From Volume 41, Issue 2, March 2014 | Pages 168-173
There is increasing concern amongst dentists, and dental care professionals (DCPs), about the risks associated with complaints from patients and the possibility of escalation to legal action or referral to the General Dental Council (GDC). This is the first of a series of four articles considering the management of risk. It will describe why complaints happen, how to identify problems at an early stage and strategies for preventing complaints occurring.
Complaints are unhappy occasions and the emotional impact upon the whole team should never be underestimated.1
Dental treatment is very personal. If a patient likes their dentist, they usually feel great loyalty towards him/her. Unfortunately, if the patient is unhappy then their complaint will invariably be personal as well. Discontent is rarely directed against the building or the organization, but rather against the individual. Essentially, the patient is saying ‘I don't like what you have done for me'.
A complaint can produce a range of reactions, but perhaps the most frequent is fear that the matter may escalate to legal action, or even ultimately be a threat to an individual's registration with the GDC. Whilst this fear is in most cases illogical, for example a single complaint about treatment is highly unlikely to jeopardize a dentist's or DCP's registration, emotion and logic do not always sit easily together.
Whilst the number of complaints has been steadily increasing,2 despite some recent decrease in National Health Service (NHS) complaints,3 it is reassuring to remember that patients are no more likely to be justified in a complaint about their treatment now than they were in the past. The difference between past and present is the ease with which unhappiness can now be expressed. For example, a single letter can initiate an investigation by the NHS or private complaint systems, and the same is true of the GDC. Also, a patient could attempt a potential clinical negligence claim on a ‘no win no fee’ basis. The complaint, or potential legal claim, may have no ultimate justification, and result in no blame, but it still carries the stress and strain that the process can cause.
Whilst good resolution of complaints, when they happen, is essential, as well as being an ethical requirement of the GDC,4 the prevention of complaints occurring in the first place is much more efficient of time and resources, as well as reducing concern and worry. A proactive approach to complaints can produce real benefits to all of the dental team.
So how can complaints be prevented?
The prevention of a complaint devolves from an understanding of why patients are unhappy. It is frequently thought that most complaints happen entirely because of a clinical mistake or error. However, this is not necessarily true.
Some dentists, and dental practices, receive a large number of complaints whilst others have very few, or none at all. Whilst it may often be thought that the former are providing poor treatment, and the latter good, medical research by Hickson et al5 shows that there is frequently little difference in clinical standards between clinicians who are frequently sued, and those who are rarely or never sued.
Further medical research6 has shown that only a very small proportion (around 2–3%) of patients who suffered harm because of treatment initiated legal action. However, complaints, and potential claims, were still being made, but additional dental research shows that in over two-thirds of cases there was no evidence of fault with the treatment.7 So, if it is not necessarily an adverse outcome, what motivates some patients to complain whilst others do not?
It is often assumed that complainants are seeking financial compensation. However, research by Vincent et al8 shows that fewer than 20% of litigants stated that they were seeking monetary recompense. The main other reasons for complaining are:
So much for the motivation, but what are the major factors in the patient's decision to initiate a complaint?
Medical research by Bunting et al9 describes two main groups of factors that influence a patient's decision to make a legal claim or not.
These factors mainly relate to the non-clinical interactions between a patient and a dentist or dental practice. Such interactions may be positive or negative. Negative predisposing factors could, for example, be unexplained delays, a perception by the patient of rudeness, inattentiveness or apathy on the part of the clinician. Negative predisposing factors can also reflect a lack of communication between the patient and the dentist, or other members of the dental team. They could, however, be more tangible, for example an impression of a lack of cleanliness or organization, if any part of the practice or surgery is not looking at its best, even if there is absolutely no real evidence for that impression. Positive predisposing factors are of course the opposite and again may have little or nothing to do with the technical standard of the treatment.
Precipitating factors occur when something goes wrong: for example an injury, error or systems failure. These are of course problems that are inevitable in a small percentage of treatments. Dentistry, like any other field of healthcare, cannot give absolute guarantees of success on each and every occasion. Something, sometime, will go wrong, no matter how much care is taken or how talented the treating team.
However, as has been described already, complaints or potential claims seem to occur in only a small percentage of cases, despite an adverse outcome actually happening. The chance of a complaint occurring seems therefore to relate not necessarily to the immediate problem itself, the precipitating factor, but whether there are positive or negative predisposing factors present. If the patients' feelings are positive, they like the staff and feel comfortable and valued, then they will invariably be more forgiving when a problem occurs. Unfortunately, the opposite is true when their predisposition is negative.
It is also important to remember that patients do not, as lay people, usually judge the technical standard of their care. They will, almost always, take it as a ‘given’ that the treatment is, or should be, good. They know that the dentist and the treating staff are qualified and registered, so the treatment must be of an appropriate standard.
Their judgement may, however, be strongly influenced by factors that they can relate to, such as the welcome, the surroundings and the standard of the information. If this view is positive, then they will usually judge the standard of the dentistry to be good. Unfortunately, the reverse is also true. This may not seem fair, but it is reality.
If a patient's views and perceptions about a dentist or dental practice are already negative, then when a problem occurs a complaint is much more likely. The patient will already have a low tolerance of mistakes, and perhaps have an expectation of fault or failure, even before a problem occurs. They were almost ‘waiting’ for something to happen.
So how can a positive predisposing view be created to reduce complaints?
One interesting study of patients who litigated10 shows that approximately 70% of litigation is caused by what patients consider to be poor communication where they may feel that they have been misunderstood or inadequately informed and therefore have a perception of a lack of care. Further research by Levinson et al11 shows that clinicians with a low, or no, history of complaints and claims possessed a high proportion of the following characteristics:
In short, they and their teams communicated well and the patients felt well disposed towards them. This is a very significant and powerful learning point.
Healthcare workers and teams who did not show these characteristics had a higher history of complaints and claims, even though the technical standard of their treatment was not necessarily worse, and may indeed have been better. However, the prevention of complaints is not just down to good communication alone, vitally important though it is, but also the appropriate handling of patient expectations.
Successful organizations, large and small, devote considerable time and resources to assessing their customers' or clients' expectations. If their expectations are not met then those customers will be unhappy.
Whilst this may sound very commercial, compared to dental care, the comparisons are significant. Patients attend with expectations that they expect to be fulfilled. These are a mixture of non-clinical and clinical, but also non-realistic as well as realistic. Not all of their expectations can be met. For example, it is unrealistic for a patient to expect his/her treatment always to be free of discomfort. It is, however, realistic to expect discomfort to be effectively managed. The former cannot be achieved but the latter can.
It is vital to assess a patient's expectations before commencing treatment. Trying to meet an unrealistic expectation will invariably lead to disappointment. Complaints can therefore be greatly reduced by asking patients what they are wanting from their treatment. This may seem obvious but can be overlooked. Then gently, but firmly, any unreasonable expectations can be modified. Finally, declining to treat patients who still persist with their unreasonable or unrealistic expectations, despite all efforts to modify them, can help to mitigate the number of complaints.
Many complaints relate to a failure to meet a patient's expectations. Finding out what patients want, and whether it is a reasonable or unreasonable expectation, is very important in complaint prevention.
Good communication is therefore vital but what else can be done to prevent complaints or resolve them at an early stage?
Complaints can be distressing for all team members, so it is important that all of the team have a role in their prevention. So what are the practical steps?:
The following case demonstrates the value of the team in rapid resolution of patient unhappiness.
A new patient telephoned requesting treatment for a painful lower molar. An emergency appointment was booked for the following morning. Unfortunately, two of the three dentists in the practice, and two other staff, had called in sick that day, all of them suffering from a gastric virus. The patient arrived on time but was told that there would unfortunately be a delay as there was only a single dentist present but he would be seen as soon as possible. No further explanation was given.
The patient was eventually seen, the pulp extirpated and a dressing placed. The treatment was straightforward.
Unfortunately, the patient returned the following day with continued pain and a now visible swelling. He was prescribed antibiotics. Whilst leaving he appeared unhappy and upon being asked if he had concerns, stated that he was worried about his treatment the previous day. Specifically, there were insufficient staff and dentists, he had had to wait (despite being on time for his appointment) and for these reasons he considered that the initial root treatment was ‘probably substandard’ resulting in his continuing problems.
The patient's concerns were immediately discussed with him by one of the practice nurses who explained the unusual circumstances of so many staff being away ill at the same time. The nurse also apologized if the situation had not been made clear the previous day, again due to circumstances. The patient eventually accepted the explanation and stated that he now felt reassured about the standard of his care.
This case shows that the problem could have been avoided if a full explanation of the circumstances had been given beforehand. It further demonstrates how a patient's assessment of his/her standard of care can be influenced by non-clinical factors. Finally, it illustrates the role of team members in identifying a problem and preventing it developing into a more serious complaint.
Complaints can be very stressful and time-consuming. Good communication, to create a positive patient perception, identifying and meeting patient expectations and effective teamworking, will help to prevent problems occurring. In addition, practical steps and systems, including early recognition of patient unhappiness, will help to resolve concerns quickly and prevent complaints escalating.
