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Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ o...

Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-­line insights Jackie van Dael ‍ ‍,1 Tom W Reader,2 Alex Gillespie ‍ ‍,2 Ana Luisa Neves ‍ ‍,1 Ara Darzi,1 Erik K Mayer1 1 Centre for Health Policy, ABSTRACT Health Service (NHS), the number of Institute of Global Health Introduction A global rise in patient complaints has formal complaints received yearly has Innovation, Imperial College been accompanied by growing research to effectively London, London, UK doubled to over 200 000 between 2008 analyse complaints for safer, more patient-­centric care. 2 Department of Psychological and 2018.1 2 Complaints are complex and Behavioural Science, Most patients and families complain to improve the quality of healthcare, yet progress has been complicated narratives that report on perceived fail- London School of Economics and Political Science, London, by a system primarily designed for case-­by-­case ures of healthcare delivery from the UK complaint handling. patient’s perspective. Complaints have Aim To understand how to effectively integrate patient-­ been recognised as a valuable source of Correspondence to centric complaint handling with quality monitoring and data for a number of reasons. Unlike most Jackie van Dael, Centre for improvement. Health Policy, Institute of Global patient feedback mechanisms (eg, patient Method Literature screening and patient codesign Health Innovation, Imperial shaped the review’s aim in the first stage of this three-­ satisfaction surveys, patient consulta- College London, London SW7 stage review. Ten sources were searched including tions), complaints are unsolicited: they 2AZ, UK; ​j.​van-d​ ael18@​ic.​ac.​uk represent the care issues that breach a academic databases and policy archives. In the second Received 25 April 2019 stage, 13 front-­line experts were interviewed to develop threshold of concern and compel patients Revised 24 December 2019 initial practice-­based programme theory. In the third and families to take action. This includes stage, evidence identified in the first stage was appraised Accepted 26 December 2019 safety incidents3–6 and poor experi- Published Online First based on rigour and relevance, and selected to refine 4 February 2020 programme theory focusing on what works, why and ences7–9 that are not always identified in under what circumstances. internal systems of healthcare monitoring Results A total of 74 academic and 10 policy sources (eg, incident reports, retrospective case were included. The review identified 12 mechanisms reviews). Complaints contain data on to achieve: patient-­centric complaint handling and difficult-­ monitor areas of practice,10 to-­ system-­wide quality improvement. The complaint such as care access or continuity, systemic handling pathway includes (1) access of information; (2) collaboration with support and advocacy services; (3) problems and care omissions. Complaints staff attitude and signposting; (4) bespoke responding; further describe clinical, social and insti- and (5) public accountability. The improvement pathway tutional aspects of perceived care fail- includes (6) a reliable coding taxonomy; (7) standardised ures5 11 12; capturing sociostructural, or training and guidelines; (8) a centralised informatics ‘systems’,13 14 dimensions to error and system; (9) appropriate data sampling; (10) mixed-­ negligence.15 However, in contrast to methods spotlight analysis; (11) board priorities and leadership; and (12) just culture. standard feedback and incident reporting Discussion If healthcare settings are better supported mechanisms, complaints systems are not to report, analyse and use complaints data in a primarily designed for quality monitoring standardised manner, complaints could impact on care and improvement, and predominantly quality in important ways. This review has established a concern processes to provide individual range of evidence-­based, short-­term recommendations to complainants with a formal response; that achieve this. is, complaint handling (box 1).16 17 © Author(s) (or their Previous research suggests that patients employer(s)) 2020. Re-­use permitted under CC BY. and families who make a formal complaint Published by BMJ. Introduction primarily desire two outcomes: a patient-­ A steady rise in patient complaints has centric response (eg, an explanation of To cite: van Dael J, Reader TW, Gillespie A, et al. been accompanied by increasing efforts to how the incident could have happened) BMJ Qual Saf effectively analyse complaints for quality and system-­ level quality improvement 2020;29:684–695. improvement. In England’s National (eg, to prevent errors from happening 684   van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704  Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. user reasoning.29 In contrast to systematic literature Box 1 Definition of terms used in this review reviews that simply examine ‘what works and to what Complaint terminology degree’, realist reviews recognise the complexity of Complaint: ‘a formal communication reporting a failure health policy interventions, and therefore examine that seeks an institutional response’10 what it is about an intervention that works (or not), Complaint handling: receiving and responding to under what circumstances and why, by employing a individual complainants, typically performed by a wide range of evidence sources.29–31 To understand complaints department how to successfully integrate patient-­centric complaint Quality monitoring and improvement: standardised handling with quality monitoring and improvement in reporting and aggregated analysis of complaints data existing practice, this study undertook a realist review to generate continuous improvement insights at an of academic literature, policy evidence and front-­line organisational and national level insights. Patient-­centric responding: the institution’s communication to individual complainants in response to Methods their complaint, including response elements important to Stage 1. Identifying the aim of the review: literature complainants (eg, an explanation of poor care, expression screening and lay partner codesign of responsibility, learning or action taken) The aim of this review was shaped by initial litera- Realist review terminology ture screening and patient lay partner involvement. Programme theory: the ‘underlying assumptions about Academic and policy evidence was screened to capture how an intervention is supposed to work’32 procedures and policy involved in healthcare complaints Contexts: ‘aspects of the background, people and management and to understand patient priorities for setting that moderate outcomes’114 how their complaint is handled by healthcare settings. Mechanisms: ‘underlying entities, processes, or The limited volume of complaints literature allowed structures which operate in particular contexts to for literature searching based on broad search terms generate outcomes of interest’115 (eg, ‘healthcare complaints’ or ‘patient complaints’). Outcomes: ‘expected or unexpected intermediate Searches were conducted between February 2018 (mediating) and final outcomes’116 and July 2019, and included academic (ie, PubMed, Context-­mechanism-­outcome (CMO) configurations: Google Scholar, Medline) and England-­based policy uncovered interactions between contexts and searches (ie, government archives (UK), National Insti- mechanisms leading to certain outcomes; providing ‘a tute for Health and Care Excellence, Social Care Insti- step toward generating or refining the theory or theories tute for Excellence, General Medical Council (UK), that become the final product of the review’.117 For Care Quality Commission, Parliamentary Health example, a defensive organisational culture (‘context’) and Social Care Ombudsman). Further sources were leading to staff bias in recording complaints data included based on reference list screening. Articles (‘mechanism’) which results in unreliable insights for were excluded if older than 15 years, if not written in quality improvement (‘outcome’). English or if they discussed informal complaints that do not require a formal response (such as online or verbal complaints). Policy sources were excluded if to others).18–26 The existing literature suggests, they were older than 5 years, did not include primary however, that healthcare complaints practice has not data or if they included a small sample size (eg, less yet been successful at achieving the complex dual role than 15 interviewees or 30 complaints). A total of 216 of case-­by-­case handling and system-­ wide improve- sources were identified and screened, of which 164 ment.16 17 27 Combining organisational learning and sources initially met the inclusion criteria (for further complaint handling has previously been suggested in review in stage 3). non-­healthcare organisations, yet remains conceptual To shape the review’s focus, we first conducted a in nature, and existing literature gives little insight rapid review of academic studies that directly explored into how this would work in practice.28 To address the remedies sought by complainants when they submit a translational gap between developments in complaints complaint to healthcare settings or regulators (n=9; research and current complaint handling practice, table 1). it is critical that theory to improve learning from Literature screening was then discussed with patient complaints is grounded in the implementation context lay partners (three participants in an initial workshop; including an understanding of whether and how it can two in each of two follow-­up sessions) to determine be linked to complaint handling practice. the aim of the review and articulate key programme Realist reviews are increasingly used in health and theories to be explored. Lay partners highlighted the public services, as they recognise that the success of accessibility of complaint procedures as an important complex interventions is fundamentally dependent part of complaint handling which was therefore on integration into pre-­existing systems, contexts and included in the review. van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704 685 Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. Table 1 Summary of evidence on complainants’ main remedies sought in healthcare (stage 1) Complainants’ Domain* prioritisation† Description Quality improvement18–26 High Studies consistently demonstrate that patients and public find it most important that their complaint leads to quality improvement. Complainants often seek system-­level care improvement rather than an intervention in their own care.‡ A patient-­centric response18–26 Medium-­high Of medium to high importance were outcomes related to the institution’s communication in response to the complaint, such as an explanation of how poor care could have occurred, an apology, or expression of responsibility. Financial Low Most studies found that patients and public perceive financial compensation of minor importance compensation19 20 24–26 to healthcare complaints management. Sanctions to involved Low Importance of sanctions to involved professionals (eg, a hard-­hitting conversation or disciplinary professionals action) was considered lowest of all outcomes, and further qualitative evidence suggests that 18 20 21 23 24 26 patients and public often do not want their complaint to impact on involved staff. *The four domains (ie, quality improvement, a patient-­centric response, financial compensation and sanctions to involved healthcare professionals) or close variations thereof (eg, ‘correction’—lessons learnt, system change25) were consistent outcome measures identified in included studies. †Complainants’ priority ratings were developed by the reviewers based on results of included studies that examined: relative proportion of remedy domain sought by complainants21 23–25 or importance ratings attributed by complainants to the various remedy domains.18 20 22 26 ‡Only four out of nine articles18 20 25 26 specifically distinguished between quality improvement in their own care (eg, ‘I want a solution to my problem’26) and quality improvement at a systems level (eg, ‘to prevent it happening to others’26). All four studies indicated that complainants more frequently seek, or attribute higher scores of importance to, system-­level quality improvement. Stage 2. Defining hypothesised programme theories: theories of interest into practice-­based hypothesised expert framing and practice-based theory mapping programme theories (table 2). To develop key programme theories identified in stage 1 into hypothesised programme theories that are grounded in practice, we then interviewed 13 front-­ Stage 3. Testing hypothesised programme theories: line experts at a large multisite teaching hospital in review and synthesis of academic and policy evidence London. A topic guide was developed with questions In stage 3, hypothesised programme theories were tested related to the key areas of interest as identified in stage and refined based on existing literature. Initially selected 1. Additional questions were developed to reveal activ- articles (stage 1; n=164) were appraised based on ities, tools, staff and organisational context behind ‘theory testing potential’, that is, presence of evidence current practice. We conducted a purposive sampling that can help explain why hypothesised programme strategy to include participants with significant expo- theories might or might not work in particular circum- sure to complaints management at different organ- stances, and rigour.32 33 Eighty-­ four documents were isational levels. Participants included: complaints deemed ‘fit for purpose’ and were included for final manager (n=1); complaints officers (n=4); senior analysis. In line with the realist approach, sources clinical leads responsible for monitoring complaints were assessed to develop context-­mechanism-­outcome within their service (n=5); Patient Advice and Liaison (CMO) configurations.29 34 To extract relevant data to Service manager (n=1) and officer (n=1); and quality develop CMO configurations, a bespoke data extraction board member (n=1). Transcripts were analysed to form was completed for each document. The extraction map current complaints processes, identify key user form included study design, objectives, study short- needs and contexts and translate our key programme comings and key information considered relevant to Table 2 Hypothesised programme theories for patient-­centric complaint handling and system-­wide quality improvement* (stage 2) Programme theory Procedural pathway title Description Complaint handling Invite Healthcare settings support and encourage patients and families to submit a complaint following negative experiences, incidents or negligence. Respond Complainants receive a patient-­centric response that provides an explanation of poor care, admission of responsibility and learning or action taken from their complaint. Quality monitoring and Report Important information from complaints is recorded in a reliable and standardised manner to allow for improvement aggregated analysis. Analyse Aggregated analysis of complaints supports the identification of systemic and severe complaints and leads to actionable insights for improvement. Improve Insights derived from complaints analysis are used to inform quality improvement priorities and interventions. *Hypothesised programme theories were conceptualised by the authors based on literature screening, lay partner involvement and 13 expert interviews. 686 van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704  Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. Figure 1 Review process and document flow. the working of one or multiple programme theories (to primarily based on literature synthesis, expert inter- populate CMO configurations). Iterative analysis and view findings guided the weighting of evidence based synthesis of extracted data led to the final CMO config- on relevance to implementation context. urations.29 34 Realist And MEta-­ narrative Evidence Syntheses: Evolving Standards (RAMESES) publication Invite: enabling access to and use of complaints standards guided the reporting of the review.33 procedures CMO1: patients and families are more inclined to complain if they are Results aware of their rights and can easily access information that outlines The review process and document flow are docu- procedures involved mented in figure 1. Seventy-­four academic sources were A substantive proportion of aggrieved patients and undertaken in the Netherlands (n=16), USA (n=13), families do not complain due to negative expectations UK (n=10), Sweden (n=5), New Zealand (n=5), of procedures, not knowing where to go to with their Australia (n=4), Canada (n=4), Taiwan (n=3), Israel complaint, or what their rights were.35–46 Providing (n=3), France (n=2), Turkey (n=2), Denmark (n=1), comprehensive information through a range of chan- Singapore (n=1), Vietnam (n=1), Italy (n=1), Japan nels45 47 48 (eg, elderly patients less often access infor- (n=1), Norway (n=1) and Switzerland (n=1). Settings mation online than younger patients49), outlining primarily included hospitals (n=47) or were conducted procedures involved, rights and potential outcomes across multiple health services (eg, complaints submitted are key in improving accessibility. to national health regulators; public surveys) (n=24). Academic literature predominantly involved complaints analysis (n=49), followed by surveys or interviews of CMO2: collaboration with support and advocacy services improves patient and public (n=11), healthcare staff (n=8), or accessibility for commonly excluded patient groups both (n=2). Four papers were case studies of hospital Ethnic minority,50–54 lower income or educa- complaint handling. Ten policy sources were further tion25 36 50 51 55–57 and, in some cases, elderly25 50 51 57 included that reviewed current practice in England and individuals are under-­represented among complainant examined views of service users and front-­line staff (case populations across different countries, suggesting reviews, workshops, surveys). that complaints procedures do not typically meet all The final programme theories are reported here user needs. Specific barriers include burden of health and summarised in table 3. In accordance with the condition,35 37 42 lack of perceived power58 and illit- realist approach,32 reported outcomes were not neces- eracy.59 Local provision of interpreting and advocacy sarily main study outcomes of examined sources (eg, services, and collaboration with patient and commu- but relevant side findings). Although CMOs were nity outreach organisations, can help address such van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704 687 688 Table 3 Summary of 12 context-­mechanism-­outcome (CMO) configurations for patient-­centric complaint handling and system-­wide quality improvement* (stage 3) Relevant programme Systematic review Procedural pathway theory Mechanism reference Context (C) Mechanism (M) Outcome (O) Complaint handling Invite CMO135–49 Clarity of complaints procedures and policies Patients and families are more inclined to complain if they are …and facilitates patient and family access aware of their rights and can easily access information that to seek redress outlines procedures involved. CMO225 35–37 40–42 45 46 49–60 68 Complainant characteristics and accompanying Collaboration with support and advocacy services improves …and increases the representativeness of needs (eg, complainants burdened by health accessibility for commonly excluded patient groups. complaints data condition or language barriers) CMO317 40–43 46 49 58 61–64 Stigma of complaints and staff attitude Staff encouragement of, and signposting to, complaint …and encourages patients and families to procedures reduces anxiety and stigma that prevents patients share their feedback and families from filing a complaint. Respond CMO417 21 22 24 25 38 42 48 65–67 Staff coordination and response toolkits  Comprehensive and bespoke responding improves …and ensures that the complaints complainant satisfaction. process provides redress CMO518–26 38 40–43 46 65 67 National standards used to monitor the quality Transparency increases accountability of complaint handling …and encourages the use of complaints of complaint handling and encourages other patients and families to provide procedures feedback. Quality monitoring and Report CMO67–12 16 55 65 68–82 Framework used to record insights held in An evidence-­based reporting framework supports meaningful … and leads to reliable and useful improvement complaints aggregation of complaints data. learning insights CMO710 11 16 17 80 81 Staff type responsible for reporting, Standardised training and guidelines for coders who are … and leads to data that represent accompanying incentives and received training sufficiently removed from front-­line practice will increase patient voice in complaints reporting objectivity and consistency of reporting. CMO816 17 48 65 71 Informatics system used to create and retain A centralised informatics system facilitates data monitoring ….and allows for effective, continuous complaints information and triangulation. monitoring of care issues Analyse CMO916 52 69 75 83–92 Frequency of complaints received at service (eg, Conducting analysis at an appropriate organisational level …and helps identify system-­wide care sample size) enables the identification of trends of poor care. issues CMO104 5 7 10 16 69 81 93 Staff analysis skills and data infrastructure (eg, Combining quantitative trend analysis with targeted …and helps locate and prioritise automated dashboards, triangulation) qualitative analysis produces granular, actionable lessons for improvement initiatives improvement.  Improve CMO117 16 17 20 26 27 38 43 45 46 48 69 70 94 Board priorities and leadership Board priorities and leadership shape the degree to which …and allows complainants to have a complaints data are used for quality monitoring and greater impact on care improvement improvement. CMO1216 17 36 42 43 46 60–64 87 95–98 Organisational culture and stigma of complaints A just culture that welcomes complaints as opportunities for … and reduces staff apprehension learning counters negative impact of complaints on staff. towards complaints *References included 74 international academic papers and 10 England-­based policy sources. van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704 BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright.  Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. barriers and improve the representativeness of the analysis, the taxonomy should fulfil the following complainant population.40 41 45 46 49 53 60 minimum criteria: the categories in the framework are collectively exhaustive, mutually exclusive and CMO3: staff encouragement of, and signposting to, complaint reflect patient voice as reported in complaints (ie, procedures reduces anxiety and stigma that prevents patients and validity).11 79 80 The categories should also be clear and families from filing a complaint similarly understood by different coders to support A prevailing stigma of complaints and negative consistency (ie, inter-­rater reliability)8 12 68 69 79 81 82 and staff attitude towards ‘complainants’17 61–64 were support meaningful structuring of complaint narra- consistently reported barriers to submitting a tives, for example, by codifying problem type, loca- complaint,40–43 46 especially in the context of longer tion, severity and harm reported in complaints.10 11 80 term patient–provider care relationships.49 58 Some service users reported they felt more encouraged to CMO7: standardised training and guidelines for coders who are complain if front-­line staff would proactively welcome sufficiently removed from front-line practice will increase objectivity feedback and were better able to signpost to the appro- and consistency of reporting priate point of contact.40 42 To generate reliable aggregated complaints data sets, it is essential that coders apply classification taxonomies Respond: patient-centric responding to the consistently and take each complaint at face value.80 complainant Although text-­based coding does not involve immediate CMO4: comprehensive and bespoke responding improves complainant extraction of root causes in individual complaints,16 81 satisfaction meaningful structuring of complaints data is essential Complainant satisfaction is positively associated to identify collective concerns of patients and families with a formal response that includes an admis- including the extent and location of systemic issues, sion of responsibility, an explanation of how events major harm and near misses.10 If coding staff are suffi- could have occurred and specific learning or action ciently independent from front-­line service and receive taken.21 22 24 25 65–67 This requires information from standardised coding guidelines and training,11 17 it front-­line staff who did not always provide compre- will be more likely that national and organisational hensive and detailed statements to the complaints team complaints data sets accurately represent patient voice within the necessary timelines.48 67 Case studies report (eg, rather than the care provider’s perspective). that complaint handlers are not always trained with the necessary communication skills (eg, expression of CMO8: a centralised informatics system facilitates data monitoring and listening; empathy) to provide satisfying responses to triangulation complainants, suggesting the need for training mate- Complaints are traditionally handled case by case rials and response toolkits.17 38 and therefore not always included in local quality systems.16 17 A centralised reporting system (eg, CMO5: transparent and accountable complaint handling encourages internally linked to patient experience and incident other patients and families to provide feedback reporting systems) can support continuous monitoring Although most complainants desire quality improve- of systemic quality and safety issues16 17 48 65 71 and ment18–25 settings often failed to inform complain- enables data triangulation for comprehensive problem ants of corrective action taken following their analysis. A functionality to flag high-­ priority complaint.19 20 22 23 26 38 46 65 67 Next to individual complaints (eg, through severity coding) could appro- learning, national guidelines for healthcare settings to priately triage complaints that require immediate report, analyse and publicly share trends in complaints investigation.65 would strengthen accountability42 43 and establish a complaints process that aligns with complainant Analyse: deriving actionable and system-wide learning expectations (ie, systematic improvement). Demon- insights strable impact of complaints would also encourage CMO9: conducting analysis at an appropriate organisational level more patients and families to seek redress.40 41 enables the identification of trends of poor care A sufficiently large sample of complaints is required Report: recording quality and safety issues reported in for aggregated analysis to detect meaningful trends complaints of problematic care.16 69 Depending on the frequency CMO6: an evidence-based reporting framework supports meaningful of complaints at a particular healthcare setting, aggregation of complaints data complaints data can either support the identification The rich, unstructured narrative within complaints of under-­recognised areas of poor practice or function complicates reliable and meaningful extraction of as a secondary source of granular data to better under- quality and safety insights.16 Various coding taxon- stand acknowledged quality and safety issues from the omies have been developed to support complaints patient perspective. However, even for small health- teams and researchers in codifying complaints reli- care settings, it is critical that reliable coding outputs ably.7 9 11 55 65 68–78 To achieve reliable aggregated are produced locally and shared externally to enable van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704 689  Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. national monitoring of complaints. Quantitative data allow for recurring harm (rather than individual outputs should however not be used independently to blame). measure or benchmark between-­setting care perfor- mance as the risk of receiving complaints is not evenly Situating quality monitoring and improvement in distributed across clinicians, specialties, procedural existing complaint handling practice risks and patient characteristics.52 75 83–92 Exploring our CMOs in the context of existing prac- tice in a large multisite teaching hospital (ie, 13 expert CMO10: combining quantitative trend analysis with targeted qualitative interviews) revealed unrecognised tensions between analysis produces granular, actionable lessons for improvement traditional case-­ by-­case complaint handling and Quantitative complaints analysis studies highlight the system-­wide quality monitoring and improvement. need for additional qualitative analysis to derive gran- First, complaints did not always reach the ular and actionable learning lessons.7 69 81 A two-­step complaints department as patients and front-­line staff ‘spotlight’ approach has been suggested that combines were not always aware of the difference between quantitative trend analysis with targeted qualitative formal and informal complaints. Informal complaints analysis.10 If coding is performed in a meaningful and were higher in number but not officially reported consistent manner, quantitative complaints trends on. Formal complaints were classified and publicly can identify, for example, the extent and location shared following the national reporting framework.2 of harm, near misses and blind spots (eg, admission However, in practice, the immediacy of resolving or discharge, systemic and omission problems) at a a complaint took precedence over coding, as the national and organisational level. By locating systemic taxonomy was not perceived to generate meaningful issues reported across complaints, healthcare settings information (but rather, a tick box exercise). Subse- are then able to zoom in to areas of unsafe care and quent analysis of reported data was considered a time-­ perform deeper qualitative investigation to identify consuming process, including manual processing of contextual causes and human factors that allow for data, requiring skills and expertise beyond the role of common error. The potential of further triangulation a complaints manager. Although the complaints infor- with patient feedback and incident reporting systems matics system was integrated with patient experience has been recognised5 16 although overlap appears data, identification of systemic complaints and trian- somewhat inconsistent.4 5 93 gulation with wider patient feedback reports relied on memory and word of mouth—complicating iden- Improve: translating complaints insights into quality tification of under-­recognised or system-­wide issues. improvement The primary role of the complaints department was to CMO11: board priorities and leadership shape the degree to which investigate individual complaints and decide whether complaints data are used for quality improvement a complaint would be considered ‘upheld’. Although At present, there is little evidence of systematic use of this occasionally led to individual improvements, these complaints data for system-­wide problem resolution— were largely localised, one-­by-­one solutions. with improvements being limited to local issues.16 17 27 These findings highlighted the need for better policy, Complainants7 20 70 perceive social and institutional tools and guidance to establish a quality monitoring and issues as critical aspects of care quality. Yet, non-­ improvement pathway that is distinct from immediate, clinical complaints are unlikely to be prioritised by case-­by-­case practice. Our literature review suggests care providers and regulators.20 26 69 94 If complaints a more meaningful complaints taxonomy and guide- are strictly secondary to internal quality and safety lines (CMO6, CMO7); an effective analysis strategy to data sets, they may not reveal the issues that are critical identify key hotspots and blind spots (eg, automated to patients but not to staff. Leadership commitment dashboards or analysed by healthcare informatics to perceive complaints as a valuable, independent staff) (CMO9, CMO10); information infrastructure data set for improvement is necessary to increase their that allows for further data triangulation (CMO8); impact.17 38 43 45 46 48 and leadership commitment to using complaints data to trigger and prioritise patient-­driven improvement CMO12: a just culture that welcomes complaints as opportunities for initiatives (CMO11, CMO12) (figure 2). At the case-­ learning counters negative impact of complaints on staff by-­case level, improving access to formal complaints Due to prevailing stigma, complaints still impact nega- (eg, better patient information and staff education) tively on staff well-­being and are often perceived as (CMO1–3) and patient-­centric responding to specific threatening or unwarranted.42 61–64 95–98 A just culture concerns raised (CMO4–5) will further remain imper- may relieve negative impact of complaints on staff well-­ ative to securing patient and family redress. being and enhance openness to learning.16 17 36 43 46 60–62 Accordingly, system-­ wide complaints analysis—in Discussion contrast to using complaints to predict individual clini- This review involved patients and front-­line experts, and cian risk (eg, Predicted Risk Of New Event (PRONE) reviewed academic and policy evidence, to understand scores87)—facilitates focus on structural causes that how to effectively integrate patient-­centric complaint 690 van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704  Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. Figure 2 Mechanisms for patient-­centric complaint handling and system-­wide quality improvement. 1This step was not included in the review due to limited available literature. handling with quality monitoring and improvement. systemic issues10) may be used to trigger deeper inves- In complaints literature, the complex reality of a dual tigation into critical incidents that are under-­reported objective system has not been adequately addressed. by staff99 (eg, near misses100 or incidents that occur Complaints literature could largely be divided into over time101). Second, the complexity and granularity two fields. First, studies that examined aspects of of complaints data mean it can function as a secondary complaint handling (eg, complainant expectations or data source to better understand quality or safety issues clinician experience of receiving a complaint). Second, exposed by other feedback and incident reporting studies that analyse complaints data to support quality systems.5 Patient-­reported narratives tend to describe improvement (eg, identifying recurring problem the patient’s journey across care visits and settings, themes in complaints). Complaint handling literature including social and institutional events before and indicates that system-­level improvement is an essential after patient harm.102–104 This could help address some outcome for complainants in healthcare,18 20 25 26 yet of the known issues with root cause analysis,105 106 such did not address how to process and use complaints to as the limited value of internal incident data (eg, frag- achieve this. Complaints analysis studies have gener- mented and clinically focused). Similarly, complaints ated promising methodologies to unlock the value of could be linked to overall patient satisfaction rates to complaints, yet were rarely situated in practice. It is reveal latent incidents that may explain changes over therefore somewhat unsurprising that policy evidence time.91 107 Most importantly, ensuring reliability and and expert insights echo earlier studies16 17 27 that validity of national and institutional-­level complaints suggest improvement initiatives do not often move data sets will be imperative to unlocking the collec- beyond ‘putting out fires’.27 tive voice of complainants. Reliable complaints data Our review contributes to the existing literature by sets underpin the function of complaints as a public providing pragmatic insights on how, why and under accountability mechanism to govern care quality, what conditions complaints can be systematically safety, and patient-­ centricity. By revealing systemic learnt from in existing practice. Our review suggests patient concerns (including low-­severity but frequently that, although complaints necessarily require case-­by-­ reported care issues), complaints could support the case handling, there is a need for novel policy strat- development and prioritisation of patient-­ centric egies that enable a distinct improvement pathway to improvement initiatives (which could include further address systemic and system-­wide issues reported in patient codesign108–110). complaints. If healthcare settings are better supported Although improved analysis of complaints allows to codify, analyse and use complaints data (eg, through patients and families to have a greater impact on standardised taxonomy and guidelines), patient-­ health systems, it is important to note that complaints reported insights could impact quality management data are unlikely to be representative of the overall in important ways. First, meaningful structuring of patient population. Our findings reinforce work complaints data (eg, filtering complaints through to address poor accessibility of complaints proce- ‘severity’ coding11 80) could support effective triage of dures,40–43 ongoing stigma of complaints46 60 61 63 and critical patient concerns through the appropriate safety a defensive organisational culture.17 43 46 60 Without management processes. For example, blind spot issues accessible and equitable complaints procedures, held in complaints (eg, preadmission, postdischarge or complaints data may only represent the ‘tip of the van Dael J, et al. BMJ Qual Saf 2020;29:684–695. doi:10.1136/bmjqs-2019-009704 691 Systematic review BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009704 on 4 February 2020. Downloaded from http://qualitysafety.bmj.com/ on August 31, 2024 by guest. Protected by copyright. iceberg’ and disproportionately omit learning from strategy to generate actionable learning insights (eg, ethnic minority50–54 elderly25 50 51 57 and lower income mixed-­ methods ‘spotlight’ approach) and translation or education populations.25 36 50 51 55–57 It is there- into quality improvement (eg, leadership and culture). fore important to understand complaints data in the This is critical for patients and families, who aim to drive context of other patient voice mechanisms (eg, satis- quality improvement, and for healthcare providers, who faction surveys, public consultations). An essential could learn from their experiences to provide safer, first step to effective triangulation of different data more patient-­centric care. sources is to understand how to meaningfully struc- ture and analyse each data set individually. It can be Twitter Jackie van Dael @JackievanDael and Ana Luisa Neves expected that some of the findings in this review (eg, @ana_luisa_neves standardisation of coding, spotlight analysis) apply to Contributors JD and EKM conceived this project. JD, EKM, TWR and AG contributed to data analysis and synthesis. The the processing of other free-­text feedback mechanisms manuscript was written by JD with contributions from ALN, (eg, informal complaints, online comments). TWR, AG, AD and EKM. Funding This work is supported by the National Institute for Study strengths and limitations Health Research (NIHR) Imperial Patient Safety Translation Research Centre. Infrastructure support was provided by the In line with the realist review approach, this paper NIHR Imperial Biomedical Research Centre. has reviewed heterogeneous evidence sources (eg, Competing interests None declared. expert interviews, academic literature, public consul- Patient consent for publication Not required. tations) allowing for a nuanced understanding of all Provenance and peer review Not commissioned; externally aspects of complaints management and policy.111 peer reviewed. Although this is an important strength of the review, Data availability statement This study is a literature review it somewhat limited our ability to establish satura- and largely includes existing evidence. Anonymised interview tion in some of the review’s findings. A limited body data can be requested from JD (​j.​van-­​dael18@​imperial.​ac.​ of evidence further meant that our CMOs are by uk). External data sharing will however require separate approval from the healthcare organisation where the data were no means exhaustive and do not necessarily include generated. Data sharing is therefore not guaranteed. all processes involved in complaints management Open access This is an open access article distributed in (eg, there was insufficient evidence on investigative accordance with the Creative Commons Attribution 4.0 procedures involved in complaint handling). Further- Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any more, most of the selection, extraction and appraisal purpose, provided the original work is properly cited, a link of literature was conducted independently by a to the licence is given, and indication of whether changes were single researcher (JD) leading to potential bias.111–113 made. See: https://​creativecommons.​org/​licenses/​by/​4.​0/. Measures were taken accordingly to maximise stand- ORCID iDs ardisation (eg, data extraction form, rigid appraisal Jackie van Dael http://​orcid.​org/​0000-​0002-​9949-​5802 criteria). Finally, although a large proportion of Alex Gillespie http://​orcid.​org/​0000-​0002-​0162-​1269 Ana Luisa Neves http://​orcid.​org/​0000-​0002-​7107-​7211 the evidence (n=74) was drawn from a range of countries, policy sources (n=10) and expert inter- views were based on NHS practice in England, and often secondary care. Some of the reported issues References 1 NHS Digital. Data on Written Complaints in the NHS and contexts of existing practice may therefore not - 2007-08, 2008. Available: https://​digital.​nhs.​uk/​data-​ directly translate to other settings. and-​information/​publications/​statistical/​data-​on-​written-​ complaints-​in-​the-​nhs/​data-​on-​written-​complaints-​in-​the-​nhs-​ 2007-​08 [Accessed 16 Mar 2018]. Conclusion 2 NHS Digital. 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