Highlights from the Literature

Beyond Press-Ganey: The Value of Unsolicited Patient Complaints

By John G. Albertini, MD, FACMS

Every major health care institution administers some form of patient satisfaction survey, as do most of us in our outpatient office setting. These efforts fulfill various quality reporting requirements, but are often viewed skeptically by physicians who do not equate the standardized survey results with the quality of their individual care. In our practice, we also developed and distribute a survey instrument, the aggregate results of which, admittedly, I generally ignore…except for one item: the blank write-in section on the last page. I methodically scrutinize these comments, my mood rising (a little) and falling (a lot) with each heap of praise or criticism. Instinctively, I appreciate that these unsolicited patient remarks, whether delivered in writing, by phone or in person, provide the highest value to my team and me as we strive to optimize the care we deliver. I now have a better idea why, (and hopefully you will too after reading this piece).

It is well established that unsolicited patient complaints serve as the strongest proxy for a surgeon’s risk of lawsuits, greater than physician experience, training or specialty or volume of clinical activity. ¹ Patients and families cite poor communication of results, plans and expectations; disrespectful treatment of team members; and loss of trust during an adverse event as the primary drivers of litigation, rather than money. Clearly improving one’s patient relationships can save a physician the tremendous emotional strain and financial costs of being sued. Plus, work is just more enjoyable when you get along with patients and family members. But to a scientist or skeptic, could physician interactions really have a direct impact on patient safety and outcomes?  Is there a true correlation between subjective patient comments and objective measures of physician quality?

A study and commentary published last month in JAMA Surgery^2,3 posed the intriguing question of whether the same physician behaviors that generate patient dissatisfaction might also contribute to the actual underlying adverse outcomes. Cooper et al examined surgeons from 7 geographically diverse academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Advocacy Reporting System during study years 2011-2013. Researchers controlled for various patient, surgeon and operative confounders. Among 32,125 adult patients undergoing inpatient and outpatient procedures, 10.9% experienced a surgical and/or medical complication. Unsolicited patient complaints about a surgeon during the 24 months prior to the procedure were significantly associated with greater risks for any surgical complication, any medical complication, and for readmission. The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest vs. lowest quartile of patient complaints.¹

When researchers extrapolate this data across the entire United States, they estimate patients could suffer >350,000 additional complications costing the health care system more than $3 billion annually, independent of litigation costs. We all know colleagues with amazing bedside manner who are not the most gifted surgeons, and others with incredible skill who lack charm, patience and interpersonal skills. The former get sued less often, but with this study we are now faced with a new reality; physicians who achieve higher patient satisfaction also provide safer care with fewer complications. Why and how does that happen?

Do they elicit more thorough histories and/or better integrate non-verbal cues? Maybe they have higher Emotional Quotients? Do they communicate better with all health care team members, gaining insights, information or attentiveness otherwise withheld from abrasive or indifferent colleagues? Or have they simply benefitted from superior training experiences and environments where faculty consistently produced more highly skilled surgeons while also modeling effective patient and peer interactions? These answers remain elusive but worth pursuing.

Cooper’s study does add to the growing body of evidence demonstrating the high value of unsolicited patient observations to quality improvement efforts. These patient complaints should be highly prioritized as action items by all of us in our practices. Indeed, work by Pichert et al has proven that these QI efforts can be worthwhile and sustainable.⁴ A 2013 study in the Joint Commission Journal on Quality and Patient Safety showed that “high risk” physicians identified by unsolicited patient complaints can successfully modify behavior through a relatively simple intervention model, similar to the Improving Wisely initiative. A ‘peer messenger’ process was designed in which respected colleagues, recognized by leadership and appropriately supported with ongoing training, shared high quality data regarding patient complaints for the provider relative to local and national norms in a confidential collegial visit. Peer messengers asked “high risk” colleagues to reflect on the complaint contents in a non-judgmental manner and invited development of plans to address recurring dissatisfactions. Follow up feedback and data were provided during regular visits. 97% of physicians received the feedback professionally and 64% were ‘Responders’ whose risk scores improved >15%, usually within 3-4 intervention meetings, and were sustained over time. Pichert et al concluded, “The physician peer messenger process reduces patient complaints and is adaptable to addressing unnecessary variation in other quality/safety metrics.”

On a related note, I am pleased to report that preliminarily, the ACMS Physician Engagement Council has received overwhelmingly positive feedback on the Improving Wisely Data Reports delivered last month and we thank all who have communicated to date. We remain open to input and look forward to providing a further update at the Annual Meeting next month.

1. StuddertDM,BismarkMM,MelloMM,SinghH, Spittal MJ. Prevalence and characteristics of physicians prone to malpractice claims. N Engl J Med. 2016;374(4):354-362.
2. Cooper  WO, Guillamondegui  O, Hines  OJ,  et al.  Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications [published online February 15, 2017].  JAMA Surg. doi:10.1001/jamasurg.2016.5703
3. Kachalia A, Mello MM, Studdert DM. Association of Unsolicited Patient Observations With the Quality of a Surgeon’s Care. JAMA Surg. Published online February 15, 2017. doi:10.1001/jamasurg.2016.5705
4. Pichert  JW, Moore  IN, Karrass  J,  et al.  An intervention model that promotes accountability: peer messengers and patient/family complaints.  Jt Comm J Qual Patient Saf. 2013;39(10):435-446.