Using Complaints to analyze and address patient needs
by Sister Julie Hyer & Roger Hite, PhD

The word "complaint" has a pejorative meaning to most people, and it certainly did initially to the executive team of Dominican Santa Cruz Hospital as we struggled in 1992 to design a quality improvement program. Indeed, the outside-looking-in view of the organization is difficult for people inside an organization to adopt: We are often too comfortable with the status quo, and too able and eager to justify why a process is the way it is.

But customers don't want to know about the inner workings of an organization or to hear excuses about why it is difficult to meet their expectations. They evaluate the care experience they receive at a hospital on criteria that we as healthcare professionals may not have considered or acknowledged. These criteria are most freely available in the form of customer complaints, and in fact analyzing complaints became our lowest cost, most accurate source of information about what needs improvement at Dominican Santa Cruz from the perspective of our patients.

Working with Shaw Resources of Cupertino, California, we made it our first priority to increase the documentation of comments from customers and to spend more time understanding why dissatisfaction was perceived. To better capture and analyze what customers were telling us, we launched a "Manage Complaints Process Improvement Team." This team (the first of a number of process improvement teams in various focus areas) is composed of staff members from several areas of the hospital that are "entry points" for customer complaints: administration, patient relations, nursing, accounting, food service, emergency room, environment services, risk management, and engineering.

The team reviewed how complaints had been addressed historically (with little or no documentation or tracking), and then designed a comprehensive complaints process. Objectives for the process included:

• A better way to capture all complaints
  
• The ability to respond to complaints quickly and efficiently
  
• ·A methodology for plotting complaints on an "adversity" scale to measure their severity and analyzing patterns and frequencies of complaints to uncover root causes of customer dissatisfaction
  
• ·A way to identify and implement "bigger picture" changes that would prevent recurrence of specific complaints in the future.

The team was aware that organizations that don't want to hear complaints would unconsciously make it difficult for customers to make them. Although patient satisfaction surveys are routinely administered, they are not the appropriate tool needed to capture spontaneous complaints made by patients when they experience dissatisfaction. One of the team's objectives has been to focus all of the people who work at Dominican so that they believe capturing and dealing with a customer complaint will earn them a pat on the back.

Organizations that don't want to hear complaints will unconsciously make it difficult for customers to make them.
Every complaint is now documented, whether or not it has been successfully handled on the spot. The current goal is to have every complaint receive an initial response within 72 hours and, for any that cannot be resolved immediately, completely resolved within five days. The ultimate goal will be to have each complaint initially addressed within 24 hours and resolved within five days.

Some managers had difficulty recognizing the benefits of the new complaints process. They initially viewed it as another piece of paper on their desks needing attention, and they dreaded conversations with unhappy customers because "they're just going to yell at me." It took many months of real-time experience for managers to see value in the time they spent addressing complaints. Now, they frequently share stories of satisfying dialogues they've had with customers. Staff members also report they feel good knowing they helped a patient while providing the organization with valuable insight into customer-perceived problems that may be impairing our overall performance and image. Staff members frequently go beyond the goals of the complaint policy and volunteer an extraordinary effort to achieve customer satisfaction. One employee, for example, after following up on a complaint, asked a patient upset about a visit to radiology if there was anything else the hospital could do to make her feel better about her experience. Joking, the patient responded, "Sure, send me some candy and flowers." The employee arranged for the hospital to do just that and the patient is still talking to her friends, family, neighbors, and co-workers about it. "I know you knew I was kidding," she wrote in a letter to hospital staff, "but your gifts showed that you are serious about following through on what I had to say."

COMPLAINTS USED TO LOCATE ISSUES FOR ADDITIONAL TEAMS
Once the Manage Complaints Process Improvement Team was well underway, we began to assemble and launch additional cross-functional teams that corresponded to key processes in the hospital-again, from the customer's point of view. As each of the two-dozen teams came on-line, it used customer complaints to locate issues most important to our customers that could be tackled as a process improvement project. Always, the emphasis is on finding the root cause of customer dissatisfaction and improving the process so that problems are prevented in the future and our performance continuously improves and exceeds customer expectations.

Here are two of the complaints and the improvement results achieved to date by process improvement teams at the hospital:

• Complaint: slow response to pain. Patient complaints about staff concern and response to their pain-one of the most frequent concerns patients express in any hospital setting-led the Manage Inpatient Care Team to explore this as a distinct process. As a result, several changes were made in the way we respond to pain needs. There is now a separate patient call buzzer for pain medication so that nurses can give those requests top priority. The goal is to respond to pain calls within three minutes. Data on how well a nursing unit is doing in achieving these goals is documented as a process key quality measure.

The same team also developed a pain "cue card" and offered training to all levels of staff that come in contact with patients on how to recognize the visual clues that a patient is suffering. Now even housekeepers and other nonclinical personnel can alert nurses that "Mr. Jones in 214 appears to be experiencing pain" and the caregivers can respond before Mr. Jones even asks for help.

The problem of multi-protocols was also addressed. As a result of the process improvement initiative, physicians have collaborated on standardizing protocols. Pending orders are placed on file when the patient arrives on the unit. If the patient should need pain medication, there is no time lost in trying to track down the physician.
Now housekeepers and others can alert nurses that "Mr. Jones in 214 appears to be experiencing pain" and the caregivers can respond before Mr. Jones even asks for help.

Recently, we also created a five-minute video educating patients about their responsibility to let caregivers know when they are experiencing pain and at what level. The video is broadcast over the hospital's in-house TV channel.

• Complaint: too many "no" answers to simple requests. Graniterock Company, located just a few miles down the road from us in Watsonville, California, was awarded a Malcolm Baldrige National Quality Award in 1992. Although our two organizations are dramatically different, all enterprises have one thing in common: We all have customers we need to delight. We studied how Graniterock established a culture among its 500 people that encourages them to say "yes" to customer needs and then to do what it takes to fulfill that promise.

Healthcare organizations, like all "institutions," are prone to fall into exactly the opposite habit. The standard reply often becomes "no, we cannot do it that way" or "no, we will not accommodate your request" before much thought is actually given to whether or not the customer's wish can be serviced.

A customer complaint about the lack of a towel for a mid-morning shower led us to two improvements that needed to be made. The team following up on this complaint learned that clean towels were routinely delivered in mid-afternoon and that this supply of fresh towels was frequently depleted by mid-morning the following day. Adjusting delivery times and unit specific par levels so that there is always a clean towel on the shelf was relatively easy. Changing the attitude of the individual employee to respond differently the next time a patient asks for a towel and none is available is a much more difficult task. An "institutional" corporate culture leads that staffer to say "Sorry, no towels. You'll have to wait to take a shower." A customer-focused corporate culture has the employee running down the hall to another unit to bring a clean towel-and not giving this "extra service" an extra thought.

In addition to Graniterock, we benchmarked quality service with the prestigious Ritz Canton hotels and used some of their guidelines to help us manage and measure quality performance of room preparation. We've also adopted the Ritz Carlton notion of "lateral service" that encourages all staff, regardless of their position on the organization chart, to pitch in and do what needs to be done to serve customers, whether that be a vice president directing traffic in the parking lot while a medical helicopter lands, a manager staffing the gift store when a volunteer fails to show up for work, or the CEO helping a departing patient into a car at the front door-situations that have occurred at Santa Cruz Dominican in the past few months.

DYSFUNCTIONAL ASPECTS OF PROCESSES DISCOVERED
The Maternal/Child Health Process Improvement Team has worked on a dozen different process improvement projects in the past two years in which dysfunctional aspects of standard procedures-from the customer's point of view-were discovered through a close scrutiny of patient complaints. Here are two examples:

• Improve nurse-to-patient communication. Patients complained that nurses in postpartum check up on patients too infrequently. The team discovered that the problem here was the difference between what the healthcare provider considered "frequent" follow-up and what patients assumed would happen. Many of the new mothers expected the same level of care in postpartum that they had received while in labor-one caregiver to one or two patients. The postpartum ratio is one caregiver for every six patients. No wonder patients felt ignored!

Once they understood the nature of the problem, staff began to educate patients about the difference between the two areas and clearly explained the routines. As a result, patient satisfaction ratings went up and the number of complaints went down.

• Make late-night meals available. Moms, dads, and other family members were often exhausted and hungry after a midnight delivery and frequently complained about the lack of food options when the cafeteria and kitchen are closed. The Maternal/Child Health Process Improvement Team set up a subcommittee to find a nourishing solution to the problem. Committee members researched several other hospitals and found a wide array of options-everything from pre-prepared cold meals to a chef on duty all night. After meeting with dietitians, patients, physicians, and nurses, the subcommittee recommended a boxed meal program.

Now Food and Nutrition Services prepares boxed meals containing a large portion of deli-grade lunchmeats, a small loaf of bread, vegetable sticks, picnic salads, and a large cookie. The boxes are dated for freshness, delivered to the Family Birthing Center each evening, and kept in a unit refrigerator until needed. About seven meals are distributed each night, and complaints about the lack of late-night food have been virtually eliminated.

STRUCTURE IMPOSES ACCOUNTABILITY
Without a structure for feedback and accountability, it is easy for process improvement teams to veer off into reactive problem solving or dissolve into social get-togethers, rather than keeping their focus on proactive prevention of problems. One of the challenges faced by the teams concerns data needs; like most hospital information systems, Dominican's was designed to fulfill a myriad of reporting requirements, but doesn't provide data for improvement. As each team selects an issue to tackle, it must decide how to quantify improvements. In most cases, that means hand tallying by managers already overly tasked.

With this kind of effort being required, the structure supporting the process improvement initiative needed to be strong and credible. The senior management group created to assume overall responsibility for the program is the Process Improvement Council, which includes the president/CEO, executive vice president/ COO, senior vice president/CFO, senior vice president of medical affairs, all vice presidents, the director of information services, and several department managers. Each of the teams meets on a regular basis and reports results and problems to the Process Improvement Council every six months, where they get ideas and encouragement. The Council demands hard data to back up heart-warming anecdotes so these regularly scheduled reports prevent the teams from sidestepping accountability. The reports describe both how the process was improved and how that changed process is improving results-in specific detail.

We also schedule a monthly "PIT Stop" for the members of all process improvement teams. These events combine education and training on a specific skill with an open forum that encourages questions, idea sharing, and problem solving if a team has reached a particularly difficult obstacle. In addition, a Quality Improvement Center was established in a convenient location where each process improvement team has a display board for showcasing their results in graphs and charts.

To underscore the hospital's seriousness about quality improvement we have tied the annual bonus structure to hospital/department/service targets. And, at all levels of the organization, we celebrate quantifiable accomplishments. Following is a sampling of recent achievements:

• Myocardial infarctions are ruled out in less than 24 hours.
• Patients' requests for between-meal snacks are fulfilled in less than 20 minutes.
• Outpatient surgery registration takes only three minutes.
• Patients wait in the outpatient laboratory less than nine minutes.
• Corridor noise levels outside patient rooms declined according to the readings of our newly purchased decimeter.
• Incidence of phlebitis has been reduced via IV therapy protocols.
• Acute rehab FIMS (functional independence measures) have improved.

Sister Julie Hyer is president and CEO of Dominican Hospital in Santa Cruz, California. Roger Hite, PhD, is vice president and COO. They can be reached at 831/462-7501.

Published in 1996 by COR Healthcare Resources.