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A case study in management: The patient complaint
PrInted u- the USA
The Journal of Emergency Medicine, Vol 1, pp 151-l 53. 1983
Copyright R 1983 Pergamon Press Ltd
??
A CASE STUDY IN MANAGEMENT: THE PATIENT COMPLAINT Ellen Taliaferro, Department of Emergency
MD
Medicine, Holy Cross Hospital, 15031 Rlnaldl Street, Mwon
0 Abstract-The complaints of dissatisfied patients provide useful tools for monitoring the effectiveness of medical care delivered in the emergency department. To facilitate responsiveness to individual complaints and to also capture valuable feedback information, a standardized approach is recommended. Presented here is one example of a patient complaint and the manner in which it was handled.
1. He felt the history was one-sided and that the physician fired rapid questions at him and then cut off his replies. 2. The patient concluded marked anger on the physician’s part because the physician shouted at him and asked very rapid questions. 3. The patient did not understand the physician’s explanation of his condition and he
0 Keywords - administration; patient relations; MD responsibility
Case Presentation A hospital employee approached the director of the emergency department to complain of his recent treatment as a patient. The director elicited from the patient/employee concern regarding the inappropriate behavior of the emergency physician who saw the patient and regarding part of the physician’s fee. The director then summarized the patient’s comments for the emergency physician involved and sent him the following memorandum: A patient seen by you on January 23rd has expressed the following concerns:
asked the physician to return to the examining room. He said the physician returned “really mad,” and said to the patient, “My time is very expensive, and I’m going to charge you for this.” The patient reports the doctor also said, “This is not a medical school.” 4. The patient did understand the physician’s second explanation of his condition and was comforted. 5. The patient told me on several occasions, “I don’t want the doctor to get into trouble for this.” The patient was primarily disturbed because (a) his visit had been so stressful, (b) he felt the physician’s charge for observation time was excessive, and (c) similar experiences might be encountered by other patients, with an adverse effect on the hospital’s reputation. 6. Subsequently, the patient has spoken to me several times regarding his bill. Specifically, he feels the charges for observation time reflect the promise of the threat, “My time is very expensive, and I’m going to charge you for this.” He seems to have become fixated on this issue. After you have reviewed this, let’s get together
B
The Administration of Emergency Medicine offers practical strategies and administrating emergency departments for maximum efficiency.
RECEIVED:
5 January
1983;
ACCEPTED:
Htlls, CA 91345
15 June 1983 151
0736-4679/83
on organizing $3.00 + .OO
152
so that we can follow up with the patient as soon as possible.
The emergency physician and the director later discussed the case. The physician noted that he had found the patient’s manner irritating: The patient asked repetitive questions and seemed never to be satisfied with any answers. The physician also acknowledged that although he did not think he had expressed anger, the patient had certainly perceived anger. Accepting the director’s offer that he take responsibility for answering the patient’s complaint, the emergency physician wrote the following letter to the patient/ employee: Dear Mr. Doe: I have recently been made aware of some serious concerns that you had regarding your recent visit to our emergency department. I understand you felt I was “really mad” at you. I’m sorry my behavior gave you that impression. You certainly gave me no cause to be and I do not recall ever being angry with you. We had a communication problem and my comments and attempts at humor were not interpreted as I had wished. Since I was providing the service to you, then the blame and responsibility for this miscommunication lies mostly, if not solely, with me. I also understand you were concerned regarding the fee for observation time. The entire fee was completely reasonable and appropriate, especially considering the future benefits to you based on what you learned by visiting the department. I did not charge you extra for asking additional questions. You were charged for 30 minutes’ observation time, which is a customary charge for the evaluation of chest pain. Therefore, I did save you a great deal of time, money, effort, and peace of mind by resolving your distress from passing out and chest pain. I was able to do this in the emergency department, observing and evaluating you there, without admitting you to the hospital as an inpatient. Our group values your input as a hospital employee, and I personally appreciate your bringing to my attention a communication problem that could adversely affect other emergency department patients. Because of this communication problem, much of your concern seems to center on the charge for observation time. I will instruct the business office to dis-
E. Taliaferro
count your emergency department bill by the amount equal to the critical care charge. Thank you again for expressing your concerns.
Discussion The memorandum from the director summarized the patient’s complaint in as factual a manner possible and contained no assumptions as to the rightness or wrongness of the physician’s attitude or behavior. The nonjudgmental tone of the memorandum allowed the emergency physician to address the real issues brought up by the patient without becoming defensive. The emergency physician’s letter recognized the patient’s concerns and addressed the patient’s perception of physician anger, lack of communication, and inappropriate charges. The emergency physician responded by expressing regret for the patient’s distress, while balancing the patient’s perceptions with his own, and by deleting the disputed critical care charge. Although as a general rule fees deemed “appropriate” should not be dropped, there were hospital employee relations considerations to be addressed in the case presented here. This aspect of the patient/employee’s complaint heavily affected the decision to delete the disputed fee, but the decision is certainly arguable. In his letter, the emergency physician addressed the facts of the patient’s complaint without judgment. This created a win-win situation where the dignity of both the patient and the physician were maintained. The physician acknowledged the patient’s perception as different from his own and accepted responsiblity for the miscommunication without placing blame. No excuses were given and the patient received an apology escorted by a “thank you.” Deletion of Fees The value of the “thank you” is underscored by the deletion of the critical care charge. In general, as noted, charges should not be deleted unless they are clearly inappropriate or outright incorrect. Occasionally, a very specific gain-in this case
153
The Patient Complaint
positive hospital employee relations -is sought by deleting all, or part, of a bill. When exceptions are made, a careful explanation should be included lest the patient interpret the fee deletion as an acknowledgement of wrongdoing. When fees are not deleted, the appropriateness of the fee should be stated along with an expression of hopefulness that the patient will pay the bill promptly. If any doubt exists as to the appropriateness of the patient’s complaint, then the business office should be immediately notified so that the patient’s bill will not be sent to a collection agency should the patient elect not to pay the bill. Upon receiving collection agency letters in response to what seems to be an appropriate complaint, the patient may seek the opinion of a lawyer, escalating the dispute. Responsibility Problems are best solved by their owners. In this case, the staff physician, not the director, had the problem of this patient’s dissatisfaction. Emergency physicians learn little about dealing with patient complaints when the director answers all complaints coming into the department. Indeed, staff physicians may even come to expect “the chief” to handle one of the less technical but crucial aspects of good patient care: clear communication with the patient. Additionally, a valuable communication channel is established between the director and staff physicians when complaints are addressed in this manner. The staff physician is left with no doubt concerning the director’s standards for patient care in the department. The director gains insight into what is important to the staff physician, and in the case of a new staff physician, can identify areas where further development is indicated.
Pattern of Patient Complaints Dissatisfied patients who report their complaints can be looked upon as valuable critics. Their feedback, collected and analyzed, eventually provides insight into recurring problems. In the case presented, the patient verbally reported the complaint to the director. Occasionally complaints are submitted by letter or are gleaned from evaluation forms provided to patients at the time of their visits. Ultimately, all complaints need to be directed to the director, who can then see that the complaints are appropriately handled. The general pattern of patient complaints will occasionally point to a difficulty in interpersonal relationships in one of the physician staff. The medical administrator must address this with openness and concern, focusing on facts and not personal worth. If the staff physician becomes defensive and begins making excuses, learning cannot occur. One of the medical administrator’s most important functions is to eliminate excuses.’ When they are eliminated, the air clears and responsibility can be accepted. Criticism in the form of administrative feedback, correctly applied and directed, should stimulate, not stunt, professional growth.
Summary
Patient complaints are valuable management tools that provide insight into patient frustration, departmental problems and function, and practice patterns of emergency physicians. To fully appreciate the value of patient complaints, a consistent method of handling patient complaints is needed. One such approach is presented in this article.
REFERENCE 1. Townsend
R.:
Up The Organization. New York, Fawcett Crest, 1970, p 41.
The Journal of Emergency Medicine, Vol 1, pp 151-l 53. 1983
Copyright R 1983 Pergamon Press Ltd
??
A CASE STUDY IN MANAGEMENT: THE PATIENT COMPLAINT Ellen Taliaferro, Department of Emergency
MD
Medicine, Holy Cross Hospital, 15031 Rlnaldl Street, Mwon
0 Abstract-The complaints of dissatisfied patients provide useful tools for monitoring the effectiveness of medical care delivered in the emergency department. To facilitate responsiveness to individual complaints and to also capture valuable feedback information, a standardized approach is recommended. Presented here is one example of a patient complaint and the manner in which it was handled.
1. He felt the history was one-sided and that the physician fired rapid questions at him and then cut off his replies. 2. The patient concluded marked anger on the physician’s part because the physician shouted at him and asked very rapid questions. 3. The patient did not understand the physician’s explanation of his condition and he
0 Keywords - administration; patient relations; MD responsibility
Case Presentation A hospital employee approached the director of the emergency department to complain of his recent treatment as a patient. The director elicited from the patient/employee concern regarding the inappropriate behavior of the emergency physician who saw the patient and regarding part of the physician’s fee. The director then summarized the patient’s comments for the emergency physician involved and sent him the following memorandum: A patient seen by you on January 23rd has expressed the following concerns:
asked the physician to return to the examining room. He said the physician returned “really mad,” and said to the patient, “My time is very expensive, and I’m going to charge you for this.” The patient reports the doctor also said, “This is not a medical school.” 4. The patient did understand the physician’s second explanation of his condition and was comforted. 5. The patient told me on several occasions, “I don’t want the doctor to get into trouble for this.” The patient was primarily disturbed because (a) his visit had been so stressful, (b) he felt the physician’s charge for observation time was excessive, and (c) similar experiences might be encountered by other patients, with an adverse effect on the hospital’s reputation. 6. Subsequently, the patient has spoken to me several times regarding his bill. Specifically, he feels the charges for observation time reflect the promise of the threat, “My time is very expensive, and I’m going to charge you for this.” He seems to have become fixated on this issue. After you have reviewed this, let’s get together
B
The Administration of Emergency Medicine offers practical strategies and administrating emergency departments for maximum efficiency.
RECEIVED:
5 January
1983;
ACCEPTED:
Htlls, CA 91345
15 June 1983 151
0736-4679/83
on organizing $3.00 + .OO
152
so that we can follow up with the patient as soon as possible.
The emergency physician and the director later discussed the case. The physician noted that he had found the patient’s manner irritating: The patient asked repetitive questions and seemed never to be satisfied with any answers. The physician also acknowledged that although he did not think he had expressed anger, the patient had certainly perceived anger. Accepting the director’s offer that he take responsibility for answering the patient’s complaint, the emergency physician wrote the following letter to the patient/ employee: Dear Mr. Doe: I have recently been made aware of some serious concerns that you had regarding your recent visit to our emergency department. I understand you felt I was “really mad” at you. I’m sorry my behavior gave you that impression. You certainly gave me no cause to be and I do not recall ever being angry with you. We had a communication problem and my comments and attempts at humor were not interpreted as I had wished. Since I was providing the service to you, then the blame and responsibility for this miscommunication lies mostly, if not solely, with me. I also understand you were concerned regarding the fee for observation time. The entire fee was completely reasonable and appropriate, especially considering the future benefits to you based on what you learned by visiting the department. I did not charge you extra for asking additional questions. You were charged for 30 minutes’ observation time, which is a customary charge for the evaluation of chest pain. Therefore, I did save you a great deal of time, money, effort, and peace of mind by resolving your distress from passing out and chest pain. I was able to do this in the emergency department, observing and evaluating you there, without admitting you to the hospital as an inpatient. Our group values your input as a hospital employee, and I personally appreciate your bringing to my attention a communication problem that could adversely affect other emergency department patients. Because of this communication problem, much of your concern seems to center on the charge for observation time. I will instruct the business office to dis-
E. Taliaferro
count your emergency department bill by the amount equal to the critical care charge. Thank you again for expressing your concerns.
Discussion The memorandum from the director summarized the patient’s complaint in as factual a manner possible and contained no assumptions as to the rightness or wrongness of the physician’s attitude or behavior. The nonjudgmental tone of the memorandum allowed the emergency physician to address the real issues brought up by the patient without becoming defensive. The emergency physician’s letter recognized the patient’s concerns and addressed the patient’s perception of physician anger, lack of communication, and inappropriate charges. The emergency physician responded by expressing regret for the patient’s distress, while balancing the patient’s perceptions with his own, and by deleting the disputed critical care charge. Although as a general rule fees deemed “appropriate” should not be dropped, there were hospital employee relations considerations to be addressed in the case presented here. This aspect of the patient/employee’s complaint heavily affected the decision to delete the disputed fee, but the decision is certainly arguable. In his letter, the emergency physician addressed the facts of the patient’s complaint without judgment. This created a win-win situation where the dignity of both the patient and the physician were maintained. The physician acknowledged the patient’s perception as different from his own and accepted responsiblity for the miscommunication without placing blame. No excuses were given and the patient received an apology escorted by a “thank you.” Deletion of Fees The value of the “thank you” is underscored by the deletion of the critical care charge. In general, as noted, charges should not be deleted unless they are clearly inappropriate or outright incorrect. Occasionally, a very specific gain-in this case
153
The Patient Complaint
positive hospital employee relations -is sought by deleting all, or part, of a bill. When exceptions are made, a careful explanation should be included lest the patient interpret the fee deletion as an acknowledgement of wrongdoing. When fees are not deleted, the appropriateness of the fee should be stated along with an expression of hopefulness that the patient will pay the bill promptly. If any doubt exists as to the appropriateness of the patient’s complaint, then the business office should be immediately notified so that the patient’s bill will not be sent to a collection agency should the patient elect not to pay the bill. Upon receiving collection agency letters in response to what seems to be an appropriate complaint, the patient may seek the opinion of a lawyer, escalating the dispute. Responsibility Problems are best solved by their owners. In this case, the staff physician, not the director, had the problem of this patient’s dissatisfaction. Emergency physicians learn little about dealing with patient complaints when the director answers all complaints coming into the department. Indeed, staff physicians may even come to expect “the chief” to handle one of the less technical but crucial aspects of good patient care: clear communication with the patient. Additionally, a valuable communication channel is established between the director and staff physicians when complaints are addressed in this manner. The staff physician is left with no doubt concerning the director’s standards for patient care in the department. The director gains insight into what is important to the staff physician, and in the case of a new staff physician, can identify areas where further development is indicated.
Pattern of Patient Complaints Dissatisfied patients who report their complaints can be looked upon as valuable critics. Their feedback, collected and analyzed, eventually provides insight into recurring problems. In the case presented, the patient verbally reported the complaint to the director. Occasionally complaints are submitted by letter or are gleaned from evaluation forms provided to patients at the time of their visits. Ultimately, all complaints need to be directed to the director, who can then see that the complaints are appropriately handled. The general pattern of patient complaints will occasionally point to a difficulty in interpersonal relationships in one of the physician staff. The medical administrator must address this with openness and concern, focusing on facts and not personal worth. If the staff physician becomes defensive and begins making excuses, learning cannot occur. One of the medical administrator’s most important functions is to eliminate excuses.’ When they are eliminated, the air clears and responsibility can be accepted. Criticism in the form of administrative feedback, correctly applied and directed, should stimulate, not stunt, professional growth.
Summary
Patient complaints are valuable management tools that provide insight into patient frustration, departmental problems and function, and practice patterns of emergency physicians. To fully appreciate the value of patient complaints, a consistent method of handling patient complaints is needed. One such approach is presented in this article.
REFERENCE 1. Townsend
R.:
Up The Organization. New York, Fawcett Crest, 1970, p 41.