The profile of patients ’ complaints in a regional hospital

Background: A hospital should be an institution of understanding and respecting patients’ rights, their families, physicians and other caregivers. Hospitals and all other healthcare centers must be cautious toward respecting ethical aspects of care and treatment. On the other hand, patients’ satisfaction reflects capabilities of physicians and medical staff as well as the extent patients’ rights and treatment quality are observed. Nowadays, complaints handling is considered as an essential component of healthcare system in line with promoting health standards. In the present study, researchers attempt to identify the resources, individuals, complained issues, and measures which are considered to handle these issues in a regional hospital. Methods: We employed a descriptive, cross-sectional study to conduct this research. The research population included cases registered at the complaints unit of one of the hospitals in Isfahan in selected months of 2012 to 2013. The data were collected through observation of available documents. Excel software program was used for data analysis. Results: Findings indicate that despite a decrease in the total number of complaints, there was an increase in the number of complaints about medical staff. Nursing staff were considered as the second highly complained unit during the study period. Conclusion: Results obtained from the present study can be taken as experiences to modify and amend the hospital’s future performance. In general, the existence of complaints in a system is an indication of gaps when providing healthcare services. Creating an organized system to collect complaints and reviewing them helps hospitals to be cognizant of their defects and plan to prevent their reoccurrence.

In a study titled as "investigating the Negligence Frequency of General Practitioners in complaints referred to Tehran's Commission for Forensic Medicine", Rafizadeh Tabai Zavareh et al. investigated all cases against general practitioners referred to the Commission Center of Teheran from 2003 to 2005 and found that the most reasons of medical malpractices were due to failure in appropriate treatment and medication.The findings of their study are consistent with those of the present study (10).Mirza Aghai et al. in their investigation of complaints recorded at three hospitals affiliated with Tehran University of Medical Sciences surveyed 363 cases of complaints filed with hospitals.Most of complaints were about postponed or cancelled medical visits and improper behavior at 29.7% and 24% respectively (11).Taking proper actions to remove problems and prevent their reoccurrences is also essential and requires attention (12).In fact, by handling the complaints in the healthcare centers, the domains of malpractices and patients' dissatisfaction are identifiable while principles and solutions can be proposed to correct organizational and human issues (13).In other words, by dealing with the results of complaints, the causes and factors of dissatisfaction and complaints could be determined and consequently removed.It is noteworthy that the rate of registered complaints does not reflect the actual organizational dissatisfaction, but just states some aspects of reality because the fear from the consequences prevents patients to complain about their situations.Nowadays, dealing with complaints is considered as an essential component of healthcare systems to promote health standards.Accordingly, this paper investigates the state of handling complaints in a principal teaching hospital and tries to identify the challenges facing the process and take action to improve it.The objectives of the present study are to identify the frequency distribution of the people complained about, the units complained about, the total number of complaints, and frequency distribution of the results of complaints.

Methods
This research is a descriptive, retrospective cross-sectional study in which its data was collected after obtaining permission from respective authorities.The population included cases registered at the complaints unit of a hospital in selected months of 2012 to 2013 and data were collected through observation and investigation of the existing documents.In the checklist of collecting data, the units complained about, the person complained about, and the results of complaints were investigated.The cause and resource of complaints issues were examined in this study, but their estimations were not possible due to the lack of accurate registration information.
For ethical considerations, data were kept as confidential and analyzed anonymously.For data analysis, Excel software program was employed.

Results
Findings of the present study show that the highest number of complaint cases against individuals (143 cases) was recorded in the second quarter of the year 2012 compared to other months of the year, and the lowest number (90 cases) was recorded in the last quarter of 2013.In the second quarter of 2012, the highest rate of complaints was filed against nursing staff (35.7%) and the lowest rate of complaints (6.3%) was filed against servicing staff.In the third quarter of 2012, the highest rate of complaints (39.5%) was filed against medical staff and the lowest against administrative staff.In the fourth, the highest (42.9%) and the lowest (7.6%) numbers of complaints were filed against medical staff and servicing personnel, respectively.In the first quarter of 2013, the highest number of complaints was filed against medical staff (54.4%) and the lowest against servicing personnel (3.3%) (Table 1).Findings indicate that despite the overall drop in the total number of complaints, the number of complaints about medical staff increased.The nursing staff were the next highly-complainedabout individuals during the investigated period (Table 1).Findings show that in the third quarter of 2012 compared to other months of the investigated period, the highest number of complaints (229 cases) was filed against the hospital units while the lowest number of complaints against these units were filed in the first quarter of 2013 (94 cases).In the second quarter of 2012, the highest number of complaints was filed against private booths (30.4%) and the lowest was against special clinic (6.2%).In the third quarter of 2012, the highest number of complaints was filed against administration and support units (22.3%) and the lowest number was filed against food service units (3.1%).In the fourth quarter of 2012, the highest number of complaints was filed against private booths (31.4%) and the lowest number of complaints was filed against hygiene (9.5%).In the first quarter of 2013, the highest number of complaints was filed against clinics (42.6%) and the lowest number was against hygiene (0.0%) (Table 2).The highest number of complaints was in the second quarter (348) and the lowest number of complaints (200) was in the last quarter (Table 3).Throughout the second half of the investigated period except Feb-Mar, a significant percentage of complaints was solved at the complaint unit of the hospital.In Feb-Mar, however, a large number of complaints (47.1%) was still pending.A larger proportion of complaints was also handled by other managements in this month.In Dec-Jan, around 57% of complaints remained unhandled.No feedback was given to complainants in Jan-Feb and Feb-Mar at 18.8% and 20.4%, respectively (Table 4).

Discussion
Findings show that complaints about medical staff increased throughout the studied period despite the decreasing number of total complaints.The nursing staff received the most complaints after the medical staff (Table 1).Haghi et al. concluded that patients complain about surgeons more than other physicians; while most of the time treatments were standard, they considered insufficient explanations of physicians in informing patients and the lack of providing sufficient information regarding the potential consequences of medical treatment as the causes of complaints in Mashhad-based Medical Council (14).Therefore, they maintain that enhancing doctor-patient relationship is an effective factor in preventing complaints.This issue shows the irrationality of complaints from a technical point of view which can be prevented through an appropriate doctor-patient relationship (13).Rangraz Jedi et al. in their study showed that about 67.74% of the patients' bills of rights were met in public hospitals of Kashan and it was necessary to increase the awareness of care providers and patients at the time of acceptance (15).Divided by the second half of the investigated period, results regarding individuals complained about indicate that the highest number of complaints was related to physicians and interns while the lowest number of complaints was about anesthesia and operating room technicians.The reason for these results seems to be physicians' and interns' unawareness of patients' bill of rights, which must be handled by training interns in the same way they learn medical issues.Technicians, on the other hand, have little contact with patients due to the nature of their job; and maybe that is the reason why they are less prone to complaints.Davati et al. proposed that the awareness level of 68.4% of physicians regarding patients' bill of rights was at medium level and there was a significant correlation between their score of awareness and years of practice.Physicians are not well aware of patients' bill of rights and an appropriate plan is needed to tackle this problem (16).
In a study on the skin and beauty-related complaints registered in Tehran-based department of Forensic Medicine from 2002 to 2010, Athar et al. names a number of factors which can reduce the number of complaints; these factors include: observing medical ethics and professional commitment, appropriate doctor-patient relationship, full explanation of the treatment process and its possible consequences, no exaggeration of treatment results, continuous study and upgrading medical knowledge, skilled and experienced physicians, avoiding methods not trained yet, choosing patients appropriately, and informed consent process regarding the high number of complaints about physicians in this study.These implications can be used for reducing such complaints (17).Mirzaaghai et al. investigated complaints registered at three hospitals of Tehran University of Medical Sciences and their related factors.The highest number of complaints was claimed to be about physicians.This finding is consistent to the results of our study in some cases.Complaints about nurses were reported 10.2%, while in our study nurses were less prone to complaints.About 59.1% of complaints were solved at the hospital which is in line with the present study.In general, they states that since delaying or cancelling sessions, and improper doctor-patient relationships are the issues most complained about, interference is necessary in these domains.Sharing the data of complaints among hospitals can be used to identify common problems and to plan strategies (11).Most physicians and dentists working in Tehran who were complained about, did not do anything wrong according to experts of Medical Council and a large proportion of complaints were resulted from improper doctor-patient relationships.Behaviors based on physicians' professional commitment to patients can prevent a majority of complaints; in the aforementioned study, the causes of complaints were not registered, while registering them may help to identify and remove the weaknesses of this domain.In general, the quality of services and welfare were among the important issues of that research (18).In a study carried out by Entman et al. it was shown that there is no significant difference between the qualities of treatment provided by the female specialists who were complained about and those who were not.This is confirmed in another study that the quality of treatments is not an important factor of patients' complaints.In the present study, however, this factor is among the issues with high complaints (19).
Findings of the present study indicate that the highest number of complaints was registered in the third quarter of 2012 (348 cases) and the lowest number of complaints (200 cases) was in the first quarter of 2013.In the third quarter of the studied period, the largest number of complaints was about the hospital's units (229 cases) and in the first quarter of 2013 (the last third months of the studied period), the lowest number of complaints was about the hospital's units (94 cases).The most important case of complaint was about private booths in almost all months (Table 2).Patients and their attendants often use private booths.If these booths are supervised regularly, the number of the complaints will decrease to a great extent.Supervising the observation of ethics and respects as well as monitoring compliance with tariff prices are very important.With respect to complaints about the units, findings show that the lowest number of complaints was about diagnosis and support units.Since patients and their attendants have little direct contact with support units, the rate of complaints are low about these units.The accountability of the hospital's various deputies to complaints can play a decisive role in responding to complaints and giving feedback to patients and their attendants; this issue needs special planning too.

Limitation
The present research suffers several limitations including: incomplete recording of data related to complaints, the lack of access to all the data recorded in the hospital divided into the months, the lack of a comprehensive system for filing complaints in the hospital.Future research can focus on the qualitative assessment of complaint causes divided into different treatment groups and on the examination of practical strategies to control complaints.

Conclusion
Because the rate of complaints in hospitals particularly about the treatment staff is high, these complaints may be considered as experiences for modifications and amendments of hospitals' future performances.Generally, the existence of complaints in a system may be an indication of gaps in case of providing healthcare.

Table 1 .
The frequency distribution of individuals complained about in the hospital divided into four quarters

Table 2 .
The frequency distribution of the units complained about in the hospital divided into quarters

Table 3 .
Total number of complaints in the hospital divided by quarters

Table 4 .
The frequency distribution of the results of complaints divided by months