We can complain because rose bushes have thorns or we can rejoice because thorn bushes have roses. – Abraham Lincoln

Human beings seem hardwired to complain. To breathe is to complain, it seems. No one on earth is immune to complaints, or complaining! Unfortunately, the landscape can be so inundated with criticism, the more serious issues may be overshadowed, and left without the necessary ‘space’ for meaningful discussion.

In the healthcare arena, superficial complaints, which are a dime a dozen, are mixed in with well founded complaints. In the past, physicians usually held the most power in healthcare. Now there are many stakeholders, each viewing themselves as having a lot to lose (or gain). With the new empowerment of patients (called ‘consumers’ by some), and increasing power of government and industry, comes more engagement, more disagreements, and more opportunities to make suggestions or criticize.

Empowered customers are more demanding than ever….One of the ways businesses provide value is by doing the little things right…and that includes handling complaints. – Stan Phelps

Stakeholders and Complaints

Healthcare is a siloed industry, and, too often, stakeholders are not aligned, and not in agreement. Complaints ping back and forth between them, in different contexts:

• Complaints about Health systems and Hospitals, by Patients
• Complaints about Health Insurance
• Complaints about Physicians, by Patients
• Complaints by Healthcare Providers about Technology
• Complaints about Patients, by Physicians
• Complaints about other Physicians, by Physicians
• Complaints from Physicians, Patients and Payers, about the Cost of Medications

Complaints about Health systems and Hospitals, by Patients

Healthcare delivery systems have much to learn about attentive customer service regarding their patients. Some hospitals or healthcare organizations “get it” and some are tone deaf.

Everyone in the service industry knows that a certain percentage of people are just terrible whiners – complaining about everything under the sun. However, nine times out of 10 when a patient brings forward complaints about issues such as rude staff, bad food, or too much noise, they are invariably justified. – Suneel Dhand MD

Patient criticisms regarding safety, cost, quality of care/treatment, need to be addressed promptly and completely. Whether the patient complaint seems legitimate or not, it is imperative to listen and respond. Patients and their families have valuable insights about the healthcare experience. On the ‘provider’ (systems and individuals) side, transparency about errors and cost and pricing structures would help immensely. User friendly, informative, and engaging patient portals, access to complete medical records, and interoperability are all things important to patients, and important for patient engagement and quality of care.

Complaints about Health Insurance

Through the Affordable Care Act (U.S.) health insurance companies have gained more “control” (and responsibility) over a much larger share of healthcare delivery payments. To finance the risk, companies are shifting costs to patients through high deductibles and copays, and also limiting patient choice of physician through narrow networks.

Health insurance companies can anticipate complaints from this by:

1. Informing their constituents in an clear and timely manner about change in network status of their physicians
2. Providing a smartphone app whereby a patient’s expenses for various treatments can be calculated ahead of time. These costs are known because they are negotiated every year with providers
3. Processing claims fairly, promptly and in a non-confrontational manner. People just want the service for which they have dearly paid

Complaints about Physicians, by Patients

Paraphrasing from a brief piece by Richard P. Mills MD, MPH “Patient Complaints: Do You Open the Door?”:

Have heard of the Rules of 10? For every patient who complains to you, there are 10 who complain about you to their friends and family. For every patient who complains to you, there are 10 who complain to your office staff and you never hear about it. Do the math. If you hear a complaint, you’ve got a problem.

From “Malpractice Dangers in Patient Complaints” by Lee J Johnson, Esq:

Patient complaints about physicians and a healthcare event (s) must be taken seriously. Studies show that patient complaints correlate positively with malpractice risk. The unsolicited complaints cited problems with communication, humaneness, clinical care, billing, access and availability. Patients sometimes sue because they’re angry. If they are upset with you and you don’t listen to their complaints, they can find a plaintiff’s attorney who will listen. Plaintiff attorneys report that the patients/ potential plaintiffs often just want to be heard.

From the study “Relationship between patient complaints and surgical complications”:

In our study, surgical admissions associated with a patient complaint were more likely to be associated with major surgical complications, although overall the patient complaint rate was low. We were unable to determine from this study whether surgical complication experienced by patients who complained are preventable or directly related to poor quality of care. The patient might have experienced a non-preventable poor outcome and chose to register a complaint regardless of the quality of care provided.

Complaints by Healthcare Providers about Technology

Physicians and other healthcare professionals have much to complain about regarding today’s medical practice climate. Almost nothing is as it was; the disruption is chaotic, and, too often, seems counter to good patient care. The digital/mobile age has brought huge opportunities to improve healthcare but multiple adjustments (by all parties) must be made:

1. MDs need to take time to learn about the technology.
2. MDs need to be willing to test out/implement technology in their practices, and with patients.
3. MDs as “employees” of large hospital systems have a right to adequate training, and ongoing support for all technology systems bought/installed in hospital organizations.
4. Technology venders have a responsibility to follow through after installation to insure smooth workflow. Current complaints by physicians about EHR systems are legitimate, serious and show that patient care can be compromised by subpar technology systems and technical support. It is incumbent on both the purchasers and sellers of technology to adequately and completely service the end users: the healthcare providers (the systems) and physicians.
5. Healthcare professionals deserve respect, and, even further, leadership positions in healthcare systems, to insure that healthcare and overall system priorities are crafted to have maximum benefit for the MD/patient therapeutic relationship, and, patient care and patient safety.

Complaints about Patients, by Physicians

There is significant physician frustration centered on the epidemic of lifestyle diseases, poor patient lifestyle choices, and overall lack of patient adherence to (or understanding of ) agreed-upon healthcare treatment plans. Physicians are challenged by ever increasing legions of sick people due to our population’s sedentary lifestyle, poor diet, and lack of exercise. However healthcare professionals are challenged by poor lifestyle choices too. It must be physicians’ goal to communicate more effectively with patients about the therapies being proposed, as well as to teach and model optimal self-care, and a healthy lifestyle.

Complaints about other Physicians, by Physicians

Candor isn’t cruel. It does not destroy. On the contrary, it’s built on the idea of empathy – we’re all in this together. – Andrew Stanton

Physicians have their own “tribes”, their silos, what is commonly called “turf”. There have always been territorial feelings within and among the various medical fields. These blossomed in the age of specialization and sub-specialization (largely the 1980s and 1990s). Over the last decade we’ve seen that silos can be very expensive, and, worse, counterproductive to good patient care. We would do better for ourselves, and our patients ,to shed the ego and control, and to work more collaboratively as a team.

Complaints from Physicians, Patients and Payers, about the Cost of Medications

The pharmaceutical companies are frequent targets of complaints. The high prices, less than transparent clinical trial data, generic vs brand issues, aggressive marketing, and suggested conflict of interest in research have given these massive businesses the nickname of “big pharma”. Pharmaceutical companies can anticipate and answer these complaints through greater transparency both in their research and marketing, providing greater value to patients through their content, decreasing push marketing, and fostering lower drug prices by bringing back inexpensive, old generics wherever possible. Drug costs are skyrocketing; somehow pharmaceutical companies must help address this.

Complaints: A Fresh Look
Crafting a complaint

There’s a difference between criticism and constructive criticism. With the latter, you’re constructing at the same time you’re criticizing. You’re building as you’re breaking down. Telling the truth is difficult, but its the only way to ensure excellence. – Andrew Stanton

There are also those who feel that to be effective criticism should not be softened in any way, but more hard core. For a humorous take on how to craft a complaint, take a listen to the podcast of the Here and Now program on The Greatest Complainer.

Avoid amplifying the complaint

Complaint amplification is prefacing the complaint with threatening or overly assertive statements: “Do you know who I am….” etc. Avoid this and consider starting with a compliment, something positive and then add “but….” A change in how the complaint is phrased can make a world of difference.

Empathy for the complainant

Why do people complain? To make things better for themselves or the next guy. To deal effectively with a complaint, the first step is to validate it directly to the patient. A complaint is never trivial to the complainer. – Richard Mills

Gratitude

Consider adopting the mindset that complaints are a gift, and welcome difficult customers. The following story about fertility clinics in the UK re: the value of welcoming challenge and difficulty is particularly appropriate.

When we computed the so-called learning curves of all the clinics in the business (the clinics who selected for “good prognosis” patients and those who took all patients ie including the difficult cases), we discovered the clinics which treated a relatively large number of poor prognosis cases improved their overall success over time quite dramatically. In fact, they learned so much from their challenging patients —in terms of new innovative processes, tests, and techniques – that, after a year or so, these clinics overtook those that thought they were being clever by doing easy cases only. – Frank Vermuelen

Maybe it is time to celebrate patient complaints. Without them quality improvement would depend on satisfaction questionnaires, which are increasingly viewed as burden by those asked to complete them ( and inaccurate by others). When an opportunity for practice improvement knocks, open the door and welcome it in. – Richard Mills

Your most unhappy customers are your greatest source of learning. – Bill Gates

Perspective

Being aware of a single shortcoming within yourself is far more useful than being aware of a thousand in someone else. – Dalai Lama

BK

Resources

“Patient Complaints: Do You Open the Door?”, Richard P Mills MD MPH, EyeNet, March 2005,http://www.aao.org/publications/eyenet/200503/opinion.cfm, accessed March 27 2015

“Malpractice Dangers in Patient Complaints”, Lee J Johnson Esq, Medscape Business of Medicine, July 19 2010, http://www.medscape.com/viewarticle/725001, accessed March 27 2015

“Relationship between patient complaints and surgical complications”, H J Murff et al, Quality and Safety in Healthcare, February 2006, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564001/, accessed March 27 2015

“Britain’s ‘Greatest Complainer’ Doesn’t Get Mad, He Gets Even”, Here & Now, NPR, March 24 2015,http://hereandnow.wbur.org/2015/03/24/britains-greatest-complainer, accessed March 27 2015

“5 things patients say that should make doctors sit up and listen”, Suneel Dhand MD, KevinMD.com, March 12 2015, http://www.kevinmd.com/blog/2015/03/5-things-patients-say-make-doctors-sit-listen.html, accessed March 27 2015

“Don’t Make Constructive Criticism So Soft That People Miss Your Message”, Mark Murphy, Forbes, March 13 2015, http://www.forbes.com/sites/markmurphy/2015/03/13/dont-make-constructive-criticism-so-soft-that-people-miss-your-message/, accessed March 27 2015

“Amplifying Complaints”, Seth Godin, January 13 2010,http://www.typepad.com/services/trackback/6a00d83451b31569e20120a7beed0d970b, accessed March 27 2015

“The Value of Complaints”, Beyond Philosophy, June 20 2013, http://beyondphilosophy.com/the-value-of-complaints/, accessed March 27 2015

“Comment: Hang up your gloves, social media – it’s time to understand grief and loss”, Rebecca Shaw, SBS, March 17 2015, http://www.sbs.com.au/news/article/2015/03/17/comment-hang-your-gloves-social-media-its-time-understand-grief-and-loss, accessed March 27 2015

“Take ‘the Other’ to lunch”, Elizabeth Lesser, TEDWomen, December 2010,http://www.ted.com/talks/elizabeth_lesser_take_the_other_to_lunch?language=en#t-361790, accessed March 27 2015

“Difficult Patients: It’s Not Them, It’s You, Doctor”, Jacqueline Fellows, HealthLeaders Media, September 25 2014, http://www.healthleadersmedia.com/content/PHY-308765/Difficult-Patients-Its-Not-Them-Its-You-Doctor, accessed March 27 2015

“Why Your Latest Customer Service Complaint is a Gift”, Barry Moltz, SmallBizTrends.com, October 16 2013, http://smallbiztrends.com/2013/10/customer-service-complaint-gift.html/print/, accessed March 27 2015

“Complaints are a Gift in the Age of the Empowered Customer”, Anthony Myers, CMS Wire, November 13 2013, http://www.cmswire.com/cms/customer-experience/complaints-are-a-gift-in-the-age-of-the-empowered-customer-023139.php#null, accessed March 27 2015

“Why You Should Welcome Difficult Customers”, Freek Vermeulen, Forbes, March 7 2014,http://www.forbes.com/sites/freekvermeulen/2014/03/07/why-you-should-welcome-difficult-customers/, accessed March 27 2015

Image Credit: Steve Greer

On Tuesday March 31 2015, the following topics were discussed in #HCLDR

• T1 Are you a frank & honest critic or do you take a soft touch approach when providing feedback/complaining? Why?
• T2 Do you find readily available avenues for your complaints (criticisms)? Do they
  work, do you get action?
• T3 How have you learned from complaints you have received? Do you view them as gifts now?
• T4 Are complaints & criticisms via social media different from other complaints (ex. in-person)?