PA P E R S

The use of patient complaints to drive quality improvement: an exploratory study in Taiwan
Sophie Y Hsieh
Department of Healthcare Information and Management, Ming-Chuan University, 5 De-Ming Road, Gui-Shan, Taoyuan, Taiwan, ROC E-mail: hsieh_yahui@hotmail.com

Summary
This study aims to investigate the nature and resolutions of patient complaints and further to explore the use of complaints to drive quality improvement in a selected hospital in Taiwan. A teaching hospital (i.e. the Case Hospital) in Taiwan was purposefully chosen for a case study. The author conducted the critical incident technique (CIT) using questionnaires to obtain information about the complaints and the process of their resolutions. To enhance the reliability of the study, the author also conducted non-participant observations as an outsider at the Case Hospital. In this study, 59 complainants registered 87 complaints. The CIT found that care/treatment, humaneness and communication were the most common causes of complaints. The response time of patient complaints averaged 1.76 days, except for ve cases in which response time was not reported. The majority of complaints were resolved within three days. Moreover, this study found that of 149 resolutions, 105 taken by the hospital involved an explanation of the facts to complainants (n 41), investigation of events (n 33) and empathy with complainants (n 31). The lack of any systematic use of complaints data was one of the most crucial failures of the Case Hospital. Instead of attempting to use such data as the basis for initiating quality improvement measures, complaints were consigned to a black hole where their existence was conveniently forgotten. Based on this study, the author suggests ways to strengthen the capacity of the hospital in terms of using patient feedback and complaints to improve the quality.

Introduction
Traditionally, patients have not had a direct impact on the choice of services they received and did not know what standards they should expect.1,2 The health-care system often neglects patients rights and their complaints.3 In those circumstances, patients are simply expected to follow the rules and regulations of the health-care organization and to obey the commands of the health professionals. However, it is increasingly recognized that as customers, patients can often identify problem areas that management is not aware of and can offer health-care managers innovative ideas for improvement. A well functioning patients complaints system enables patients to contribute to the improvement of services and to participate more actively in their own care and treatment. The rationale of quality improvement is to create an environment where it is possible to understand and be responsive to patient needs. There is a growing body of literature which suggests that complaints can provide good opportunities for developing risk management or quality improvement programmes.4,5 The nature of patient

complaints can affect the focal areas of quality improvement activities in health care in which preventive or proactive mechanisms can be set up, for example risk management and a patient safety mechanism to provide safer and sound quality of care for patients.6 11 The searches used the electronic databases PubMed and ProQuest, which in turn expanded access to further literature. Of the 43 studies published between 1983 and 2006, only four addressed organizational behaviour and strategy concerning patient complaints, those of Carmel12 in Israel, Gilly et al. 13 in the USA, Van der Wal and Lens14 in the Netherlands, and Douglas and Harrison15 in Australia. It is still not clear, however, how patient complaints could be used to improve quality of care in health-care services. This represents a gap in knowledge which this study aims to address by examining how patient complaints can be used to drive quality improvement in practice in a selected hospital in Taiwan.

Methods
A teaching hospital (i.e. the Case Hospital) in Taiwan was purposefully selected as the site for the eldwork for three main reasons. Firstly, the Case Hospital is an exemplary organization, one which has gained visibility and respect

Sophie Y Hsieh PhD, Assistant Professor, Department of Healthcare Information and Management, Ming-Chuan University, 5 De-Ming Road, Gui-Shan, Taoyuan, Taiwan, ROC.

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nationally in Taiwan with regard to managing quality of care. Secondly, the Case Hospital has a good national reputation for providing quality patient services. Thirdly, the Case Hospital agreed to allow the researcher to conduct this study in situ as much as possible. The critical incident technique (CIT) is an innovative research strategy for studying moments of truth and involves gathering self-reported data about subjects most memorable experiences, positive or negative, within a specic context.16 It is a systematic qualitative research strategy17 19 as well as an appropriate tool to reect patient-perceived quality or patient dissatisfaction based on negative critical incidents.20,21

Data analysis
This study adopted the techniques of the thematic analysis with an interpretivist approach to investigate and interpret the meanings of empirical data. The study looked at the occurrence of certain terms/concepts (e.g. complaint types) within texts. The approach in analysing data was to systematically search text for categories and themes. The researcher then quantied and analysed the presence, meanings and relationships of such terms and concepts. Finally, the researcher made inferences about the messages within the texts.

Ethics consideration
With the hospitals permission, the researcher visited the Case Hospital to meet with the manager assigned to coordinate this project. This organizational study was conducted in a natural setting without performing any experiments on participants. The role of the researcher was that of an outsider. All participants in this study were employees and managers. Each participant was free to withdraw or discontinue his or her participation in this study at any time.

Data collection
The author conducted CIT using questionnaires to obtain information about the nature and resolutions of complaints from 1 May to 31 July 2002. Social workers within the Social Work Department at the Case Hospital were trained to ll out this critical incident questionnaire, taking into consideration the sensitivity and condentiality of the data, the education level of the complainants and the consistency of the study. To enhance the reliability of the study, the author also conducted nonparticipant observations as an outsider at the Case Hospital. Being a non-participant observer enabled the researcher to collect the necessary data without being involved in the management of the organizational system. Any other quality improvement activities were noted as well. Some informal interviews were also conducted if the situation was of interest to the study and permission was granted. The themes observed/interviewed primarily included methods of contacting complainants, how the hospital staff handled complaints, the interaction between departments and units, complainants satisfaction in the way their complaints were handled and severity or failure magnitude of complaints.

Results
General background
A total of 59 cases were collected by conducting the CIT. Of these, 17 cases were lodged in May 2002, 20 cases in June and 22 cases in July. In terms of the units that were being complained about, 48 complaints concerned the clinical unit, in which the main complaints related to humaneness (n 16), care/treatment (n 15) and communication (n 13) (Table 1). Of 87 complaints, 16% (n 14) were related to the administrative unit and most of them were about billing/payment problems (n 4; 28.6%) or environment/equipment problems (n 4; 28.6%). In addition, 15% (n 13) were about

Table 1 Number and percentage of complaints by category for four unit types Unit types/complaint types Care/treatment Communication Humaneness Business practice Access/availability Billing/payment Environment/equipment Suggestions Total No. % No. % No. % No. % No. % No. % No. % No. % No. % Clinical unit 15 31.3 13 27.1 16 33.3 2 4.2 1 2.1 0 0 0 0 1 2.1 48 55.2 Allied health unit 5 41.7 1 8.3 2 16.7 3 25.0 0 0 1 8.3 0 0 0 0 12 13.8 Nursing unit 4 30.8 1 7.7 5 38.5 1 7.7 0 0 0 0 1 7.7 1 7.7 13 14.9 Administrative unit 0 0 2 14.3 1 7.1 1 7.1 2 14.3 4 28.6 4 28.6 0 0 14 16.1 Total 24 27.6 17 19.5 24 27.6 7 8.0 3 3.4 5 5.7 5 5.7 2 2.3 87 100

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the nursing unit and mainly concerned humaneness (n 5; 38.5%) and care/treatment (n 4; 30.8%). Of a total of 59 cases, 43 cases were categorized as none (i.e. no obvious harm, no injuries or low nancial loss) in terms of severity; nine were catastrophic; four were major; and three were minor. Personal visit (n 26) and telephone (n 22) were ranked as the most popular methods of staff contact with complainants after the complaint was made. Others were letter (n 3), email (n 2), phone and personal visit (n 5), and personal visit and letter (n 1). In most cases (n 29), complainants accepted the results of the complaint handling by the hospital. While complainants in 24 cases did not state their satisfaction in terms of the complaint handling; 15 cases were considered by them to be fair; and they were dissatised in six cases.

The nature of complaints

In this study, 59 complainants registered 87 complaints. The CIT found that care/treatment (n 24), humaneness (n 24) and communication (n 17) were the most common causes of complaints (Figure 1). That is, threequarters of patient complaints (n 65) were related to care/treatment, humaneness and communication in the Case Hospital. These results are generally consistent with Webbs study in the UK,22, that inadequate care and poor staff attitudes were the most common causes. Furthermore, other studies show that care/treatment and the quality of communication are the most common subjects of complaints, for instance, Pichert et al.s23 study in the USA and Anderson et al.s10,24 study in Australia. However, the groupings of complaints in both studies were not clearly identied and it is therefore difcult to make comparisons between the two. Specically, 36 out of 59 cases involved one complaint. Most of these 36 cases related to care/treatment (n 8) and humaneness (n 8). In terms of humaneness, seven of eight cases were about staff who were regarded as being unconcerned, rude or disrespectful to patients. Others were business practice (n 6), communication (n 5),

environment/equipment (n 4), billing/payment (n 3) (all three cases were about the level of parking fees) and access/availability (n 2). Despite this, some cases related to more than one subcategory of complaints. For example, one case was mainly concerned with care/ treatment, and this was related to an incorrect diagnosis, dissatisfaction with treatment outcome and inadequate treatment, thus reecting different subcategories. Furthermore, there were 23 cases where more than one complaint was made. Of the 23 cases, 18 contained two complaints. There were six combinations in which two complaints were made in a single case, two of which were more frequent. Firstly, most of these were related to care/treatment and humaneness (n 6). Half of them (3 of 6 cases) were associated with inadequate treatment and staff who were unconcerned, rude or disrespectful to patients. The second most frequent combination of patient complaints was communication and humaneness (n 5). Specically, four of ve cases were associated with incorrect or misleading communication and staff who were unconcerned, rude or disrespectful to patients. For example, the social workers case-notes stated:
The patient was told by his general practitioner (GP) that . . .were problematic and needed to be operated on. The GP suggested that the patient go to the hospital for an examination. Therefore, when the patient came to the hospital, he asked the doctor to arrange an MRI examination. The doctor was unhappy with this request and said you cannot just order whatever examination you want. The doctor then turned over the medical record. The doctor did not make an examination and wrote out a prescription for the patient.

Another ve of 23 cases involved combinations in which three complaints were made by a single complainant. Of these, the main complaints (i.e. four of ve cases) were about care/treatment, communication and humaneness. For example, one case involved inadequate treatment, unconcerned attitude of medical staff and inadequate communication. Another case involved a combination of three complaints by a single case which related to humaneness, business practice and

Figure 1 Complaint types by frequency (May July 2002)

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environment/equipment (n 1). In the case-notes of the social worker:

The patients bed faced the entrance of the toilet. The movement of other patients and beds affected the patients sleep. The relative originally sought a transfer for the patient to another bed when the patient in the next bed was discharged. But a new patient was admitted when the next beds patient was discharged. Moreover, the relative was dissatised with the ward environment and thought the nurse did not deal with their request seriously.

(n 41), investigation of events (n 33) and empathy with complainants (n 31). In other cases, as can be seen in Figure 2, these were: (1) Social workers referring the complaint to other units to deal with (n 15); (2) Replacement (n 8) indicates that the hospital offered substantial services to complainants, for example alternative exam, bed arrangement and substitution of meals; (3) Apology (n 7) means the doctor expressed their apology to the complainants; (4) The intervention of the Medical Disputes Team (MDT) (n 4); (5) Social workers making suggestions to unit managers (n 4); (6) Correction (n 2) refers to the hospital taking action to correct wrong procedures or processes, for example, modication of computer programs; (7) Social workers making suggestions to complainants (n 2); (8) Compensation (n 1) means that the hospital reimbursed its fee to complainants; (9) Using continuous quality improvement technique (Plan-Do-Check-Act, PDCA) to solve the complaint problem (n 1). These results show that the resolutions taken by the Case Hospital were more complex than in Hunt and Glucksmans study. One reason is that the current study conducted the CIT to observe the actual scenario as complaints took place. In terms of the strategies of complaints resolution taken by the hospital, the study found that the hospital intended to conduct the PDCA technique (n 1) to improve nursing care (i.e. clinical quality) when complaints involved care/ treatment. However, at the time of the study, the Nursing Department coordinated relevant staff/units to work out a quality improvement project and it was unclear whether

The resolution of complaints

The response time of patient complaints averaged 1.76 days, except for ve cases in which response time was not reported. Of 59 cases, 38 cases were resolved within one day; six cases within two days; three cases within four days; two cases within three days; two cases within seven days; one case within ve days; one case within six days; and one case within 11 days. That is, the majority of complaints (46 of 59 cases) were resolved within three days. However, 80 90% of complaints in 21 hospitals in Netherlands were dealt with within two months.14 This was a result of various complaints management systems being used in different countries. Additionally, of the 59 cases described, if the complaints involved no obvious harm, no injuries or low nancial loss (n 43), most were resolved within four days and 36 of 43 within one day. However, if complaints involved a major or catastrophic consequence, it took a longer time to resolve, though exactly how long was not known. Over a three-month period, the study found that of a total of 59 cases, in terms of frequency, 149 resolutions were taken by the hospital. Hunt and Glucksman25 conducted a case study in an accident and emergency department in the UK and found that complainants tend to seek an explanation, an apology and compensation for unsatisfactory services. However, this current study found that of 149 resolutions, 70.4% (n 105) taken by the hospital involved an explanation of the facts to complainants

Figure 2 Resolution of complaints by frequency for May July 2002

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the hospital actually used the PDCA to improve its clinical care. On the other hand, methods of explanation (n 41), empathy (n 31), replacement (n 8), compensation (n 1), apology (n 7), correction (n 2) and suggestions to complainants (n 4) were likely to have contributed to satisfying the expectations of patients/complainants, whether they were tangible or intangible. However, there was no empirical evidence for sustainable improvement within the hospital. The study revealed that the response pathway of empathy with complainants, investigation of complaints and explanation of the facts to complainants was an effective approach when resolving individual patient complaints that involved communication and humaneness occurring simultaneously in a single case. Two-thirds of complainants were satised with the response of the hospital when they used strategies of empathy, explanation, apology or replacement, when complaints involved care/ treatment and humaneness or care/treatment and communication simultaneously occurring in a single case. However, while these strategies tended to satisfy complainants needs, they did not contribute to any systematic quality improvement. In addition, multiple actions were taken to handle patient complaints by social workers. Generally, the hospital empathized with complainants, investigated events, explained the facts to complainants and referred complaint problems to the relevant unit(s). While the researcher looked at how frequent specic resolutions appeared in sets of data, investigation and explanation occurred simultaneously to resolve 29 of 59 (49.2%) cases. Explanation and empathy (n 19) occurred as the second most frequent resolution. Furthermore, investigation and empathy (n 11), investigation, explanation, and empathy (n 11), and empathy and refer to relevant units (n 11) were ranked as third most common actions taken conjointly.

Discussion
In terms of the strategies of resolutions taken by the hospital, approaches of explanation, empathy, replacement, compensation, apology, correction and suggestions to complainants were more likely to have contributed to satisfy patients needs. When handling complaints, the Case Hospital tended to investigate and correct the problem on hand without examining the appropriateness of the current ways of doing work within the organization. The hospital attempted to correct administrative errors (e.g. business practice and billing/payment), as well as to satisfy the needs of complainants, by offering replacement and compensation, making suggestions to complainants and giving an apology. While the hospital followed correct procedures, it appears that it did not make systematic effort to learn from these complaints. In other words, the hospital proceeded with the detection and correction of problems/errors without any serious interruption to the organizations business, and focused on resolving problems without examining assumptions underlying the

way in which work was currently performed. In terms of organizational learning, single-loop learning26,27 occurred in the Case Hospital when handling complaints. On the other hand, the hospital did plan to conduct the PDCA technique to improve nursing care. There is no empirical evidence, however, that sustainable quality improvement occurred within the hospital. It is difcult for the researcher to follow up actions or improvement activities taken by the MDT due to the condentiality and sensitivity of some cases; this has led to the development of a black hole syndrome within the organization. The chief characteristic of a black hole is its non-transparency. In other words, it is impossible for the researcher as an outsider to know what happens to data or information that goes into the black hole. Therefore, it is unclear whether complaints drive quality improvement when strategies of resolutions involved (1) the intervention of the MDT (all 4 complaints involved care/treatment), (2) social workers referring complaint problems to the relevant units (7 of 15 complaints involved care/treatment), and (3) social workers making suggestions to unit managers (2 of 4 complaints involved care/treatment). Based on observations made in this study, only one critical incident was used to enhance clinical quality. A review of the nature of the complaints reveals that, of the 59 cases observed, 24 related to the quality of care/treatment. Thus, the hospital responded at least partially to patient complaints related to clinical issues. It appears, however, that many complaints disappeared into a black hole due to lack of transparency in handling complaints. The inadequate handling of patient complaints was most likely to occur when managerial intervention by the MDT was required, when social workers referred complaint problems to relevant units, and when social workers made suggestions to unit managers concerning complaints associated with care/treatment (e.g. inadequate treatment) (n 13). These ndings reinforce the notion that if the hospital intends to use patient complaints to improve its quality of clinical care, it needs to eliminate the aforementioned black hole to act as a double-loop learning organization,27,28 i.e. do the right things and to question why errors happened and problems occurred. This may require modication of the hospitals underlying norms and policies.28

Conclusions and implications

No matter how good the complaints management system is, complaints are a small part of patient voices and are passive. Many dissatised patients and their relatives do not lodge a complaint. For achieving a double-loop learning organization, the ndings of this study suggest a number of implications with regard to a best practice system for using patient complaints as a trigger to improve quality of care (Figure 3). This study has suggested that the lack of any systematic use of complaints data was one of the most crucial failures of the Case Hospital. Instead of attempting to use such
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The hospital could also institute, either internally or externally, a system (such as an ombudsperson) that would enable patients to lodge their grievances if they were not satised with complaints resolution procedures or when they felt they had been discriminated against. Such a grievance system could enhance the hospitals accountability for the way it dealt with complaints.

Management and analysis of complaints

The second phase of complaints management would involve appointing designated personnel (e.g. a quality improvement coordinator) to collect, analyse and communicate complaints data. Such personnel would have direct or ready access to the senior management of the hospital and would be able to initiate and monitor any quality improvement activities resulting from complaints management. In addition, the senior management of the hospital would be responsible for designing and providing quality services in the hospital such as the establishment of the complaints management policy and its relevant organizational structure. The involvement of the senior management is important as they can review the hospital-wide complaints handling and management system, and also examine the effectiveness of using complaints to improve quality of care. Based on this information, they would, if necessary, provide support resources with regard to complaints management.

General pathways
Generally, the hospital should systematically document all complaints for auditing and improvement purposes. One way of avoiding systems overload would be to triage all complaints separating the more serious from the trivial. That is, complaints registered can be classied as major or minor problems. Having this classication, the designated personnel responsible for receiving and resolving complaints would be able to judge whether to take immediate or remedial action. If complaints have been recognized as severe or major (e.g. the transfusion of a wrong blood type), the organization would provide an urgent response by immediately reporting to the authority for quick resolution of the problem. If complaints are minor (e.g. cold food), the hospital could provide initial responses to complainants such as giving support or solving problems. Following these actions, the nature of complaints, the investigation process, the causes of complaints and the outcome of complaints would be documented in a formal report as either a minor or major problem. It would be important to maintain the condentiality of the complaints data by, for instance, keeping it in a lockable ling system. The documented complaints would then be reviewed on a monthly, or at least periodical, basis, by undertaking secondary analysis of accumulated complaints to identify any common or special causes of complaints, as well as to review which location, category of staff, procedure or particular set of patients are the cause of the most frequently lodged complaints. It is important to note that minor problems might lead to major problems

Figure 3 The ideal model for using complaints to help drive quality improvement

data as the basis for initiating quality improvement measures, complaints were instead consigned to a black hole where their existence was conveniently forgotten. In order to remedy this situation, it is suggested that a basic requirement would be the implementation of a twophase system in which (1) the investigation and resolution of complaints was separated from (2) the process of data management and its secondary analysis. The ideal system for using patient complaints to drive quality improvement would work as follows:

Investigation and resolution of complaints

It is suggested that, rst of all, patient complaints at the frontline be resolved on a case-by-case basis either by social workers or other staff (e.g. nurses). The hospital may have designated personnel (e.g. social workers) or a unit (e.g. a standing committee, a department) responsible for helping patients register their complaints, resolving the immediate difculty they are facing and then documenting every complaint. Such personnel or unit may also give support to complainants, investigating their problems and explaining the facts to them where necessary.
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in daily care activities. The establishment of a complaints management information system would assist managers to undertake the secondary analysis effectively by using a spreadsheet or SPSS. Then, once a minor problem occurs, the content of the event could be entered into the specic columns of the software package for future analysis. Such an information system would reduce the danger that secondary analysis of all minor complaints would impose an excessive burden on the organization. Based on this analysis, the management of complaints data would help with benchmarking between the locations, groups of complaints or professional groups to evaluate their competence and capacity. As a result, the hospital would be able to use this analysis of complaints to carry out problem-based quality improvement programmes by using the PDCA technique in a prospective and systemic way to improve its quality of care.

Acknowledgement
The author would like to thank the participants for their support and participation.

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