Approaches and mechanisms used in managing patient complaints

The study identifies both formal (table 2) and informal approaches and mechanisms used in handling patient complaints.

1. Negotiation between hospitals and complainants

The complaint handling department within the hospital is responsible for dealing with patient complaints and was first established on 20 February 2002, in accordance with the Regulation on the Handling of Medical Malpractices.28 Since November 2009, these departments have been regulated by Measures for the Handling of Patient Complaints in Hospitals (for Trial Implementation).6 These acts require that a medical institution establish a department specifically for the purpose of handling and resolving medical disputes. The department is primarily responsible for receiving patient complaints via calls, letters, visits and/or cases referred from other departments and institutions. Their role also includes counselling and communicating with patients, verifying and documenting disputes as well as resolving disputes.

• Administrative mediation and civil lawsuits

If the hospital is unable to resolve certain conflicts through negotiation, the cases may be referred to an external body such as the health administrative department or they may be settled in court by means of litigation. The Tort Law of the People’s Republic of China, adopted at the 12th session of the Standing Committee of the Eleventh National People’s Congress on 26 December 2009, provided a new legal definition of liability for medical malpractice, liability presumption and exemption.29

• Complaint Letters and Visits System

In February 2007, Measures for the Complaint Letters and Visits System for Healthcare was established.30 Its purpose is to protect the legal rights and interests of citizens, legal entities and other organisations, and to regulate behaviour and maintain order within the Complaint Letters and Visits System. It requires health administrative departments to set up Complaint Letters and Visits offices at different levels. These offices are responsible for receiving, assigning and transferring matters as appropriate, as well as supervising the handling of various issues and complaints.

• People's Mediation—a form of Third-Party Facilitated Mediation

In July 2008, the Shanghai Justice Bureau and Health Bureau issued Opinions on Regulating People’s Mediation Organizations to Participate in Medical Dispute Mediation, to establish the People's Mediation Committees for Medical Disputes.31 Committee members, mainly retired judges and doctors, served to mediate disputes through reporting, explaining and analysing cases under the supervision of the local judiciary. In January 2010, the Ministry of Justice, the Ministry of Health and the China Insurance Regulatory Commission jointly issued Opinions on Strengthening People’s Mediation for Medical Disputes to bolster the role of mediation in resolving medical disputes.32 Its intent is to settle medical disputes in an effective way and to maintain order within hospitals, all with a view to ensuring harmony and social stability. In July 2011, the Shanghai Justice Bureau and Health Bureau introduced Measures on People's Mediation for Medical Disputes in Shanghai to replace Opinions on Regulating People’s Mediation Organizations to Participate in Medical Dispute Mediation.31 ,33

In addition to the aforementioned channels of complaint, patients have also been found to express their discontent by “Yi Nao”—exhibiting disruptive behaviour within the hospital by targeting doctors and nurses or hospital managers by way of abuse, assault and other forms of violence. Much of this has garnered media attention, resulting in bad publicity for the hospital and damaging the reputation of doctors and staff.

The application of different complaint approaches

The complexity of relationships between different approaches can be seen where many actors are involved. The responsible institutions of all approaches can receive complaints. Generally speaking, patients first lodge complaints to hospitals. If complainants or hospitals are unwilling or fail to negotiate, they may file applications to other approaches. Approaches that can resolve medical disputes are mainly negotiations and civil lawsuits, while other approaches play a part in forwarding cases, such as Complaint Letters and Visits System, or easing conflicts, such as mediation. None of the approaches are considered the ultimate arbiter. For example, patients can continue to lodge complaints through the Complaint Letters and Visits System even if a decision has been finalised after a second trial in court or after negotiations with hospitals.

In the aforementioned approaches, the hospital is the main handler for patient complaints. First of all, it can handle patient complaints completely independently, from reception to solution, while the other approaches, such as the Complaint Letters and Visits System and mediation, must engage hospitals in complaint handling. Second, since the hospital is principally responsible for compensation, the complainant is more inclined to directly negotiate with the hospital. Findings from the literature show that the majority of medical disputes are resolved by negotiation between hospitals and complainants.22 Third, if hospitals handle complaints improperly, conflicts will become more volatile, resulting in serious incidents, such as “Yi Nao”.34 Therefore, hospitals have become the most common receiver, handler and resolver of disputes (figure 1).

Barriers to the effective management of patient complaints and their underlying causes at different stages

Our interviews revealed that different hospitals often use different complaint systems. For example, some hospitals operate a centralised complaints office that may or may not be independent of the Medical Affairs (Administration) Department. Other hospitals have several complaints offices, each of which is responsive to different kinds of complaints. A hospital's deputy director, who also heads hospital complaint management, generally manages complaint departments. Barriers to effective complaint management vary at different stages of the complaint process, both from the sides of the user and provider.

A. Barriers to receiving the complaints

Low awareness of users about the handling system for patient complaints: Although hospital staff claimed that the complaints office was accessible to those with grievances, patients did not always feel this was the case. One user looked up the hospital telephone number on the internet and said the complaint handling process was ‘very easy’ while others did not concur. Almost all the patients interviewed found that signs and directions (to the complaints office) failed to catch the eye. In some cases none could be seen at all: I wanted to lodge a complaint, but did not know how to find [the complaints office]…Because the hospital was so big, I did not know which department [was responsible for handling complaints]…I simply did not know who to turn to. You see, the complaints department was in another building [rather than in the one in which I was treated i.e. the clinical department] (Female, Users-1, 01-09-2011)

• Barriers to handling the complaints

Poor capacity and skills of healthcare providers: The capacity and skills of healthcare providers in managing patient complaints is critically important in problem solving. Our study found that the reasons patients complained lay mainly in poor communication and factors such as the provider's attitude, use of language, unprofessional behaviour, as well as dissatisfaction towards service procedures. The Medical Doctors Association carried out a survey on the nature of medical disputes. 50 per cent of cases were results of inappropriate attitudes about health care delivery, 25 per cent were caused by technology misuse and the rest were related to management. (Female, Policy makers-1, 16-12-2010)

The majority of complaints can be resolved by an explanation issued by the hospital and/or a verbal apology by the offending party.5 ,35 ,36 However, practitioners are often too preoccupied with their clinical duties to be able to respond to patient complaints. Doctors are not able to devote much time to handling disputes, because clinical work is highly demanding. [They need to attend to] many patients every day. If they spend more time communicating with patients, they would lose time needed to carry out [clinical work]. That is to say, [doctors should be given] less [clinical] work, and more time to explain their work to patients. Our workload is very heavy, like a battle. (Female, Health care providers-1, 01-09-2011)

Incompetence and powerlessness of complaints handlers: In comparison to healthcare providers, complaint handlers played a more important role in cooperation and coordination. Although complaint departments were specifically set up in hospitals for receiving and handling complaints, the responsible persons in the department were mainly part-time medical staff. In some cases those handling staff were found to be inadequate due to lack of training. Many of them had studied handling techniques on their own and had not acquired sufficient professional skills to appropriately analyse, assess and solve complaints. Complaint handlers in the hospitals cannot solve everything because the disciplines involved in complaints are highly specialised. I am only familiar with general surgery and issues that require common sense, but [I am not familiar] with professional problems in other disciplines. (Male, Hospital managers-5, 08-09-2011) It is difficult to recruit staff for our Medical Dispute Handling Office. No one wants to come. A boy recruited in 2007 could not stand the demands of the job [complicated disputes and violence] and so resigned. (Female, Hospital managers-3, 31-08-2011) We have little time to do things other than receiving complaints. We lack staff members. We are responsible for receiving and processing complaints, and expected—on top of this—to deal with other things, hence why we are exhausted. (Male, Health care providers-2, 16-09-2011)

Given that most complaints are handled and resolved in the hospital, it appeared that every complaint handler interviewed felt the same way: tired and stressed. Complaint handlers were insufficiently empowered to handle complaints. It was hard for them to coordinate between different departments, investigate cases, organise mediation, find solutions and then draw on patients’ feedback to improve quality of care. Recently, a fierce medical dispute occurred because of a possible misunderstanding between administrative departments. [Abusive] words erupted. As a consequence, staff members involved in this incident were distraught—to the extent that they wanted to resign. Hence, we need understanding and support among colleagues…Sometimes the clinical department at hand refused to cooperate when investigated. He [the clinical department] is not very serious about cooperating with the investigation. (Female, Hospital managers-3, 31-08-2011) Communication between administrative departments and clinical departments is not very effective sometimes. I am not satisfied with this. (Female, Hospital managers-2, 25-08-2011)

Non-transparent exchange of information: In addition, the complaint handling process was not truly open to the complainant, and information exchange was largely limited to hospital staff. In fact, it was found that the staff at the complaints office was generally evasive towards patients who arrived wishing to be updated with the specifics of their complaint. Complainants had no opportunity to directly engage in the handling of their complaints or to meaningfully participate in the process. In addition, hospitals tended to oversimplify cases, assuming that the complainant's only desire was to report their complaint and ask for compensation. This implies that the entire handling process is disclosed only among hospital staff. Therefore, the process becomes a ‘black box’ to patients. It is easy for the hospital to manipulate a complainant by providing limited information to gain advantage in negotiations, that is, reduce loss from compensating patients. Sometimes you have to circumvent something and use negotiating skills. Mistakes in medical services do not necessarily harm patients’ health, but they can be very serious for the provider [...] for example, someone may not be very careful when writing a medical record and alter it by accident. But you are likely to lose a lawsuit on the grounds of having tampered with records. Incidents such as these cloud the matter, making transparency difficult. (Female, Hospital managers-2, 25-08-2011)

If the incident is urgent or presents itself as a recurring problem, it might be shared to educate healthcare providers but disclosure to complainants themselves remains limited. Only outcomes deemed to be of direct interest to patients, including compensation amounts and medical service privileges, were provided. However, other results, including penalties imposed on physicians and departments or improvements made to hospital services, were largely withheld from patients if they did not ask. In individual cases, what are the outcomes of their complaints? How might a physician be punished/penalised/disciplined? Such information is requested by patients only occasionally. (Male, Health care providers-2, 16-09-2011) I want to know how to better educate the concerned health care providers. But I have not been told. (Female, Users-3, 20-09-2011)

• Barriers to resolving the complaints

Conflicts between relevant actors and regulations: Within the complaints system, conflicts or inconsistencies can arise between the legal system for handling complaints and the solutions determined by the hospital. As the structure of managing patient complaints is shown in figure 1, different regulations stipulate different approaches. Unified laws or guidelines do not exist to clearly illustrate the relationships between different approaches, which results in problems such as a lack of authority or ultimate approach, uncertainty about how to apply different regulations to one case, and no clear definitions or classifications with regard to patient complaints. The current state of complaint management is disorderly. There are too many channels. For example, many departments are involved, including but not limited to Complaint Letters and Visits, online complaints, etc. The Health Bureau has two departments [for complaint management], and each district has a mediation office, a district government website or a mayor-mail [to receive complaints], and a Complaint Letters and Visits office…Far too many heads of departments within the health sector; it is chaos. (Male, Health care providers-2, 16-09-2011) Hospitals are required to report complaints to a lot of sectors, all of which wish to understand the issue from different angles. Conflicts between regulations do not necessarily exist, but different elements are emphasised. Hospitals are tired of these kinds of bureaucracy…Each sector carries out their designated duties where resources are not shared. The information possessed by each sector is fragmented. You know yours, I know mine. (Male, Administrators-2, 18-08-2011) Medical malpractice is defined clearly in the Regulation on Handling Medical Malpractice. There are several benchmarks determining the amount of compensation issued. After the Tort Liability Law of the People’s Republic of China was promulgated, [medical damage] was compensated for more in accordance with the Tort Liability Law because it stipulates compensation for personal injury. (Female, Hospital managers-2, 25-08-2011)

Unjustifiable complaints by patients: In some cases, the patient experiences inconvenience when receiving medical services not because of poor conduct in attitude or behaviour on the part of healthcare providers, but possibly because of long wait times, too little time spent with the doctor and/or imperfect resource allocation. These are health system issues rather than problems caused by hospitals or individual physicians. And so, to a certain extent, physicians and hospitals have become scapegoats of the entire health system. At times it is not us physicians who make patients angry. Certain factors are rooted in the fabric of health care systems, but we physicians [end up] taking the blame. (Male, Health care providers-3, 16-09-2011) For example, should a doctor need to see sixty patients in half a day, or indeed one hundred, you cannot demand that he puts on a smile for each one. A lot of patients complain about doctors with a straight face, but I think it is understandable. I have a very good relationship with our young doctors. They operate on a tight schedule. This week someone worked at the outpatient facility. He was friendly with patients in the first month but struggled to sustain that sort of demeanour. He is not in the mood to smile at patients or engage in long conversations when he only has time to attend to their illnesses. (Male, Hospital managers-1, 15-12-2010)

For example, dissatisfaction voiced in the hospital may be related to health insurance policy rather than staff behaviour. Hospitals need to follow the policies made by the Health Insurance Department. The purpose of those policies was to improve rational use of medicines and control healthcare costs, while the patients covered by health insurance may demand more medicines. Chinese doctors have many rules to obey [this is to curb poor conduct]. The pressures for them to perform are relatively large. For example, doctors cannot prescribe too much medicine for a patient who has only [basic state-financed] medical insurance, but patients always want more. A while ago, the Medical Insurance Bureau issued the following statement in a newspaper: “The Medical Insurance Bureau never limits the volume of drugs prescribed, rather it is the doing of hospitals who wish to increase workload [in order to produce more statistics].” I think this is really unreasonable. The Bureau does not control the quantity of drugs prescribed in any given week, but there is a total quantity limit over a year. Doctors try their best not to prescribe drugs which must be self-financed, i.e. not covered by basic medical insurance. They must also explain very clearly before prescribing self-financed drugs, otherwise, patients will lodge complaints once they find out. (Male, Hospital managers-1, 15-12-2010) Complaints occur when the patient wants more drugs but the doctor refuses to satisfy his or her demands. Why? The health insurance institution sets a limit on drug expenditure for each hospital; in turn, the hospital sets a limit for each doctor. So if a doctor has too many patients drawing from their health insurance scheme in any one month, he or she may very possibly have exceeded his/her limit. (Male, Health care providers-3, 16-09-2011) [A patient who has] basic state-financed medical coverage is entitled to blood and other auxiliary examinations. If the number of health checks prescribed exceeds a certain threshold, the doctor is viewed as exploiting basic medical insurance. The doctor is consequently punished. I was deducted more than seven hundred yuan (RMB) because of a case like this. I feel this is simply absurd—it is [unexpectedly] doctors who are to blame. Nothing seems to be wrong with the patient…The hospital cannot do anything about medical insurance. I think this kind of thing is not the problem at the hospital level. The complaints about medical insurance define, without a doubt, problems underlying the state and society. (Male, Health care providers-4, 16-09-2011)

In addition, the safety of healthcare providers is under threat in China today. Chinese medical workers are often victims of violence. As a consequence, some healthcare providers have decided to not treat patients deemed likely to assault staff, exhibit disruptive behaviour or otherwise prove to be difficult. Prescribing redundant check-ups and drugs are alternatives to properly seeing to patients.

In our interviews, 15 interviewees mentioned “Chao” 55 times. “Chao” in Chinese means to argue with hospitals for patients’ rights and interests, while the other meaning is to wrangle fiercely in hospitals or with senior management. Most of the hospital staff interviewed suggested that some complainants were indeed unreasonable and impulsive with the sole purpose of claiming. If the case goes to court, the patient gathers a lot of people to go to the court, insulting and threatening concerned health care providers and their lawyers. That is not what we want to see. We want to talk about the truth, by thoroughly publicizing the truth. We cannot always be too specific with terminology [for fear of revealing too much]. When completely refuted, patients lose their temper. (Male, Other actors-2, 15-09-2011) I feel that the widespread situation in China today is that you can do nothing if you run into the unreasonable. The legitimate way of going about this is to propose a fair decision once I receive your complaint. If complainants are not willing to settle for this, we then transfer their case to other departments. However, complainants may not even agree to that, causing trouble and even threatening the safety of health care providers. (Female, Hospital managers-2, 25-08-2011) The claim a complainant demands goes beyond the actual problem [but for the money] and he does not wish to resolve it the legal way…Nowadays “Yi Nao” has brought about serious social effects, and has escalated the tension between service users and providers. Complainants are unwilling to resolve things the legal way, rather, just pestering and hassling you [health care providers or complaint handlers] all day. (Male, Hospital managers-6, 01-11-2011)

• Barriers to institutional changes for quality improvement using complaints data

Weak enforcement of the regulation: The regulation for managing patient complaints is merely a guideline that contains no mandatory requirements such as assessment mechanisms. Because it takes into account the difference in local conditions throughout China, specific contents were not stipulated. The regulation is to be interpreted according to local circumstances and conditions. Therefore, in the absence of strong public scrutiny, there is little accountability for how best to manage patient complaints. There are no penalties attached to (failure to follow) regulation. For example, there is no administrative aspect to the regulatory guidelines. We wanted to write a penalty provision, but it was not based on the top legislation. The purpose of the regulation is to emphasise self-discipline and to serve as guidance for the hospital. [The penalty was not enforceable,] so we decided to remove the penalty. It is indeed difficult and contradictory. (Female, Administrators-4, 30-11-2011)

Besides the legal system, the reporting system also has its problems. Some statistics about patient complaints and medical malpractice were utilised as a part of assessments of hospital performance, healthcare quality, and so on. This meant that the more cases that were reported, the worse the evaluations received by the hospitals so that hospitals were inclined to report selectively or report fewer cases. There are certainly no statistics for the number of patient complaints. There is only the data on the number of medical malpractice cases per year from the Bureau of Health, and an approximate amount of compensation issued by insurance companies. In some cases, if complaints were solved just between the hospital and the complainant, we have no data. (Male, Administrators-2, 18-08-2011) These days, the information regarding the management of patient complaints in hospitals is difficult to access. Hospitals are unwilling to provide that sort of information – it is considered confidential. We only have some profiles or the information from select hospitals. (Female, Policy makers-1, 16-12-2010)

Thus, the adoption of the incentive and sanction mechanism was contradictory for managing patient complaints. From one side, the administrative department wanted hospitals to report patient complaints because it is important for informing and improving the quality of care. From the other side, the more complaints that are registered, the worse it would appear a hospital is doing. In addition to this, managing patient complaints remains low on the health reform agenda. The force for inspecting complaint management in hospitals from senior management and administrative departments remains weak. [Having a statistic for patient complaints] is definitely necessary from the aspect of effective management. If this statistic is disposable, I think nothing of it. If the statistic is routine, in fact, it will cost [all sorts of resources]. (Male, Policy makers-2, 22-12-2011) Hospitals doubt that the purpose of administration is for information management – to help them better handle and solve disputes. However, if you want me to report incidents but meanwhile punish me for that, then I have no incentive to report anything. This contradiction stands [in the way of effective reporting]. (Female, Administrators-4, 30-11-2011)

Deficient information system for managing patient complaints: Although the regulations in place require collecting and analysing information, there exists no clear classification, definitions or unified coding system. Most hospitals have established their own systems for recording complaints and analysing cases, but no accurate or comparable data are available. In fact a lot of cases should be recorded and analysed, [but] we do not even take into account so-called major cases of medical malpractice, mass disturbance or medical malpractice. We cannot distinguish between these concepts…Relatively speaking, it is more feasible to publicize the data on public security, e.g. the number of police records and people arrested, and the number of crimes committed. Those definitions are more explicit, whereas those concerning complaints management are not. Because all statistics are calculated in the hospital, we find that where standards are slack, the resulting statistic is large and where standards are strict, the statistic is small. Hence, there is great variability in our results. (Male, Policy makers-2, 22-12-2011) Identical forms are sent to two hospitals at a similar level and the reported data can be quite different…Some hospitals only reported cases resulting in compensation and some hospitals record all persons who voice a concern, while others only report cases identified as medical malpractice. But it is impossible for me to verify [the reported data] in each hospital. (Male, Administrators-2, 18-08-2011)

Hospitals have not publicised complaints; neither have health administration departments. The Shanghai Bureau of Health launched a pilot project in 2005 to publicise the complaints reported by all hospitals in Shanghai. The project was welcomed by the public but discontinued soon after its launch due to mounting pressure from the hospitals. We already publicize complaints [medical malpractice] on our intranet for hospital staff. It is unnecessary to share this information on external sites. (Female, Hospital managers-4, 06-09-2011) To my knowledge, such information was published once on the Xinmin Evening News in 2005. The newspaper named hospitals that had won awards and gave details of the number of medical malpractice cases happening in each, as well as feedback regarding patient satisfaction. [We felt] the pressure was very, very high. It [publishing those] resulted in public outrage [from hospitals]. (Female, Administrators-4, 30-11-2011)

Unwillingness of hospitals to effectively handle complaints: Most hospitals did not devote much effort into managing complaints. There was no clear mechanism to utilise patient complaints to improve quality of care unless serious medical malpractice had occurred or complaints were found to recur. Hospitals just handle complaints when complaints happen…We are basically perfunctory, including hospitals, department directors and doctors. The best-case scenario for me: do not approach me for these things [complaints]. Deal with complaints quickly and efficiently; in other words, spend money to buy peace. The impact of managing and addressing complaints is negligible, with very little effect on improving medical procedures and quality. (Male, Administrators-2, 18-08-2011)

Hospital directors were the key actors of complaint management in hospitals. The incentive and sanction mechanisms in hospitals depended on how much attention directors pay to complaint management. In the 1980s the government reduced subsidies for public hospitals under the context of transforming the planned economy to a so-called socialist market in order to reduce inefficiencies in healthcare provision. Hospitals had to increase service charges to recoup the operational costs and to increase the income level of health workers. Complaint management occupied nothing but a small part of quality healthcare, so in most hospitals it failed to draw attention from senior management. Most complaints were solved on a case-by-case basis, without sufficient concern for the overall improvement of healthcare services. In practice, the head of department influences implementation. If he/she regards this as important, then subordinates work harder of course. Now the problem is that some heads of department do not pay attention to it [complaint management]. (Male, Health care providers-2, 16-09-2011) It is of course medical services that are the core of hospital work. Things such as [complaint management] are boring for the hospital. To a hospital, the fewer the complaints, the better. (Male, Administrators-2, 18-08-2011)