Kowshik, J.,Murphy, P.N., and Clough, T.M. (2016). Complaints in the Foot and Ankle Unit

Kowshik, J.,Murphy, P.N., and Clough, T.M. (2016). Complaints in the foot and ankle unit. British Journal of Healthcare Management, 22, 225-230.

Introduction

Although patient complaints give important information to healthcare organisations on improving patient care, there is relatively little in the medical literature relating to complaints in the Foot and Ankle units. The National Health Service (NHS) complaints procedure is the statutorily based mechanism for dealing with complaints about NHS care and treatment and all NHS organisations in England are required to operate the procedure. As documented by Mayberry (2002) the NHS complaints procedure comprises three stages: the first being local resolution, the second referral to the Health Service Ombudsman and finally health service commissioner. Complaints can be made by the patient themselves or nominated legal or parliamentary representatives. Locally, complaints are initially managed by the Complaints Department. The Complaints Department coordinate reports from staff members involved, including the responsible consultant. The Wrightington, Wigan and Leigh NHS trust complaints policy (2013) states that complaints procedure should fully comply with legislation in that they are dealt with efficiently, they are properly investigated, complainants should be treated with respect and courtesy and should receive assistance to enable them to understand the procedure in relation to complaints; or advice on where they may obtain such assistance, complainants should receive a timely and appropriate response, complainants should be informed the outcome of the investigation of their concern/complaint and appropriate action be taken in response to the findings of the concern/complaints.

Complaints may arise from poor quality of service or unmet patient expectations. Some complaints appear minor, but many relate to more serious events and lead to remedial action or compensation. Taylor et al (2004) showed that analysis of the nature of complaints is important to identify problems and assist in their elimination.

We performed an investigation to identify the causes, incidence and outcome of complaints in the Foot and Ankle unit of Wrightington, Wigan and Leigh (WWL) NHS Foundation Trust. We also wanted to investigate if complaint rate in the Foot and Ankle unit is more or less than other departments? Are trauma patients more likely to complain than elective patients or vice versa? Are male patients more likely to complain than female patients or vice versa?

Material and Methods

All complaints made to the Foot and Ankle unit of Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) over a 5 year period, from 2010 to 2014, were obtained from the Trust Office and Patient Relations Department. Information was extracted from the prospectively maintained Patient Advice and Liaison Service department electronic records. Additional information was obtained from transcripts of complaint letters, outpatient attendance records, operations database and response to complaint letters.

Data was subjected detailed qualitative analysis. Data regarding elective and trauma foot and ankle outpatient attendance, elective and trauma operative procedures, number of male and female patients, age range, content of complaints, responses, and resolution methods were obtained and analysed.

Based on the content, causes of complaints were classified into administrative, staff attitude, communication, surgical and alleged missed diagnosis. Chi square test was performed to determine statistical significance between groups. A P value of less than 0.05 was considered to be significant.

Analytic strategy

Complaint data (i.e. the number of patients complaining or not complaining) was analysed with regard to the total number of foot and ankle care events within the unit during the study period, and with regard to two components comprising this total, these being the number of complaints following appointments and the number of complaints following surgical procedures, respectively. Complaint data relating to the total number of care events, and to these two respective components, were in turn cross tabulated respectively with other variables of interest (i.e gender, trauma versus elective patients, year within the study period). This facilitated respective chi-squared analyses to test the hypotheses that the complaint data was significantly associated with the other variables in question. Obtained chi-squared values were evaluated against a conventional P .05 alpha level, and significant values interpreted on the basis of comparing observed (O) frequencies to expected (E) frequencies under the null hypothesis of no association between the variables [xS]. A priori statistical power was calculated for each analysis using the GPower Database [xF] for a small effect size (ω = 0.10). Given the large samples sizes reported, a priori statistical power was in excess of 0.99 for each of the analyses planned.

Results

There were a total of 30 complaints (Table 1). Age range of complainants was 35 to 70 years (Mean 50 years). 11 (37%) complainants were male and 19 (63%) complainants were female. 20 complaints resulted following encounters in the outpatient department, 1 complaint resulted from A&E, 2 complaints from appointments related to surgery but unrelated to surgical outcome, 7 complaints related to outcome of surgical procedures.

Content of complaint
1 / Admitted to ward at 7AM, Underwent injection at 3pm
2 / Long waiting time in clinic, previous clinic appointment cancellations
3 / Adverse reaction to anaesthesia, miscommunication from surgical team
4 / Delay in being seen in A&E, Delay in fracture clinic appointment
5 / Delay in appointments
6 / No response to letters and unable to see consultant in clinic
7 / Concerns dismissed by doctor in fracture clinic
8 / Surgery cancelled on the day
9 / Perceived poor surgical outcome following Hallux surgery
10 / Disrespectful attitude of doctor
11 / Fracture clinic wait, parking difficulty
12 / Miscommunication, Was informed plate would be used for ankle fixation but only screws used, delay in having injection, not happy that physiotherapy as they did not communicate with consultant,
13 / Bunion surgery, stiffness, questions about screw position, length, need for removal
14 / Unhappy with the attitude and advice of A&E staff
15 / Information regarding left thigh pain was ignored. Cover up of pressure sore on right heel, which occurred during a 2 week stay in hospital.
16 / Reception closed, communication poor, poor food, operation started before epidural took effect, spoken to rudely
17 / Bunion surgery, Long screw, Unhappy with outcome
18 / Achilles injury, unsatisfied with intial communication
19 / Unsatisfactory outcome following lesser toe surgery
20 / Hallux valgus surgery, unhappy with progress
21 / My human rights were not respected, did not get vital medication when needed, Noisy ward, Delay in follow up appointment.
22 / Missed fracture, Unhappy with advice
23 / Soft tissue injury ankle, Post traumatic OA ankle, ?missed diagnosis, early discharge
24 / Fracture tibia, plaster changed too quickly, not happy with progress
25 / Unsatisfactory attitude of doctor,
26 / Unhappy with communication, continues to be in pain,
27 / Ankle fixation, infection, osteomyelitis
28 / Intially seen in A&E for injury to foot and then in elective F&A clinic, Not happy with treatment, ?missed fracture
29 / Persisting pain following ankle fixation
30 / Doctor did not introduce self and ignored questions

Table 1 Complaints to Foot and Ankle Unit in the WWL NHS Trust 2010-2014

Complaints unrelated to surgical outcome

There were 23 complaints (20 from outpatient (OP) appointments, 1 A&E, 2 related to surgical appointment but not related to surgical outcome). Staff attitude and poor communication led to 13 (43%) complaints. Administrative causes (excessive waiting time, cancelled appointments, parking difficulty, poor food quality, etc) led to 7 complaints (23%). Alleged missed diagnosis resulted in 3 complaints (10%) (2 foot fracture and 1 ankle fracture).

OP appointments

There were 20 complaints from 47,522 appointments. Complaint rate was 1 per 2376 appointments.

Complaints / Total appointments / Complaint rate / P value
Trauma / 10 / 18,282 / 1 per 1,828 / 0.29
Elective / 10 / 29,240 / 1 per 2,924

Table 2 Complaints in trauma and elective outpatient clinics

Complaints / Total appointments / Complaint rate / P value
Male / 08 / 20,957 / 1 per 2619 / 0.71
Female / 12 / 26,565 / 1 per 2214

Table 3 Male and Female complainants in outpatient clinics

Complaints related to surgical outcome

There were 7 complaints from surgical procedures. Total number of surgeries was 9435, complaint rate was 1 per 1347 operations.

Complaints / Total procedures / Complaint rate / P value
Elective / 5 / 5131 / 1 per 1026 / 0.36
Trauma / 2 / 4304 / 1 per 2152

Table 4 Complaints in trauma and elective surgeries

Hallux surgery led to 4 (57%) complaints, 2 complaints followed ankle fracture fixation and one lesser toes surgery.

Complaints / Total procedures / Complaint rate / P value
Male / 2 / 4100 / 1 per 2050 / 0.43
Female / 5 / 5335 / 1 per 1067

Table 5 Male and Female complainants following operations

Grand total (OP + Surgery)

Total number of foot and ankle care related events in the unit during the study period was 56,957. Total number of complaints was 30. Overall complaint rate was 1 per 1898 events.

Complaints / total / Complaint rate / P value
Male / 11 / 25,057 / 1 per 2277 / 0.42
Female / 19 / 31,900 / 1 per 1679

Table 6 Male and Female complainants following all foot and ankle events

Yearwise breakup of complaints

Table 7 summarises the complaint data broken down for each year of the study period, for the total of 56,957 care events recorded, with expected frequencies (E) in brackets. The obtained chi-squared value was significant (χ2 [4, N = 56,957] = 10.11, P .05. Comparison of the O and E values shows that there were fewer complaints in 2010 and 2014 than would have been expected under the null hypothesis, but more complaints than would have been expected in 2011, 2012, and 2013.

OP / Procedures / Total / Complaints / Surgical Outcome
Complaints
2010 / 9392 / 1883 / 11275 / 01 / 00
2011 / 9988 / 1666 / 11654 / 08 / 01
2012 / 8666 / 1793 / 10459 / 10 / 03
2013 / 10243 / 2119 / 12362 / 08 / 02
2014 / 9233 / 1974 / 11207 / 03 / 01
Total / 47522 / 9435 / 56957 / 30 / 07

Table 7 Yearwise breakup of complaints

Outcome of complaints

All complaints were dealt with as per Trust’s complaints policy. The process involved acknowledgement of receipt of complaint within 3 working days, thorough investigation into the events leading to complaint, input from all relevant individuals, review of notes and finally response from the chief executive. 23 (77%) complaints were resolved locally, 2 are unresolved, 1 has been referred to independent review, 2 are with the legal department and 2 have been rejected after legal review.

Discussion

As per the data on written complaints in the NHS 2013-14 the total number of all reported written complaints in the NHS in 2013-14 exceeded 175,000, the equivalent of more than 3,300 written complaints a week and 479 per day. Though the publication ‘Data on written complaints in the NHS 2013-14’ is comprehensive it has very little information specific to a Foot and Ankle unit. The present study, to our knowledge, is the first study to investigate complaints in a Foot and Ankle unit of a tertiary referral centre.

The complaints arising from outpatient attendees and those undergoing foot and ankle operations in our unit is low (0.53 per 1000 events) and better than the rates reported by other specialties in the western world. Mailis-Gagnon et al (2010) reported complaint rate of 1.76 per 1000 attendances in a tertiary pain clinic in Canada. Mann et al (2012) reported complaint rate of 1 per 400 healthcare episodes in a surgical department in the UK, Taylor et al (2004) reported 1.42 complaints per 1000 hospital visits in Australia. The complaint rate in our unit was higher than that reported by hospitals in Asia; Lim et al (1998) reported a complaint rate of 0.04 per 1000 attendances in primary care in Singapore and Ooi in 1997 reported a complaint rate of 0.26 per 1000 attendances in Emergency departments in Singapore.

The information obtained from analysing such complaints is an important part of quality assurance and quality improvement for health-care service delivery. Mann et al (2012) and Hickson et al (2004) have shown that surgical departments generate a higher number of complaints than nonsurgical departments. However, this is not supported by the results of our study and the lower than expected complaint rates could be due to motivated employees, empathetic approach of staff towards patients and prevalent practices in the department.

In this study, we also explored whether there was a gender difference to complaint rate, as it is known men and women react differently to unpleasant experiences and events. Be it trauma or elective setup or OPD or surgical procedures, we found there was no significant difference between male and female overall complaint rate in Foot and Ankle (one female patient complaint for every 1679 events and one male patient complaint for every 2277 events; p=0.53). Our results are in contrast to those published by Taylor et al (2004), who reported females were significantly more likely to complain than males.

In the acute setting as in trauma clinic/theatre, one would expect an individual to be under stress due to the unexpected and sudden nature of the event, the event is likely to significantly affect childcare, work, social meetings and other day to day engagements than a planned healthcare event such as an elective surgery/clinic. We wanted to know if a patient is more likely to complain in acute setting than in elective setting. The results of the study confirm this not to be the case.

This study reiterates that staff attitude, communication and administrative issues are the reasons for the majority of complaints (67% in our study). Our results are supported by other papers on this issue, Taylor et al (2004), Lim et al 1998, Ooi 1997 and Woofford et al (2004). We cannot overemphasise the importance of good communication, professional attitude and empathetic treatment of patients to improve patient’s hospital experience and significantly reduce the complaints. We agree with Lim et al that a positive and proactive approach to the issue of why patients complain would result in a more satisfying relationship between healthcare provider and user.

Complaints cannot be taken lightly, as they reflect badly on the department and each complaint has the potential for significant legal and financial costs. Our study has shown however that this is an unlikely outcome of complaints, only 7% of the complaints went on to claims stage.

The strengths of the study are that it is performed in a tertiary Foot and Ankle unit receiving referrals from all over the UK; this ensures that all the cross sections of the society with regards to ethnicity, race, religion, social class, age and diagnosis are included in the study. The study was performed over 5 years and included over 55,000 foot and ankle related events. The topic investigated is very pertinent to modern day health care and the results could serve as baseline to compare and contrast complaints in other Foot and Ankle units across the globe.

There are limitations to our study; as the investigation was performed in a Foot and Ankle unit it may not fully apply to other specialties. We feel as the number of complaints across all subgroups in the study is low it was difficult to show statistically significant difference in comparisons even with very high number of health related events. A multicentre study of complaints in Foot and Ankle units may be the answer?

The data also shows that the number of complaints over the past 5 years including complaints related to surgical outcome have neither uniformly risen or decreased, however the number of complaints in 2014 were 62% less than in 2013 and the findings are similar to the trends in litigations in foot and ankle surgery in the NHSas documented by Ring et al(2014).

Another heartening fact, from our data, is that Foot and Ankle interventions seem to result in a very low rate of complaints. Only 1 out of every 1898 interventions resulted in a complaint. Hallux surgery is the most likely surgical intervention to give rise to complaint. This may be because it is the most common surgical procedure performed in foot and ankle units.

Conclusions

Keeping complaints low is in the best interests of the service provider and the user. Good communication and a professional attitude will significantly reduce complaints. Understanding the causes of complaints will enable us to improve services and patient satisfaction. Whilst most complaints will have local resolution, the potential for significant financial cost with every complaint should not be underestimated.

Word count: 2350

Funding: None

References

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