Clinical complaints and their handling: a time for change?
OBJECTIVES: To assess the performance of the hospital complaints procedure for complaints proceeding to peer review and the quality of responses to complainants. DESIGN: Retrospective study of data on clinical complaints proceeding to peer review during 1986-91 from clinical records, correspondence, reports of the complaints investigations, and expert review of written responses to complainants. SETTING: Northern Regional Health Authority, covering three million people. SUBJECTS: All 71 clinical complaints investigated to the third stage of the hospital complaints procedure and a sample of 65 written responses to complainants. MAIN MEASURES: Characteristics, duration, and outcome of complaints; findings of peer review; and quality of written responses at various stages in the procedure as evaluated by an expert panel against eight agreed criteria. RESULTS: The median duration of a complaint investigated through all stages of the procedure was 381 days. The longest median stages were those involving attempted resolution locally (131 days) and in which peer review was being arranged (113 days). More complaints alleging failure of communication were upheld by peer review (46/59, 78%) than those alleging misapplication of clinical skills (20/98, 20%) or failure to initiate appropriate investigations or treatment (8/32, 25%). Written responses commonly fell below the standards agreed by the expert panel. CONCLUSIONS: The hospital complaints procedure takes too long and its final peer review stage may not demonstrate sufficient impartiality. The written responses suggest that criticism is not welcomed as a way of improving service. IMPLICATION: The clinical complaints procedure needs to be reformed to ensure true accountability to patients. (+info
How patients perceive the role of hospital chaplains: a preliminary exploration.
OBJECTIVE: An exploratory study of the attitudes of hospital patients to the service provided by hospital chaplains. DESIGN: Questionnaire study of hospital inpatients in December 1992. SETTING: One large teaching hospital in London. PATIENTS: 180 hospital inpatients in 14 different general wards, 168 (93%) of whom agreed to take part. MAIN MEASURES: Attitudes to chaplains and their role contained in 12 questions developed during a pilot study on hospital inpatients (16) and staff (14) and their relation to patients' age, sex, length of hospital stay, and religious beliefs, according to Kendall rank order correlations. RESULTS: Of 168(93%) respondents, 72(43%) were women; mean age of patients was 63.1 (SD 16.8) years. Forty five (27%) were inpatients of three days or less and 22(13%) for one month or more. 136(81%) were Christian; 17(10%) atheist, agnostic, or had no religion; and 15(9%) were of other religions. In general, patients showed positive attitudes towards the role of hospital chaplains and to the services they provided. The correlation analysis showed that there was a significant tendency for older patients, those who had been inpatients for longer, and those with religious beliefs to be more sympathetic to the role of hospital chaplains. CONCLUSIONS: Hospital chaplains provide a service which is appreciated by patients. This study provides a simple instrument for assessing patients' attitudes to chaplains. (+info
Obstacles to early discharge after cardiac surgery.
CONTEXT: Cardiovascular disease and cardiac surgery, in particular, are associated with a large expenditure of healthcare resources. Identifying the factors that affect length of stay for patients hospitalized for cardiac surgery and ways to safely and effectively shorten stays could have significant impact on healthcare costs. OBJECTIVE: To identify obstacles to and the effects of early discharge on outcome after cardiac surgery. STUDY DESIGN: A prospective approach using a protocol consisting of modifying anesthesia, limiting the use of postoperative narcotics, early extubation, and early mobilization, with a goal of discharge at < 5 days. PATIENTS AND METHODS: The study group consisted of 422 consecutive patients (age range 15-89 years, 65% males): coronary artery bypass graft (CABG) (n = 290), valve procedures (n = 54), and CABG + valve procedures (n = 78). The discharge criteria included hemodynamic stability, normal bowel function, independence in activities of daily living, absence of fever, and no incision problems. RESULTS: Predictors of prolonged postoperative stay were prolonged intensive care unit stay (P < 0.0001), postoperative atrial fibrillation (P = 0.0006), preoperative congestive heart failure (P = 0.002), combined CABG and valve procedure (P = 0.005), prolonged ventilator support (P = 0.01), increasing age (P = 0.012), history of peripheral vascular disease (P = 0.02), and female gender (P = 0.025). The 30-day readmission rate for the early discharge group was 7.8% vs 16.2% for the late discharge group (P = 0.01). The mortality rate for the entire group was 3.3%. (+info
Effects of patient demands on satisfaction with Japanese hospital care.
OBJECTIVE: The objective of this study was to detect whether there was any difference among the characteristics of patient satisfaction between two patient emphasis groups: patients demanding technical elements of hospital care and patients demanding interpersonal elements. DESIGN AND SETTING: The sample for this study was drawn from in-patients discharged from 77 voluntarily participating hospitals throughout Japan. The relationship between overall satisfaction with hospital care and patient satisfaction, and the evaluation of a hospital's reputation, was explored by stepwise multiple regression analysis of 33 variables relevant to aspects of hospital care for each patient group. RESULTS: In the interpersonal emphasis (IE) group, 'nurse's kindness and warmth' was associated significantly with overall satisfaction, while 'skill of nursing care' and 'nurse's explanation' were significant predictors of overall satisfaction in the technical emphasis (TE) group. On the other hand, 'doctor's clinical competence', 'recovery from distress and anxiety', and items pertaining to the hospital's reputation were significantly related to overall satisfaction in both emphasis groups. CONCLUSION: For overall patient satisfaction, it is essential to satisfy specific items related to the aspect of hospital care emphasized by the patient. Specific significant predictors of overall satisfaction (e.g. 'doctor's clinical competence') were indispensable measures of professional performance in hospital care, irrespective of the patients' emphasis. A positive perception of hospital reputation items might increase overall patient satisfaction with Japanese hospitals. (+info
Complaints concerning the hospital care of elderly patients: a 12-month study of one hospital's experience.
OBJECTIVE: to determine the number, instigators, nature and outcome of complaints concerning elderly patients treated at a single hospital over 1 year. DESIGN: descriptive analysis of computerized data gathered prospectively; follow-up of complaints until resolution. SETTING: large, urban, university teaching hospital in Australia. SUBJECTS: all patients aged 65 years and above whose hospital care was the subject of complaint. METHODS: analysis of computerized database of all complaints made in a single year. RESULTS: 1.44 complaints were made per 1000 occasions of service to elderly people (95% confidence intervals, 1.19 - 1.69). This was similar to the overall complaint rate of 1.32 per 1000 occasions of service for patients of all age groups (95% confidence intervals, 1.19- 1.45). However, 73% of complaints were made by advocates rather than by elderly patients themselves and 96% related to communication or treatment issues. Many complaints resulted in an explanation and/or an apology and, to date, none has resulted in litigation. CONCLUSIONS: complaints concerning older hospitalized people are as common as those concerning younger patients. Analysis of complaints provides pointers for improvements in quality of care. (+info
Follow up care of bereaved parents after treatment withdrawal from newborns.
OBJECTIVE: To explore parents' experiences of bereavement care after withdrawal of newborn intensive care. DESIGN: Face to face interviews with 108 parents of 62 babies born over two calendar years in the East of Scotland. RESULTS: Only 22% were seen by six weeks after the death, 10% were not recalled before 6-11 months, and 8% were not seen at all in the first year. All except one couple saw the neonatologist who had cared for their baby. Only 33% remembered a neonatal nurse being present. Most (88%) were seen in the study hospital. Parents highlighted a number of specific needs. Appointments should be: (a) scheduled soon after the death of the baby and certainly within two months of the death irrespective of whether or not autopsy results are available; (b) with the named neonatologist; (c) in a setting away from the hospital if possible. Parents value: (a) efforts to find out how they are coping; (b) full frank information given sensitively to enable them to build up a cohesive picture of what happened and assess their future risks; (c) reassurance where possible, but half truths, false reassurances, and broken promises are unacceptable. CONCLUSIONS: Follow up care is a crucial part of the management of families from whose babies treatment has been withdrawn. Resources devoted to it should be re-examined to provide a service more in tune with parental need. In choosing the place, timing, and conduct of the meeting, staff should be sensitive to the expressed wishes of the parents themselves. (+info
Initial management of breastfeeding.
Breast milk is widely accepted as the ideal source of nutrition for infants. In order to ensure success in breastfeeding, it is important that it be initiated as early as possible during the neonatal period. This is facilitated by skin-to-skin contact between the mother and infant immediately following birth. When possible, the infant should be allowed to root and latch on spontaneously within the first hour of life. Many common nursery routines such as weighing the infant, administration of vitamin K and application of ocular antibiotics can be safely delayed until after the initial breastfeeding. Postpartum care practices that improve breastfeeding rates include rooming-in, anticipatory guidance about breastfeeding problems and the avoidance of formula supplementation and pacifiers. (+info
Patient satisfaction in relation to age, health status and other background factors: a model for comparisons of care units.
OBJECTIVE: To analyse the relationship between patient satisfaction and background factors such as age, gender, health status and pain. In addition, to use background factors to create less biased ranking in comparisons of patient satisfaction between medical specialities. DESIGN: A questionnaire was sent by post to patients who had recently received inpatient care at a hospital within the County of Ostergotland, Sweden. The questionnaire contained 33 questions, 21 of which concerned the quality of health care and patient satisfaction. SETTING: Inpatient departments at all four hospitals in the County of Ostergotland, Sweden. SUBJECTS: All patients discharged from the hospital during a period of 6 weeks. Approximately 3400 patients aged 1-94 years responded to the questionnaire, resulting in a response rate of 69%. MAIN OUTCOME MEASURES: Patient satisfaction index score (PSI). RESULTS: Of the background factors tested, patient age had the greatest explanatory value regarding the PSI, closely followed by experiencing anxiety during admission. With regard to variations in the PSI, about 20% could be explained by the background factors taken as a whole. Gender did not correlate with the PSI, although males were somewhat more satisfied than females. PSI scores differed among medical specialities and, interestingly, when age and other background factors were controlled for, the picture changed regarding the medical speciality that received the best PSI score. CONCLUSION: The change in ranking among medical specialities after adjustment for background factors emphasizes the importance of including background factors in patient satisfaction analyses in order to obtain less biased comparisons. (+info