maintained Complaints Department electronic records. Secondary sources of information comprised transcripts of complaint letters, logs of telephone conversations, response to complaint letters and minutes of meetings between hospital representatives and complainants. This time period was selected on the basis that sufficient time would have elapsed to report meaningful outcome information to 1 January 2011, allowing for a minimum follow-up interval of 12 months. The following information was recorded: patient demographics, source of complaint, nature of complaint, action taken and outcome. Records were reviewed and data extracted by one reviewer (CDM).
University Hospitals of Leicester NHS Trust comprises three hospitals. Elective surgery is conducted across all three sites and includes the specialties of breast surgery, colorectal surgery, hepatopancreaticobiliary surgery, oesophagogastric surgery and vascular surgery. Emergency admissions are received at two of the sites.
Permission for the study was granted by the Institutional Clinical Audit Standards and Effectiveness board. Patient consent was not required as it analysed freely obtainable data, albeit with patient identifiable information redacted.
Over the 12-month period, complaints were received relating to the care of 113 patients. Fifty-eight of the complaints (51%) were made by the patient themselves, 45 were made by relatives (40%), 8 were made by a General Practitioner (7%) and 2 were made via a lawyer (2%). During this period, there were 10 126 emergency inpatient episodes, 3737 elective inpatient episodes, 2101 daycase episodes and 29 138 outpatient episodes, giving a total of 45 102 general surgical health-care episodes. Overall, 1 in 400 patient episodes resulted in a complaint. Complaints were made regarding emergency treatment in 41 cases, elective inpatient care in 55 cases, outpatient treatment in 39 cases and daycase episodes in 8 cases. Each consultant received a median of 5e complaints, ranging from 0 to 16.
Complaints were directed against a total of 360 separate aspects of care in these 113 patients, a median of 3 per patient (range: 1–10). Aspects of care implicated are summarized in Table 1. Cited complaints comprised clinical concerns (poor medical or nursing care, poor prescribing and hospital-acquired infections) in 110 instances (31%), delays in the health-care process (delay in access to diagnosis/treatment, cancellation or rescheduling of surgery) in 105 instances (30%), communication issues (perceived lack of information, staff attitude) in 68 instances (19%), concerns about ward or hospital cleanliness or privacy in 28 instances (8%) and poor discharge planning in 23 instances (6%). A heterogeneous group of reasons accounted for the remaining 23 (6%), including quality of hospital food (n = 6), extended nil by mouth period (n = 4), restrictive visiting times (n = 4), lost medical records (n = 2), overnight ward transfer (n = 2), property theft (n = 2), being seen by medical students (n = 2) and different surgeon operating (n = 1).
Table 1. Breakdown summary of 360 complaints received relating to treatment of 113 patients
|Perceived lack of information||51 (14)|
|Poor staff attitude||17 (5)|
|Delays in health-care process|| |
|Delay in access to investigation/treatment||45 (13)|
|Rescheduling of operation||36 (10)|
|Delay in discharge from hospital||24 (7)|
|Clinical concerns|| |
|Poor nursing care||30 (8)|
|Poor medical care||28 (8)|
|Medication errors||21 (6)|
|Provision of post-operative analgesia||18 (5)|
|Hospital-acquired infection||7 (2)|
|Low ward staffing levels||6 (2)|
|Discharge process||23 (6)|
|Institutional environment|| |
|Ward hygiene||15 (4)|
|Patient privacy or dignity||13 (4)|
Clinical concerns were the largest cause of complaints (110 complaints, 31%). The majority of these pertained to perceived poor standards of nursing care (n = 30). Twenty-one issues involved medication errors, including failure to provide regular medications (n = 10), delays in receiving prescribed medications (n = 6), prescribing penicillin to allergic patients (n = 3), incorrect route of delivery of medication (n = 1) and opiate toxicity (n = 1). Eighteen issues specifically related to post-operative analgesia – inadequate provision (n = 11) and delay in administration (n = 7). There were seven issues regarding acquisition of hospital-acquired infection – Methicillin-resistant Staphylococcus aureus (MRSA) in three cases, Clostridium difficile in three cases and both in one case.
Twenty-eight complaints specifically were related to medical/surgical care (Table 2). The majority of these are related to the development of post-operative/post-procedural complications (n = 20). These complications related to the well-recognized and described post-procedural complications listed in the patient information sheets. In-hospital falls accounted for three complaints. No patient required orthopaedic surgical intervention as a result. There were three complaints relating to incorrect or missed diagnosis.
Table 2. Breakdown of 28 complaints relating to medical/surgical care
|Development of post-operative complication|| |
|Post-endoscopic cholangiography complications||3|
|Inadvertent small bowel or splenic injury||3|
|Bile leak after cholecystectomy||1|
|Nerve injury after axillary surgery||1|
|Delay in diagnosing post-operative complication||2|
|Incorrect or missed diagnosis||3|
|Hypoglycaemia in a diabetic patient||1|
|Inability to establish venous access||1|
Overall, 15 complaints were reported to the NHS NPSA as patient safety incidents – hospital-acquired infection in seven patients, prescribing errors in five patients and falls in three patients.
An initial reply was generated a median of 35 days from receipt of complaint (range: 1–199 days). Ninety-one (81%) of complaints were dealt with by letter only and two by telephone explanation (2%). Fifteen (13%) were resolved by local meetings. At the time of completing this audit, 96% (n = 108) of the complaints had been fully dealt with and closed. Three complaints were ongoing following coroner's inquests. Two patients (2%) had commenced legal proceedings against the institution.
Our principal findings were that complaints occurred after around 1 in 400 health-care episodes. Around one-third is related directly to the delivery of clinical care, and one-third to delays in the health-care process. Four per cent of complaints was related to patient safety incidents and 2% was followed by litigation.
In a 1-year period during 2008–2009, there were 89 139 complaints against the UK NHS. The information obtained from analysing such complaints is an important part of quality assurance and quality improvement for health-care service delivery. There is surprisingly little data in the literature relating to patient complaints against medical care. To the authors' knowledge, this is the only study in the literature to specifically analyse complaints made against a surgical department in the UK. Several studies have found that surgical deparments generate a higher number of complaints than non-surgical departments.[1, 4]
The relationship between complaints and patient safety incidents remains complex. In the UK, hospital-acquired infections with C. difficile and MRSA are reportable to the Department of Health. They are one of the performance indicators of health-care performance, in effect, they indicate patient safety incidents. However, other infective problems such as surgical site infections are not generally recorded as patient safety incidents, because these are well-recognized, inherent risks of surgery. The rationale for reporting some infectious complications as patient safety incidents and not others is arbitrary. It was based on the original premise that MRSA and C. difficile were formerly largely hospital acquired. Their epidemiology has since changed and many of these infections are now community acquired. Equally, there may well be instances when surgical site infections indicate a breach in standard of care, and some of these should be deemed patient safety incidents. Benchmarking of infection rates by comparison between institutions will likely yield more information on this situation. It is possible then that the true patient safety incident rate has been underestimated as a consequence of these anomalies in the current reporting system. This is a potential criticism of the current study.
It is not surprising that delays in the health-care process made up a considerable proportion of complaints. According to the Care Quality Commision statistics, 63 644 operations were cancelled on the day of surgery in England during 2008/2009. Initiatives such as admission on the day of operation, increased daycase surgery and enhanced recovery programmes are clearly useful in creating bed capacity; however, this is clearly an area against which further strategies should be targetted.
Poor communication has been previously highlighted as an important precipitant of patient complaints[6-8] and is known to influence malpractice claims.[9, 10] Effective strategies to improve on this domain represent a challenge. Traditional educational approaches have tended to focus upon ‘the breaking bad news’ aspect of communication rather than the day-to-day role of keeping patients updated. Most medical and nursing school curricula have now recognized this and are devoting time accordingly. However, it should be recognized that continuing education in the postgraduate setting is vital. Wofford et al. identified seven categories of physician behaviour that patients complained against: perceived unavailability, disrespect, inadequate information, disagreement about expectations of care, distrust, interdisciplinary miscommunication and misinformation.
It is important to note that over 80% of complaints were dealt with by a simple letter or telephone explanation. This suggests that many may have been preventable by better communication and explanation at the time of the health-care episode. The wide variation in numbers of complaints received by the different surgeons in this study underscores this. Murff et al. found that patients who developed complications after surgery were more likely to complain. Similarly, Kline et al. found that patients with complex presentation, multiple operations or long hospital stays were more likely to complain. Special attention to these groups in terms of better information giving is clearly important.
Health care has shifted to a consumer-led business. Many of today's patients are well informed and can provide useful input into improvements in health-care provision. Only 1 in 400 health-care episodes generate a complaint, with only a small percentage of these relating to patient safety incidents or resulting in litigation. Attention should focus on developing effective strategies to improve patient satisfaction with all aspects of the patient journey.