Listen and learn: Patient complaints can help you build a better practice

Traditional surveys don’t reveal what’s bothering patients

It feels good to hear from patients who love you, but the ones you need to listen to most closely are those who complain. That is the conclusion of researchers at Vanderbilt University Medical Center in Nashville, TN, who analyzed more than 14,000 patient complaints received by the health system over a six-year period and studied malpractice risk. Some of the facts the researchers discovered are:

- A small group of doctors (about 8%) generates the most complaints, but those doctors do not differ in technical competence or outcomes when compared with their peers.1

- Aside from billing disputes, the most frequent complaint involves problems with diagnoses, treatment, and other aspects of care. Communication failures were another major cause of patient dissatisfaction.2 (See box, p. 27.)

- When patients of obstetricians with a high number of malpractice suits were interviewed, one-quarter complained of interpersonal issues, such as feeling that the doctor didn’t listen, didn’t respect their feelings, or rushed them.3

- Traditional patient satisfaction surveys can’t capture all of the dissatisfaction.

"Every marketing study that’s ever been done shows that for every one complaint, there are 25 to 100 more dissatisfied people who didn’t bother to complain but who left saying, I’m never going to deal with them again,’" says James W. Pichert, PhD, associate professor of education in medicine at Vanderbilt.

"In medicine, we’ve dealt with complaints and lawsuits one at a time," he says. "We’ve tried to deal with the individual customer. What we’ve failed to do is aggregate the data in a way to understand the patterns that may be occurring and attempt to intervene in a constructive way."

Pichert and his colleagues are developing a system of collecting, rating, and analyzing complaints, followed by feedback to physicians. They are studying the impact of interventions on complaints and malpractice-related activities.

Physicians accept feedback about complaints if it is presented in a supportive, non-punitive environment — and then will act to reduce the sources of dissatisfaction, Pichert says.

Here are some steps to take to address patient dissatisfaction:

o Understand how complaints can lead to quality improvement.

Rather than adopting a defensive attitude, physicians need to realize the value of complaints, says Gerald Hickson, MD, professor of pediatrics and vice chair of the department of pediatrics at Vanderbilt University School of Medicine.

"It’s like the old Chinese proverb, a complaint is a nugget of gold," he says. "Traditional methods of measuring patient satisfaction focus on the satisfied patient. But that doesn’t help you target your improvements."

Patients who are dissatisfied may be less likely to follow their recommended treatment regimen, says Pichert. They may leave the practice. And, in the case of an adverse outcome, they are more likely to sue, he says.

Yet physicians may not know about problems that occur outside the exam room. "You may be unaware of the ways your office staff, billing personnel, nursing colleagues, and others are treating your patients so your patients are really in a foul mood by the time you see them," says Pichert. "[Perhaps] there’s someone who’s been kept waiting, treated rudely. He had to walk half a mile because parking wasn’t convenient; there were paperwork foul-ups."

Scheduling problems, such as overbooking, also may lead patients to feel that their physicians are rushed — and not giving enough attention to their concerns.

o Set up a system for collecting complaints.

Follow the lead of other consumer-oriented businesses by making it easy for customers to report problems, say Pichert and Hickson. For example, you may place comment cards at the checkout desk.

You also can train your staff to be receptive to complaints and to record them even if the patient hasn’t taken time to put it in writing. One person may be designated as an ombudsman or patient advocate who can follow up on complaints.

Spoken complaints need to be handled in the same manner as written ones, says Bob Dewar, PhD, professor of organization behavior at the J.L. Kellogg Graduate School of Management at Northwestern University in Evanston, IL. "A little card takes time to fill out, [and] a lot of people are not articulate at the point of a pen."

Your patient satisfaction surveys also should include open-ended questions, such as "Were there any aspects of your care that you were dissatisfied with?"

"You need to take a very active role in making it clear that this culture accepts and welcomes patient complaints," says Hickson. "If we realize how valuable they are to us in molding our processes, then we should want them."

o Respond quickly to individual complaints.

Whenever Hickson receives a complaint, he follows up personally with a phone call to the patient or family member. "You may occasionally get a complaint that’s unreasonable, but I will not miss an opportunity to call the family" to allow them to air their concerns, he says.

If you leave space for comments on a patient satisfaction survey and the survey is not anonymous, you should contact all patients who respond, he says. "People will write things on there and anticipate a response and never receive one."

In fact, complaints offer the opportunity to turn negative experiences into surprisingly positive ones, says Dewar. "Look at that breakdown [in service] as an opportunity, not a problem. Because if you recover well, you can make people feel even better than they would have if the breakdown hadn’t happened in the first place."

Respond quickly to the complaint, he says. If you had a lapse in service, such as an excessive wait, explain why it happened and what you are doing to ensure it doesn’t happen again.

In some cases, you may want to reduce or eliminate the patient’s fee for the visit. The goodwill you create will far outweigh the lost payment, Dewar says. "What does it cost you to grow your practice and get new business? How do you even calculate that cost?" he asks, noting that engendering patient loyalty is good business.

Hickson agrees that writing off a bill makes sense when a patient has been inconvenienced. But in the case of a poor outcome, you don’t want to seem to be hiding anything by eliminating the bill, he cautions.

o Categorize and analyze complaints.

Individual complaints will seem like isolated incidents unless you have a system of collecting and analyzing them, say Pichert and Hickson.

"What we’re finding is too often institutions miss the opportunity to learn about themselves because they don’t centralize and analyze the capture of complaints," says Hickson.

o One person in the practice can take responsibility for reviewing complaints.

Pichert and Hickson are developing a Patient Advocates Reporting System (PARS), which includes software to capture patient complaints in narrative form. A trained rater uses descriptive codes to identify the type of complaint.

"One incident report might include more than one kind of complaint," says Pichert. "The patients may start out complaining about a bill they got that they didn’t understand. With a little probing, you find out the reason they’re complaining is because they didn’t get the service they wanted, the nurse was rude, the doctor was rushed, the waiting room was filthy, and [staff] didn’t return phone calls the next day for test results."

In PARS, physicians receive biannual report cards listing their complaints over a four-year period compared to their peers. (Codes are used instead of names; the complaints are collected by the medical center’s Office of Patient Affairs.) Through a formula that takes into account that physicians may have responded to complaints and improved their performance, recent complaints receive greater weight in the report card than earlier ones.

o Identify patterns in complaints and provide feedback to physicians.

The last step in PARS involves "peer intervention." High complaint-generating physicians receive a visit from a mentor, a fellow physician who has been trained to provide feedback. The report card and coded complaints are used to explain the variation and source of dissatisfaction.

"If you’re going to use the data to sit down with physician colleagues and say, You’ve got a problem here,’ that sort of encounter has to be based on reliable data," says Hickson.

The encounter also is nonjudgmental, and the data on high-complaint physicians aren’t revealed to administration. "The assumption is you’re not a bad apple. You may be caught in a bad system," says Hickson.

Hickson and Pichert have included other medical groups and institutions in their research, as they seek to determine whether the intervention reduces complaints and malpractice actions.

"We’ve been stunned with some of the results we’ve seen," Hickson says. "Many physicians are able to review the data, understand what it means, and act in their own way to adjust to patient sources of dissatisfaction."


1. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA 1994; 272:1,588-1,591.

2. Pichert JW, Miller CS, Hollo AH, et al. What health professionals can do to identify and resolve patient dissatisfaction. Jt Comm J Qual Improv 1998: 24:303-312.

3. Hickson GB, Clayton EW, Miller CS, et al. Obstetrician’s prior malpractice experience and patients’ satisfaction with care. JAMA 1994; 272:1,583-1,587.

Common Causes of Patient Complaints

Patient complaints often have a common refrain. In fact, when researchers from Vanderbilt University Medical Center in Nashville, TN, analyzed 14,000 complaints, they were able to sort them into the following major problem areas:

- Billing/payment: More than one-third of complaints involve questions about bills — confusing statements, excessive charges, or bills from health professionals they never saw.

- Care and treatment: About one-third of patient complaints involve medication errors, adverse outcomes, concerns about delayed admission or quick discharge, and questions about the health professional’s competence.

- Communication: About 20% of complaints involve poor communication, feelings that a health professional didn’t respond fully to questions, didn’t listen, misled them, or criticized care by another health professional or the institution.

- Humaneness: About 10% of complaints involve patients feeling that a health professional was disrespectful — rude, unconcerned, or unprofessional.

- Access and availability: About 10% of complaints involve problems such as long waits, rushed visits, or failure to return phone calls.

- Environment: Patients’ frustrations with parking, equipment, or the physical facility (such as cleanliness) may spill over into their impression of their care.