Patients' and families' opinions via suggestion boxes for improving hospital care for cancer patients: Analysis of 3419 cases over 11 years

Abstract Background There has been a paradigm shift in cancer treatment from curing disease to both curing disease and caring for patients. In terms of care for patients, the opinions of patients and their families are important for improving medical services. Aim The opinions of patients and families were collected at Shizuoka Cancer Center (SCC) and examined from the standpoint of characteristics, response status, and temporal changes. Methods Patients' and families' opinions submitted to suggestion boxes at SCC over an 11‐year period (2005–2015) were analyzed. Opinions were categorized as complaints or compliments, with sub‐categories including “facilities, goods, and medical care,” “people,” “time,” and “other.” The status of facilities' response to complaints was categorized as “responded,” “did not respond”, and “difficult to respond”. Results Changes in the number of opinions and content over time were examined. In total, 3419 opinions were collected; 69.1% were complaints, and 30.5% were compliments. Of the complaints, 53.4% were related to “facilities, goods, and medical care” (mainly focusing on “poor product quality” and “shortage of goods”), 38.7% were related to “people,” and 7.7% to “time.” Of the compliments, 82.4% were about “people,” all of which concerned facility staff. Facilities' responses to complaints were as follows: “responded” (42.4%), “did not respond” (14.3%), and “difficult to respond” (43.3%). Conclusion Understanding patients' and families' opinions is effective for strengthening trust between patients and healthcare professionals, promoting holistic care.


| INTRODUCTION
The Institute of Medicine (IOM) recommends a patient-centered approach as a goal for the medical system. 1 Evaluation by patients, as the recipients of medical care, and incorporation of patients' perspectives are increasingly important. [2][3][4] In Japan, 1 in 2 people will get cancer during their lives, and 1 in 3 people will die from cancer. 5 There has been a paradigm shift in cancer treatment from medical treatment for curing disease to medical care that focuses on both curing and caring for patients. The latter requires individual care for cancer patients as well as the treatment of cancer lesions. Thus, medical staff are required to provide holistic medical care. from "disease-centered" to "patient-centered" approaches. 6  The current study examined patients' and families' opinions collected via suggestion boxes at SCC over an 11-year period using the four aforementioned measures.
The characteristics of these opinions, the facilities' response status, and temporal changes in opinions were investigated. The results contribute to an assessment of the overall usefulness of opinions for medical institutions. A "submission" is a patient's action to provide their comments to the hospital. The contents of a submission are processed by classification and are re-written by researchers into a short message for further analysis as an "opinion." The basic response policy consists of three points: (1) to respond when an opinion is justified and responding to it is feasible; (2) to not respond when no institutional response is required; and (3) to mark the opinion as "difficult to respond" if the opinion is justified but it is difficult to make an improvement or to respond because the relevant details are unknown. Thereafter, for patients (and/or their families) who have submitted their opinions and requested a response, the results of the investigation, along with SCC's response policy, are communicated via a meeting or in writing. In cases where opinion-Respect for the opinions of patients and their families 1) "Opinions of patients and families" collected through submissions to a suggestion box 2) Report on the "opinions of patients and families" addressed to medical staff 3) "Opinions of patients and families" heard at Patient Support & Inquires (consultation support center) 4) "Opinions of patients and families" mentioned in the annual patient satisfaction survey"

| Analysis method
Taxonomies are commonly used to understand collected patient opinions. Classification is used to analyze causes, make judgments about appropriate responses, share within the organization, and improve the efficiency of responses. 7 A highly effective taxonomy (three areas, seven categories, 26 subcategories) was proposed in a systematic review. 8 However, because opinions such as patient complaints in medical care may be influenced by the medical system and individuals, 9 it is necessary to avoid using taxonomies developed in other countries, with unique patient opinion analysis systems in each country. Many taxonomies in Japan have been created independently, [10][11][12] with no widely established taxonomy. In the current study, the opinions of patients and families in "A Collection of Opinions" between 2005 and 2015 were categorized as follows: 1. First, one author independently read 1101 submissions in "A Collection of Opinions" from a 3-year period, divided them into groups based on the contents, and conducted a short sentences.
2. The contents of the opinions were categorized as "complaints," "compliments," or "other." For "complaints," along with the expressed dissatisfaction of patients and families, opinion-givers' requests and proposals were also included. "Compliments" consisted of opinions indicating satisfaction and/or gratitude. "Complaints" and "compliments" require different responses from hospitals. Many international studies have classified "complaints" as negative and "compliments" as positive. [13][14][15] However, from the perspective of customer service and medical service, "complaints" are not a cause of harm, but rather an opportunity for insight. 7,16 3. The contents of "complaints" and "compliments" opinions were then further classified into "facilities, goods, and medical care," "people," "time," and "other." "Facilities, goods, and medical care" included facilities, equipment, consumable goods, and hospital systems related to patient care. "People" was divided into "institution staff" and "non-institution individuals". Institution staff included medical staff (e.g., doctors, nurses, and co-medical staff) but also administrative staff working at various counters and facility operations staff (e.g., staff who aided with meals, cleaning, and shops).
"Non-institution individuals" included patients, their families, and other facility users. "Time" covered time-related concepts, such as waiting time. 4. Regarding the contents of opinions, the responses of facilities to complaints were divided into "responded" (i.e., the opinion is justified, and a response is feasible), "did not respond" (i.e., there is no need for the institution to respond), or "difficult to respond" (i.e., the status quo had to be maintained as per past correspondence, or the details were unclear).

| Breakdown of categories
Regarding the content categories of patients' and families' opinions over 11 years, there were 2363 (69.1%) complaints, 1042 (30.5%) compliments, and 14 (0.4%) classified as "other." Complaints were predominantly related to "hospital food," "equipment," "response and attitude," and "waiting time." Most compliments referred to "environment," "equipment," and "gratitude toward staff in general." "Other" included "consideration for the physical condition of staff members" and "well-wishes from children who cannot visit the patient" (Table 1).

| Responses to complaints
The classification of SCC's responses to complaints yielded 1003 cases (42.4%) of "responded," 338 cases (14.3%) of "not responded," and 1022 cases (43.3%) of "difficult to respond." Of the complaints, primary examples of "responded" included "the Washlet (i.e., a toilet with a bidet function) is out of order," "the windows are dirty," and "I want you to make hand soap available." Examples of "did not respond" included requests for "free parking" and "entertainmentrelated objects." Examples of "difficult to respond" included "the waiting time is long" and "dissatisfaction with hospital food." Concerning complaints regarding "people," compared with other methods of opinion gathering, opinions obtained via suggestion boxes contained unclear details concerning "institution staff." For this reason, many such opinions were classified as "difficult to respond," as no concrete answer could be provided (Table 2). In the target sub-categories of complaints and compliments, the number of complaints about "facilities, goods, and medical care" gradually decreased from 60% to 50% over time, while those related to "people" increased from 30% to 40%, indicating a gradual increase over time (Figure 3). Complaints about "time" were consistently recorded at around 10%. Conversely, while there were slight fluctuations over time concerning the target sub-categories of compliments, those related to "people" accounted for approximately 80%.

| Temporal changes
For complaints regarding "people," "institution staff" accounted for 80-90% of these complaints over the studied period, with most concerning doctors and nurses. Complaints about "non-institution individuals" were mostly related to the manners of other patients and their families. Compliments were always directed to facility staff.
Changes over time with regard to facilities' responses to complaints were in the range of 40-50% for "responded," 10-20% for "did not respond," and 30-50% for "difficult to respond" (Figure 3). The food does not taste good. At first I thought it was perhaps because of the anticancer drug, but I hear many people say the same. Can you not make the food meet the regular hospital standards?

F I G U R E 2 Total number of outpatients and inpatients, submissions, and opinions
Air conditioning (temperature, humidity, and ventilation) management I think it would be better to put a humidifier in the rooms because I feel that the heating is sometimes too high. Furthermore, I think it would be good to establish a permanently cool room (resting place) that has a little air conditioning somewhere within the hospital.
Maybe it's the smell of the injection solution, but the smell is very strong in the outpatient treatment room in 3F. I wish you'd use an air freshener or something. It makes me want to puke.
Making appliances (mostly TVs) within the ward free of charge After being hospitalized, I felt that the TV card was too expensive.

People Responses and attitudes of nurses
Careless words cast by some of the ward nurses hurt me a lot. I wish they would be more considerate.

Responses and attitudes of doctors
Because the patients are very worried, doctors talking to them when the endoscope is being inserted or during treatment could ease their distress. However, the doctor who assisted me did not talk to me at all during this time (was silent). I was in pain and felt nauseous, and it was very difficult for me.

Responses and attitudes of unidentified staff members
Please address the elderly appropriately. Maybe they are acting like children because they are senile, but they are seniors in life. If my parents were treated the way I saw one elderly person being treated, I would feel really sad.

Time Waiting time for outpatient consultations is long
The appointment time was never honored. Perhaps too many bookings are made? This makes booking appointments meaningless.
Waiting time in pharmacy is too long I felt sick because the waiting time in the pharmacy was too long.

Compliments
Facilities, goods, and medical care Environment (e.g., cleanliness, quietness, seasonal characteristics, expansiveness, great view, no smells associated with hospitals, etc.) The hospital was hygienic and impeccably cleaned The hospital is like a hotel. The view from the 11th floor is great.
Facilities (e.g., latest medical equipment, library, kids room, computers, bed-side terminals, etc.) The kids room and restaurant, patient library, were great.
I felt truly relaxed when listening to the piano music playing in the hall. It was a moment in which I felt truly at ease.

People
Gratitude toward staff in general I was able to have a pleasant inpatient experience because all my interactions with the doctors, nurses, meal staff, and window cleaners were great.

Gratitude toward doctors and nurses
The doctors, nurses, and all the other staff in the ward were very kind. They were all considerate toward patients and their families. When they communicated with us, they were always using kind words with a smile. I am truly grateful for this. Although I kept bothering them because there were so many things I did not now, I feel truly glad that I was able to be hospitalized in this hospital.

Appreciation of reception staff and attitude of the nurses
Because all of the nurses spoke to me in a friendly manner, I was able to have an enjoyable hospital experience. Patients who come from afar, myself included, are not necessarily able to always see their families and friends, so the nurses became a huge source of support. Of the 3419 opinions reviewed in this study, the ratio of complaints to compliments was 7:3. Previous studies in Japan [18][19][20] reported that, while the number of submissions varied depending on the number of beds and length of periods studied, the ratio of complaints to requests/gratitude generally ranged between 6:4 and 8:2, which is a similar trend to that observed in the present study.
Regarding the sub-categories of complaints, "facilities, goods, and medical care" accounted for 53.4%; "people" accounted for 38.7%, "time" accounted for 7.7%, and "other" accounted for 0.2%. Regarding the facilities' responses to complaints, "responded" accounted for 42.4%, which included cases of aging/breakdown of facilities and equipment, insufficient cleaning, and shortage of goods. Regarding medical facilities in general, it is common for attention to be paid to medical care management without considering patients' daily needs.
T A B L E 1 (Continued)

Content categories Sub-categories Items Example
Other Consideration for the physical condition of staff members I think it was a hospital staff member, but at the vending machine, I saw a person who was providing support, standing at all times despite being pregnant. If possible, I want her to be able to sit down even at work.

Well-wishes from children who cannot visit the patient
Please help my grandmother because I want her to get well soon.

Response categories Example
Responded Equipment failure When I checked the computer in the day room of the ward, I found that it was out of order and immediately repaired it.

Shortage of goods
The patient library purchases about 30 general books and medical books every month. We will inform you about new books on the bulletin board in the library, so please check there.

No need to respond Parking fees
The fee for the outpatient carpark is paid by the user to cover the cost of managing the carpark and for the efficient use of the limited parking spaces. Free use for under 30 minu in the outpatient carpark is assumed to be used by the patient's transportation vehicle; otherwise it is assumed that the carpark will be used for between 30 min and 4 h, at a cost of 100 yen. Please understand that the fee is not high compared with neighboring hospital carparks. For those who have permission to accompany you, an exemption will apply if they park for more than 8 h, and the cost will be 200 yen a day for up to 24 h. Please contact the ward staff if you wish to use this exemption. Setting up entertainment-related objects We are not considering preparing Othello, which is not always necessary in medical treatment. If you wish, please prepare your own.
Difficult to respond Waiting times The waiting time in outpatient clinics is an issue for the entire hospital, and efforts are being made to shorten waiting times. However, long waiting times may still occur depending on the type of medical treatment. We will continue to attempt to reduce waiting times for medical examinations, so we hope you will understand.

Details unknown
Regarding an opinion about a nurse, we have confirmed it with the person in charge of the department as an anonymous opinion. However, we could not give individual guidance to the staff member who was the subject of the opinion. We instead decided to disseminate the content of the opinion through meetings and other occasions to alert the staff. Complaints classed as "difficult to respond" accounted for 43.3%.
While some of these complaints were justified, others included matters that could not be addressed because SCC would require more staff or a considerably larger budget, or because the content was unclear. In addition, some of these complaints stated that the waiting time for consultations was taxing. However, these complaints had various causes, with no feasible solution that can be adopted by SCC to address all cases.
Complaints regarding "people" also accounted for a considerable number of opinions. However, investigation into these complaints was often impossible, because the items in relation to the person against whom the complaint was lodged and/or the facts related to the issue were unclear. In such cases, the content of the submission was still times, and the proportion of opinions based on the total number patients halved. It is speculated that one factor behind this decreasing trend is the institution's responses to the opinions of patients and their families. However, while the number of complaints decreased according to the opinion-gathering system, the number has not drastically declined. This has led to the conclusion that it is necessary to devise methods to address complaints labeled as "difficult to respond," particularly when such complaints are justified. It is also necessary for SCC to continue appealing to patients and their families regarding the importance of adhering to group-living best practices while in the hospital. There are three major limitations in this study that could be addressed in future research. The study focused on a single Japanese cancer center and used a secondary analysis of existing data. Furthermore, the classification method used in this study was developed by one researcher, with two researchers confirming its validity. As future issues arise in the classification method, we will evaluate its objectivity and the possibility of using it throughout Japan and overseas.

| CONCLUSIONS
In this study, the opinions of patients and their families at SCC were analyzed using the booklet "A Collection of Opinions," developed over an 11-year period from 2005 to 2015. Through this analysis, we were able to report the characteristics and response status of these opinions submitted as suggestions. In particular, SCC was able to respond effectively to 40% of the complaints, which accounted for 70% of the total opinions. Among these complaints, there were many issues that were difficult for facility staff to notice, and, as such, they were useful in improving the hospital quality. In addition, compliments were an important source of information for improving patient satisfaction and the quality of medical care. Compliments were also linked to improving the motivation of individuals and/or related departments to adequately perform their duties. Activities aimed at taking the opinions of patients and families into account were considered to be an important method for strengthening the trust relationship between healthcare professionals and patients and families. These activities were also deemed to be crucial steps in implementing holistic medical care practices.