The patient’s perspective: Studying written complaints addressed to Cyprus’ Public Healthcare Units

Hospitals are often the receptors of complaints that are written by dissatisfied consumers -patients or their families- as an expression of grievance or a dispute regarding what was perceived as problematic healthcare services (Lloyd-Bostock & Mulcahy, 1994). In most instances, when a complaint is submitted, patients have surpassed a threshold of dissatisfaction with the services they have received (Lloyd-Bostock & Mulcahy, 1994). In this respect, complaints represent cases of higher severity, at least from the perspective of patients. Being the recipients of healthcare services, patients can provide an independent assessment of dysfunctional aspects of care that may have become normalised; that is, they may be integrated as normal into the healthcare provision and are not recognised by healthcare professionals (Dixon-Woods et al., 2009; Vaughan, 1999).

Contrary to research relying on structured questionnaires to examine patients’ satisfaction and perspectives regarding the quality of services they have received (e.g. Thanh Vân France et al., 2011; Xie & Or, 2017), the use of unstructured written complaints can offer a more precise insight into the patient’s perspective (Alemi & Hurd, 2009; Reader et al., 2014). By narrating specific problematic incidents without being confided within the parameters of predefined questions, patients can provide a direct account of their experience. Patients’ perspective reflects the needs and experiences of the larger society towards the healthcare sector. Further, it involves privileged access to certain facets of healthcare that are otherwise unavailable to assessment (Gillespie & Reader, 2016); for example, the entire journey from admission to discharge, which only patients are in a position to report. Hence, complaints are particularly suited for identifying problems relating to continuity of care (Hadjistavropoulos et al., 2008) and different aspects of the healthcare system (e.g. management, quality of care, discrimination and human rights, relationships).

Written complaints have thus been identified as a rich and valuable source of data through which quality of care and patient safety can be assessed and improved (Donaldson, 2000; Weingart, Pagovich & Sands, 2005; 2006; Gillespie & Reader, 2018). In fact, they can prove essential in revealing hot spots (i.e. events and practices that either had the potential to cause harm or have led to serious harm) and blind spots (i.e. aspects of healthcare system not monitored adequately) (Gillespie & Reader, 2018). Further, they can highlight systemic problems in healthcare institutions, allow for comparisons among institutions at a national context and can thus be used as a reference point for planning and implementation of effective improvements in healthcare services (e.g. policy making, training programs, organisational changes).

Yet, up until recently, the lack of a reliable, standardised taxonomy for coding and analysing these complaints deterred researchers from examining such data. To address this gap in the literature, in 2015, Gillespie and Reader (Gillespie & Reader, 2015) developed the Healthcare Complaints Analysis Tool (HCAT) which is the first standardised tool for coding and analysing complaints. HCAT was developed out of systematic reviews of the existing literature and relevant theoretical work on the issue and it has been tested for its reliability using empirical data (Gillespie & Reader, 2015; 2016; Reader et al., 2014). Furthermore, it has already been successfully used in different national contexts (see de Vos et al., 2019; Gillespie & Reader, 2018; Jerng et al., 2018; Bogh et al., 2019; Wallace et al., 2018), thus it appears to be a promising tool for the systematic analysis of patients’ complaints.

Our study focuses on an understudied European context, Cyprus. According to the Euro Health Consumer Index (Health Consumer Powerhouse, 2019), the healthcare system of Cyprus was recently ranked rather low, in position 26 out of 35 countries. Until recently there was no National Health Insurance Scheme in the country, however, since June 2019 the country has shifted to the first phase of implementation of its General Healthcare System (GHS/ΓεΣΥ), a process delayed in its implementation due to the pandemic, but expected to be finalized soon.

The overall study focuses on three different time periods: the period prior to (2016-2019), during (2019-2021) and after the implementation of the GHS change (2021-2022), enabling the researchers to study both the wider issues that patients confront in the healthcare system throughout these years and to evaluate whether patients’ experiences changed following the implementation of GHS change. In Cyprus, various institutions receive, monitor and manage patients’ complaints regarding public hospitals. These are the patients’ rights offices and the complaints offices located within the hospitals, the General Healthcare System (GHS/ΓεΣΥ) Supervision Commissioner (as of June 2019), the Ombudsman’s Office, the Cyprus Medical Association, the National Federation of Patient Associations and the Health Insurance Organization (HIO/ΟΑΥ).

The Seedcorn grant was used to conduct a pilot study for the period before the implementation of the GHS change, using a sample of complaints submitted to one of these institutions, the Cyprus Ombudsman’s Office.

Methodology

The original sample for this pilot study consisted of 80 written complaints regarding public healthcare units’ services, submitted to the Cyprus Ombudsman’s Office between January of 2016 and June of 2019. The complaints were selected using stratified -per year- random sampling among the total of 215 complaints received by the Ombudsman’s Office within the time period of interest. The final sample, after removing duplicates or non-relevant complaints, was 75 written complaints. The project obtained approval from the Cyprus Bioethics Committee and all complaints were anonymised by Ombudsman’s Officers before they were sent to the research team.

Tool: Data were coded using the Healthcare Complaints Analysis Tool (HCAT; Gillespie & Reader, 2015) presented above. The HCAT categorises problems found within complaints in three domains: (a) the clinical problems domain, which captures problems relating to issues around poor-quality care and safety incidents, (b) the management problems domain, which captures problems regarding management issues such as waiting times, delays and access to care, and finally (c) the relationship problem domain, which captures problems focusing on the interactions between patients and healthcare professionals (e.g. lack of communication of important information to the patient, ignoring information given by the patient, incidents of disrespect). The three domains are further divided into categories, which clarify the nature of a problem and its severity degree in a scale from 0 (no information given) to 3 (problems of high severity).

Moreover, HCAT provides information regarding the stages of care in which the problems arise, as well as the degree of harm reported by the complainer. The scale ranges from 0 (no harm reported) to 5 (catastrophic harm). Finally, the tool takes into account basic information about the patient/complainer and the staff group(s) involved in the complaint. As a result, HCAT provides a detailed description of the problems encountered within a healthcare organisation/system but can also identify low-level problems and risk areas before they lead to serious failures in the healthcare sector (Gillespie & Reader, 2015).

Coding and Analysis process: Initially, the HCAT was adjusted to the specificities of the Cypriot public healthcare system through pilot coding. This led to small alterations in the coding scheme, such as adding an extra stage of care and expanding the category of institutional processes, to encompass disputes regarding financial requests. Following the pilot coding, all data were coded by two independent coders in order to ensure interrater reliability of the coding. Cohen’s kappa statistic was calculated for all variables that were categorical and an Intraclass Coefficient (ICC) for one continuous variable (Harm reported). For the majority of the variables, Cohen’s kappa value ranged from .6 (substantial) to .9 (excellent).

Findings

The findings reported are based on the small sample of 75 complaints used for the pilot study and thus are not representative of the complaints received by all relevant institutions for the period of analysis. Hence, they should be treated with caution.

The key findings of the project are:

• In total there were 144 problems reported across the 75 complaints analysed. On average, there were 1.92 problems reported per complaint.
• 32% of the complaints reported at least one clinical problem (i.e., issues relating to quality and safety of clinical and nursing care), 86.7% reported at least one management problem (i.e., issues relating to the environment and organisation within which healthcare is provided) and 33.3% reported at least one relationship problem (i.e., issues relating to the behaviour of a staff member towards the patient and/or their families).
• Problems of institutional processes, a category under management domain that refers to problems in bureaucracy, waiting times etc., were present in the large majority of the complaints (85.3%).
• 21% of the problems were classified as low severity, 40% as problems of medium severity and 39% as high severity problems.
• Management domain (43%) and clinical domain (39%) problems consisted the large majority of high severity problems.
• Approximately 50% of the complainants sought communication with the Ombudsman’s Office after seeking communication with another institution, primarily the Ministry of Health.
• According to complainants, the stages of “examination and diagnosis” and of “operations and procedures” were the most commonly reported stages of care in which problems arose (28% and 21.3% respectively), whereas the stage of “discharge and transfers” was the least reported one (5.3%).
• Medical (30%) and hospital administration staff (34.7%) were more frequently involved in patients’ complaints as compared to other staff groups such as pharmacists (4%) or physiotherapists (0%).

For detailed analysis of the findings please contact the research group.

Conclusions

The findings suggest that during the period of study (January 2016 - June 2019), problems relating to institutional processes were highly prevalent across patients’ complaints. These problems predominantly concerned financial assistance requests for treatments in the private sector due to unavailability of the public units to accommodate patients’ needs. The unavailability of the public units was often related with long waiting times, delays, or even uncertainty over appointments scheduling, as well as with limitations regarding access to specialist care. Institutional processes problems emerged not only throughout the healthcare process but also during complaints management. Approximately half of the sample studied consisted of complaints that were initially submitted to other institutions such as the Ministry of Health, yet they were not adequately addressed or not responded to, according to the complainants. This finding exemplifies the need for the development of an efficient unified mechanism for managing complaints in Cyprus, which can both address individual complaints efficiently as well as use them aggregately as a database, to identify blindspots and hotspots of the healthcare system or specific healthcare units. Currently, the receipt and management of complaints in Cyprus is fragmented and dealt with by various institutions.

Complaints regarding the clinical domain, despite being less frequently reported, they were exclusively of medium or high severity, with the latter comprising more than half of the domain’s size. Across the subgroup of high severity complaints, clinical domain problems were as equally present as management domain problems. This finding underlines the need not only to address bureaucratic procedures within the healthcare system, as well as issues of quality and safety of healthcare provided, and possible inter-relations between the two domains.

Regarding the stages of care, three of them: examination and diagnosis, operations and procedures, and care on the ward were particularly problematic, as they were linked to high severity problems, hence in need of close monitoring and improvement. Given that these are stages where interactions between the patient and healthcare staff are frequent, examining this relationship further could help address these issues. This can be facilitated also by focusing on the relationship problems domain which in our sample consisted approximately one quarter of the problems reported. Based on the findings reported, hospital administration staff and medical staff were the two staff groups involved in most complaints. Also, while nursing staff was rarely reported, when mentioned, it was involved in highly severe complaints. A larger sample study will be able to demonstrate whether those stages of care are in need of intervention and to identify the needs that exist across specific staff groups.

Concluding, the EASP Seedcorn Grant facilitated the conduct of a pilot study, through which we could adapt the HCAT in the local context and also identify, through these preliminary findings, how such a complaints’ analysis can prove useful for the healthcare units of the country. This study highlights the significance of a larger-scale study examining the period before, during and after the implementation of the General Healthcare System change to identify possible changes that its implementation has brought into the healthcare system of the country. Further, a larger scale study will permit the identification of blindspots and hotspots in the public healthcare services, regarding the stages of care associated with higher harm (hotspots) as well as the identification of systemic -among others- blindspots in a unit (e.g., coexistence of problems of different domains and its association with harm reported).

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