A complaint is an expression of dissatisfaction when there is a gap between expectation and delivery of a product or service. Complaints about healthcare rise year on year. Healthcare complaints are grievances that may be indicative of some system failures or individual failings or a combination of both. Individual failings may be symptomatic of typical behaviours or atypical e.g a response to an unknown mitigating factor such as workload or resources. Thus, complaints are representative of problems concerning individuals and, or their organisation.
Complaints and complainers
More recently, it has been suggested that complaints are partly indicative of the general public’s supposedly unrealistic expectations of healthcare expressed as a general lack of patient-centeredness if not ‘clinical heartlessness’ (Newdick and Danbury 2015: 956). Nevertheless, complaints are not considered patient safety red flags per se, but they do point to a broader conceptualisation of ‘harm’ (McCreaddie et al 2018). Moreover, patients’ legitimate concerns tend to extend beyond the initial complaint (or complaints) to the process and subsequent outcome (of the complaint).
Complaints are diverse, relatively unstructured, complex and emotive (Reader et al 2014). Many complaints evidence serial failings that subsequently breach a given threshold (McCreaddie et al 2018). In short, patients or relatives who complain are unlikely to simply complain about one issue. Understandably, once a transgression has occurred and there is no immediate successful attempt to resolve the grievance, then the healthcare relationship has been breached. Accordingly, this is likely to set off a cascade of additional serial complaints culminating in a formal ‘written’ complaint. In turn, complainants report psychological distress throughout the whole process; care to complaint – as well as with the subsequent outcome. Table 1 outlines complaint behaviour.
So, what can we do to help?
Service recovery is a term more akin to consumer industries and is a strategic approach to returning aggrieved customers to a state of satisfaction following a breach of expectations (Zemke and Bell 1990). Service recovery follows service failures and is aimed at maintaining the relationship and promoting positive word of mouth through prompt, efficient and successful complaint resolution. Successful complaint resolution is but one aspect of service recovery and enhances the consumer-provider relationship through a resultant perception of quality and value. Conversely, service recovery in healthcare is arguably wholly reliant upon complaint handling as opposed to complaint resolution, with the former reportedly lacking impartiality (Francis 2013), taking too much time and effort making relatives fearful of the implications for future healthcare and, perhaps unsurprisingly in the current context, unlikely to lead to a successful outcome (Wessel 2012).
The Middle East perspective
The Middle East and the UAE, in particular, is home to rapidly developing healthcare facilities who treat patients from across the region and beyond. It is also a cauldron of diverse nationalities and cultures that may have varying sensitivities and cultures – which in of itself, has the potential for gripes and grievances. Many healthcare facilities currently have patient relations officers and are likely to expend considerable time in addressing grievances. Yet, the Middle East is arguably a non-complaining culture but with a population with increasing expectations of healthcare and service. Complaints may, therefore, be made informally (via a third party) and may even focus on material aspects such as the type of room or furnishings – in addition to non-health/clinical issues.
The large non-Arabic speaking expatriate healthcare workforce who may not be viewed as positively as indigenous or western staff – more akin to maids as opposed to a respected professional grouping – may also be a contributing factor in a perception of disaffection. Moreover, the possibility of litigation and the concept of ‘blood money’ may potentially create additional pressures for staff who are dependent upon employment to support themselves and their families abroad.
Within the UAE the ‘complaints’ agenda has largely been addressed through Patient Satisfaction Surveys with the Government requiring the use of a variety of tools. In Dubai, all hospitals must be accredited by an external audit such as Joint Commission International or the Australian Council on Healthcare Standards. A critical standard within these external reviews includes assessment of patient satisfaction and the management of complaints.
The current tools used to assess patient satisfaction and review complaints in the UAE include:
- "Happy faces" – machines located throughout health facilities that allow patients to press a button that reflects their opinion of their experience and
- Formal satisfaction surveys sent to patients on discharge such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey.
Quantitative tools used to assess patient satisfaction and manage complaints should be internationally recognised, be reliable and have both construct and predictive validity. Moreover, if patients and, or, their relatives take the time to either write a complaint, press “a face button” or complete a survey, then organisations must be prepared to reflect, and if appropriate, act. However, Table 2 perhaps gives some insight into these narrow but limited approaches. Healthcare is a complex, dynamic entity that cannot be distilled into a ‘Happy’ or ‘Sad’ face.
A review of 60 written complaints in the UK concluded that healthcare staff may benefit from understanding how complaints are formulated to be able to more appropriately address patients’ grievances from the outset and therefore, reduce the considerable associated harm for all concerned: patients, relatives and healthcare staff (McCreaddie et al 2018). The aforementioned ‘tools’ are laudable, but they arguably lack context, quality and importantly, fail to take account of the diverse cultural context in which healthcare in the Middle East is practiced and consumed. For the UAE to truly become a world leader in healthcare it needs to better understand not just what people complain about but why people complain, how they complain (or not) and their expectations with regard to resolution.
References available on request.