Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

A systematic review of patient complaints about general practice

A systematic review of patient complaints about general practice Abstract Background Health care complaints are an underutilized resource for quality and safety improvement. Most research on health care complaints is focused on secondary care. However, there is also a need to consider patient safety in general practice, and complaints could inform quality and safety improvement. Objective This review aimed to synthesize the extant research on complaints in general practice. Methods Five electronic databases were searched: Medline, Web of Science, CINAHL, PsycINFO and Academic Search Complete. Peer-reviewed studies describing the content, impact of and motivation for complaints were included and data extracted. Framework synthesis was conducted using the Healthcare Complaints Analysis Tool (HCAT) as an organizing framework. Methodological quality was appraised using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results The search identified 2960 records, with 21 studies meeting inclusion criteria. Methodological quality was found to be variable. The contents of complaints were classified using the HCAT, with 126 complaints (54%) classified in the Clinical domain, 55 (23%) classified as Management and 54 (23%) classified as Relationships. Motivations identified for making complaints included quality improvement for other patients and monetary compensation. Complaints had both positive and negative impacts on individuals and systems involved. Conclusion This review highlighted the high proportion of clinical complaints in general practice compared to secondary care, patients’ motivations for making complaints and the positive and negative impacts that complaints can have on health care systems. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice is required. Access to care, community medicine, doctor–patient relationship, medical errors, patient safety, primary care, quality of care Key Messages Clinical and safety issues are prevalent in general practice complaints. Patients can be motivated to complain to improve quality of care. Further research on reliably coding general practice complaints is required. Background Health care complaints are formal expressions of dissatisfaction regarding any action or care by the health service or a health care provider that is perceived to be suboptimal and to have an adverse impact on patients and their families (1). The submission of a complaint indicates that a threshold of dissatisfaction has been crossed during the process of care (2). Health care complaints are recognized as an underutilized resource for quality and safety improvement (3). Complaints are traditionally addressed on an individual basis, typically by responding to the patient and resolving the issue identified in that specific complaint (4). However, there is recognized value to analyzing complaints at the systems level by aggregating the data from multiple complaints and utilizing the learning from this process (5,6). Patients often have insight into issues and problems that providers themselves do not recognize or are not exposed to (e.g. problems prior to admission and following discharge) (7). The knowledge gained from patient complaints could be particularly important when a culture exists in a system whereby staff are unwilling or unable to raise quality and safety issues themselves (8). Most research on health care complaints is focused on care delivered in the hospital setting (6). This is unsurprising given that the study of safety and quality in general practice lags far behind that in hospital settings (9). Typically, general practice has been considered relatively low risk (10). However, as services are increasingly being diverted from a hospital setting to the community (11,12), there is a greater need to consider quality and safety in this domain of health care. Patients interact more frequently with their General Practitioner (GP) than hospital doctors (13,14) and, with this increase in volume of interaction, the risk of errors occurring also rises (15). Adverse events have been found to occur in 2–3% of general practice appointments (16). However, despite recognition of the growing complexity and potential for error in general practice, GPs report that they find it difficult to know where to start with implementing quality and safety improvement practices (17). Health care complaints could serve as one source of data for informing quality and safety improvement in general practice. Serious issues occur in general practice, which patient complaints could identify, such as treatment delays, difficulty accessing treatment or delays in diagnosis (18). Using complaints to access patient insights into safety and quality issues in general practice could provide valuable learning, given the frequency of contact and the privileged viewpoint that patients have within the health care system (7). This systematic review aimed to synthesize the extant research on health care complaints and medicolegal claims in general practice. Medicolegal claims are defined as a written demand for compensation for medical injury (19), and complaints are formal expressions of dissatisfaction with health care (1). For the purpose of this review, both will be, hereafter, referred to using the umbrella term ‘complaints’. Specifically, we examined the following: (i) the content of complaints described in included studies; (ii) what motivated the individual to make the complaint; (iii) the impact of the complaints on the health care providers and systems involved and (iv) the harm experienced by the patients in the incident that led to the complaint. It was intended that this review would offer an understanding of the nature and impact of health care complaints in general practice and facilitate comparison between the content of health care complaints in primary and secondary care. The review also considers the potential for adapting existing complaint taxonomies to make these more readily applicable to general practice. Method This systematic review was conducted with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (20). In accordance with best practice in systematic reviews (21), a protocol for the review was registered on the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42019123245). Search strategy Five electronic databases were screened to identify relevant papers for inclusion in this review—Medline, Web of Science, Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO—between October and November 2018 and updated in March 2019. The search strategy was developed with the assistance of a research support librarian and was based on the strategy used by Reader et al. (6). The search comprised of medical subject headings (MeSH terms) and other keywords relating to patient safety or experience (e.g. ‘patient satisfaction’ and ‘safe*’), complaints (e.g. ‘malpractice’ and ‘complain*’) and primary care (e.g. ‘general practice’ and ‘primary care’). The full electronic search strategy used for Medline can be found in Supplementary Data 1. This search strategy was adapted as necessary for the other electronic databases. The search strategy included terms relating to health care practitioners and services other than general practice (e.g. dentistry, physiotherapy and pharmacy) as this review was part of a larger community care-focused project. However, for the purposes of this review, the authors only included studies that focused on general practice. In each database, search returns were limited to English language results only. There was no limit placed upon publication year. Following the electronic searches, the reference lists of studies that were identified as suitable for inclusion, and those of related review papers (6,22), were screened to identify any additional relevant studies. This search strategy complied with best practice for systematic reviews as laid out in the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) checklist (23). Study selection Inclusion criteria To be eligible for inclusion, studies were required to be peer-reviewed and to present original, empirical data on health care complaints that related to poor care experiences in general practice. Studies were required to have a focus on one or more of the following: (i) patients’ motivation for making the complaint; (ii) the content or nature of complaints; (iii) the impact of the complaint on the patient, health care provider or system or (iv) the harm experienced by patients in the event leading to the complaint. For the purposes of this review, it was considered necessary that the complaints described within studies were instigated by the patient/service user, or someone acting on their behalf, rather than being solicited by researchers through surveys, interviews or otherwise. Exclusion criteria Studies that were focused on health care complaints relating to secondary care settings were excluded along with studies that provided no original, empirical data on health care complaints (e.g. review papers, editorials or commentaries). Studies were also excluded if: (i) they were focused on the analysis of incident reports from health care professionals; (ii) complaints were solicited using a survey or qualitative methodology and (iii) they focused on community health services other than general practice. Screening process The title and abstract of all search returns in each of the five databases were screened by the first author (EOD). The full text of any study that appeared relevant was screened in order to confirm its suitability for inclusion. Further, if it was unclear from the examination of the title and the abstract whether or not the study fit the inclusion criteria, the full text of the article was also screened. A second author (SL) reviewed any article for which there remained uncertainty. Data extraction and synthesis Data extraction was conducted independently by two authors (EOD and CM). Any disagreements were resolved through discussion until consensus was achieved. Agreement was calculated as an average of 95% across all studies, ranging from 89% to 100% for individual studies. A third author (SL) was consulted in the event that consensus could not be achieved. A standardized form was used by the two authors to extract data from studies that fit the inclusion criteria. Extracted information included general characteristics of studies (e.g. year of publication, country of study, individual making the complaint and methods used) along with the data under the headings below. Methodological quality The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) (24) was used to assess the methodological rigour of the included studies. This tool was considered appropriate as the studies included in this review were heterogeneous in design. The QATSDD is a 16-item scale developed for use by health service researchers, which has been used successfully in other systematic reviews (25–27). Each QATSDD item is scored on a scale ranging from 0 (e.g. ‘no mention at all’) to 3 (e.g. ‘detailed description of each stage of the data collection procedure’), with a maximum possible score of 42 for qualitative or quantitative studies and 48 for mixed-method studies. Two authors (EOD and CM) applied the QATSDD to included studies, and disagreements were resolved through discussion until consensus was achieved. Content and categorization of complaints Data on the content of complaints (i.e. the issue[s] described) were extracted from the studies. These data took the form of raw complaints extracted from either text or tables within the included studies and/or the interpretations of complaints made by the authors of individual studies. These data were synthesized by four authors (EOD, SL, POC and CM) using the Healthcare Complaints Analysis Tool (HCAT) (28). The HCAT is a tool that allows for the systematic coding and categorization of health care complaints in a hospital setting (28). The HCAT has been found to be statistically reliable and valid and there is no suitable tool designed specifically for use in general practice. A framework synthesis approach was taken to coding the complaints with the HCAT. Framework synthesis is a structured, deductive approach to collating data, often used when there is an existing theory (29). Data were coded into the HCAT framework using an iterative process. This allowed the researchers to determine how the general practice complaints can fit under the HCAT tool, which was developed for hospital complaints. Complaints were categorized using domains (‘Clinical’, ‘Management’ and ‘Relationships’) and categories within those domains, such as ‘Quality’, ‘Safety’, ‘Listening’ and ‘Environment’. Motive for making a complaint If available, information on the reason(s) why the patient was motivated to make a complaint was extracted. Impact of complaint Where possible, the impact of the complaint on the patient, providers or health care service was extracted from studies. Harm to patient in events leading to complaint When available, the harm caused to patient in the event leading to the complaint was extracted. Results A total of 2960 records were identified from the databases screened, with further papers identified from hand searches of reference lists. Figure 1 presents the PRISMA flow diagram. A total of 21 papers (19,30–49), published between 1986 and 2018, were deemed eligible for inclusion in the review. Figure 1. Open in new tabDownload slide PRISMA flow diagram. Figure 1. Open in new tabDownload slide PRISMA flow diagram. Methodological quality (n = 21) Overall, the quality of included studies was found to be variable, with 14 studies scoring 50% or less (raw score of 24 or less) on the QATSDD (mean raw score = 19.8, range of scores = 8–29). One study was qualitative only, six were quantitative only and 14 were mixed methods. Studies scored well on items including ‘Fit between stated research question and method of data collection’, ‘Clear description of research setting’ and ‘Statement of aims/objectives in main body of report’. Studies received low scores on items including ‘Evidence of sample size considered in terms of analysis’, ‘Rationale for choice of data collection tool(s)’ and ‘Good justification for analytical method selected’. Characteristics of included studies (n = 21) Table 1 presents a summary of the characteristics of the studies that were included in this review. The majority were conducted in the USA (n = 8, 38%). Studies were also conducted in countries including the UK (n = 6, 29 %), Ireland (n = 2, 10%) and Denmark (n = 2, 10%). All studies took place in general practice settings, but varying terminology was used to describe these. As can be seen in Table 1, ‘General Practice’ was the most commonly used term (n = 14, 67%), amongst others (e.g. ‘ambulatory care’ (n = 2, 10%) and ‘family medicine’ (n = 1, 5%)). There was some variation in the characteristics of individuals who made the complaints or claims. However, in the majority of the included studies, the complaints were made either by the patient themselves (n = 12, 57%) or by a family member (n = 10, 48%). Finally, studies utilized different methods to examine the complaints, including reviews of complaints databases (n = 15, 71%), observational studies with before/after designs (n = 1, 5%) and audits of informal complaints procedures (n = 1, 5%). Further information regarding the characteristics of included studies can be found in Supplementary Data 2. Table 1. Characteristics of included studies (dated 1986–18) Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% aColumn does not sum to 100% as some studies had more than one type of complainant. Open in new tab Table 1. Characteristics of included studies (dated 1986–18) Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% aColumn does not sum to 100% as some studies had more than one type of complainant. Open in new tab Content of complaints (n = 18) The content of complaints was synthesized using the HCAT framework. The existing HCAT framework did not require adaptations in order to code and synthesize the content of complaints in included studies. Figure 2 presents how the complaints (n = 235) were organized into different categories using the HCAT framework. Of the total number of complaints, 54% (n = 126) were categorized as Clinical, 23% (n = 55) were categorized as Management and 23% (n = 54) were categorized as Relationships. Exemplar complaints that were synthesized using the HCAT framework can be found in Table 2. Figure 2. Open in new tabDownload slide Number of complaints in included studies as classified into HCAT domains and categories. Figure 2. Open in new tabDownload slide Number of complaints in included studies as classified into HCAT domains and categories. Table 2. Exemplar complaints from included studies (dated 1986–2018) categorized under HCAT HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) Open in new tab Table 2. Exemplar complaints from included studies (dated 1986–2018) categorized under HCAT HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) Open in new tab Motives for making complaint (n = 2) Two of the included papers (33,44) described patients’ motives for making a complaint. Motivations included a desire for placement of responsibility, economic compensation, and professional disciplining of the practitioner involved. In both studies, ‘preventing the same thing happening to other people’ or ‘quality improvement for future patients’ also emerged. Impact of the complaints (n = 16) Studies described a number of outcomes of health care complaints for the patient, providers and wider health service. At an individual patient level, the award of monetary compensation was described in four papers (19%). Other outcomes included an apology or explanation being provided to the patient (n = 4, 19%) or the patient changing doctors (n = 3, 14%). A number of outcomes were described for health care providers in the included studies, such as the disciplining of doctors (n = 5, 24%) or complaints against them being dropped (n = 9, 43%). Disciplinary measures included reprimands, fines or removal from performers list. System-level outcomes, such as an investigation by an external body (e.g. committee, ombudsman and governmental department; n = 4, 19%) and the implementation of an intervention or audit (n = 2, 10%), were also described in some of the included studies. Further detail of the impact of complaints can be found in the data extraction table in Supplementary Data 2. Harm to patients in events leading to complaints (n = 14) Of the included studies, 14 (67%) made some attempt to classify the harm to the patients in the event leading to the complaint. There was heterogeneity in the classification of harm across the included studies; however, it typically ranged from ‘minor temporary harm’ or ‘insignificant injury’ to ‘grave injury or death of a patient, depending on the scale that was used for classification. The National Association of Insurance commissioners severity scale (ranging from 1 ‘Emotional only’ to 9 ‘Death’) (50) was utilized in four papers (19%). Other studies developed severity scales (42) or adopted other systems (49) to measure the level of harm. Discussion There is increasing recognition of the importance of assessing, and improving, quality and safety in general practice. Health care complaints are an underutilized data source for informing such efforts. This review examined the content of complaints in included studies, the motive and harm that led to making these complaints and the impact of the complaints on patients, providers and the wider system. Key findings included the fact that there was a higher proportion of clinical complaints compared to relationship or management issues, that patients can be motivated to complain with the intent of making service improvements and that complaints had positive and negative impacts for all those involved in the process. A large proportion of complaints in the included studies were found to focus on quality and safety issues. In the past, issues around error and safety in primary care and general practice have been somewhat neglected, with the focus being on quality and safety in secondary care (9). However, the data from this review emphasize that greater attention must be given to addressing safety in general practice. Many of the complaints in this review related directly to clinical issues, which included errors, poor care and safety incidents (e.g. ‘Drug allergy missed’ (41) and ‘Failure to supervise or monitor care’ (37)). Patient expectations could have some role to play in these findings, particularly with regards to quality complaints as health care has moved to a more consumer-based model (51–54). However, patient expectations aside, it is evident from this synthesis that safety issues must be considered more seriously in general practice research. The proportion of general practice complaints in the included studies related to quality and safety was greater than has been found in a review of secondary care complaints (53.6% in general practice as compared to 33.7% in secondary care (6)). This somewhat surprising result could be because patients have more frequent contact with GPs than hospital doctors and are increasingly seeing multiple GPs (55). Lack of continuity in GP care has been flagged by practitioners as a factor leading to error (55). It is evident, therefore, that there should be an increased focus on complaints relating to safety issues in general practice research. Currently, complaints data in general practice is severely underutilized as a means of identifying issues (3). Using this aggregated data, rather than addressing individual complaints, could allow researchers to develop a broader understanding of what patients are complaining about and enable these to be addressed at a higher level, contributing to system-level organizational learning (56). GPs are competent in developing solutions to address problems around safety and quality in their own practice (15,57) and should be encouraged to examine these problems using their complaints data. However, the large body of complaints data could also be used to move beyond that, placing more emphasis on changing the system-wide problems as well as individual practices (6). Only two papers discussed the motives that led to patients making a complaint and, as such, there are limits to the conclusions that can be drawn. However, the fact that one of these motives was to improve the health care experience for other patients warrants further discussion. Motives including ‘wish for quality improvement for future patients’ (33) and ‘to prevent the same thing happening to other people’ (44) were identified in the two studies that examined this aspect of complaints. While complaints are often viewed by practitioners as negative, and individuals who made these complaints are sometimes distrusted in their motives (58,59), this review indicates that patients can desire to be agents for change. Complaints are one way through which patients and family members can feel they are contributing to service improvement (7). It has previously been identified that patients have a privileged viewpoint within the health system, which could help increase understanding of systemic issues that occur during the process of care (56). For example, in this synthesis, complaints around institutional processes were often regarding ‘blind spots’ that only patients could identify, such as not being able to access appointments (43) or the cost of an appointment being a barrier to accessing health care (31). Future research should focus on exploring patients’ motivations for complaining and engage with their wish to contribute by using complaints data and other tools, such as patient surveys. The focus of this review was on complaints made by patients. However, there is also likely a proportion of patients who may be dissatisfied with their GP care but do not complain. Previous research has found that people might not complain for reasons including power imbalances, lack of understanding of the complaint channels and a lack of responsiveness on the part of the provider (60). It is important, therefore, for GPs to proactively engage with patients who already complain and remove the barriers that may prevent others from complaining. For example, practitioners could ensure that patients receive clear information on where to complain (60). The availability of this information would be an effective way of improving patient experience, quality and safety and could ensure that the viewpoints of all patients are represented (56,61,62). The data synthesized in this review on the impact of complaints highlighted how complaints can have positive and negative impacts on the system as a whole, not just on individuals. Only two of the included studies reported practices making changes following the analysis of complaints (31,34). Included studies more often described the impact of complaints on the patient themselves, for example, ‘payment to patient’ (37) or ‘changing doctor’ (43), and on the provider involved in the events leading to complaints, such as ‘disciplinary action’ (33) or ‘complaint successfully defended’ (49). This focus on the negative impacts of complaints on individuals is reflected in how complaints are often framed as punitive, causing stress, anger and even depression for the providers (58). However, potentially more important is how complaints can impact positively on the system as a learning tool for safety improvement (e.g. ‘engaging in risk reduction’ (31)). Reframing complaints as learning opportunities, and analyzing them collectively, could benefit practices, and also the health care system as a whole, by moving away from complaints as a negative experience targeting individual providers (6,63). Limitations There are a number of limitations to the current review. First, the studies included were heterogeneous in nature. They used different methods (e.g. review of database, audit of medical records and retrospective cohort study), categorized complaints in a variety of ways (e.g. HCAT and systems developed by the authors) and focused on different outcome variables (e.g. impact, motive and content). This heterogeneity is both a limitation and strength. The heterogeneity increased the complexity of synthesizing the data and, as a result, it was challenging to derive learning from the data. On the other hand, this variation served to clarify the need for a reliable and standardized system for analyzing GP complaints moving forward. Inclusion of a wide range of studies allowed for a broad overview of the existing research on complaints about GP. By highlighting the heterogeneity within the canon of knowledge on complaints, this review has set the stage for future work to focus on more specific research questions. There was also considerable variation in the methodological quality of the included studies. Second, raw complaints from the included studies were unavailable. Therefore, the synthesis of complaints is based upon the study authors’ interpretations of the complaints rather than on the actual patient complaints. However, in most cases, the authors of the included studies did provide examples of the raw data, which facilitated the synthesis. Third, it was initially intended to examine the frequency of GP complaints. This intention was included in the PROSPERO protocol. However, during the data extraction, it became apparent that it was not possible to synthesize the data on frequency given the different methods authors used to calculate and present this data. As a result, it was necessary to amend the PROSPERO protocol. It is, therefore, recommended that some consistency is established for calculating and presenting frequency data in future studies, at which point this could be reviewed. Finally, this review only included studies that were peer reviewed and published in English. There is a lack of best-practice guidelines for searching grey literature, and it is often difficult to interpret data included in grey literature due to poor reporting (64). There is also some evidence to demonstrate that limiting the language does not negatively impact a review (65). Future research and application to practice This review has highlighted areas for future research and changes to practice. First, the use of the HCAT as an organizing framework for synthesis has indicated that it can be successfully used to classify general practice complaints. However, future work is necessary to validate the tool in primary care. The use of a standardized tool that is reliable and valid would reduce the heterogeneity of data available on complaints and facilitate quality and safety improvements in general practice (28). Standardisation in the analysis of complaints would also facilitate comparisons between the different aspects of health care (such as primary and secondary care) regarding quality and safety (56). Utilising a standardized, reliable tool, such as the HCAT, could enable future research to apply the rigour of secondary care to the analysis of general practice complaints. Second, there is a relative lack of research on complaints in general practice as compared to secondary care. Moreover, the existing research is predominately limited to the UK and USA, and more research into GP complaints internationally is required to allow for further comparisons. This review of general practice complaints included 21 papers compared to the 59 included in the hospital care review by Reader et al. (6). This finding is at odds with the high volume of contact that patients experience with general practice, indicating a need for more research on general practice complaints. Third, more research is required on how patients can contribute to improving safety and quality in general practice. It is evident from this review that patients are motivated to improve the health care system at large and, therefore, integrating patients’ experiences must be prioritized in patient safety research moving forward. Finally, there is a need for learning from this systematic review to be applied by GPs to their work. The small number of practices utilizing the complaints data to make system improvements indicate that this is an area to be further explored. By collating complaints and framing them as learning opportunities, GPs could use them to identify improvements and reduce the number of complaints they receive (15,57). Conclusion The data which emerged from this review highlighted the high proportion of quality- and safety-related complaints in general practice, patients’ motivations to improve the health care system and the various positive and negative impacts that complaints can have on individuals and systems involved. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice would be of much interest. Declarations Funding: This study was funded by the National University of Ireland, Galway, Hardiman PhD scholarship programme. Ethical approval: not applicable. Conflicts of interest: none. References 1. National Patient Safety Office. Summary—Introduction of a Patient Safety Complaints and Advocacy Policy. 2017 ; https://health.gov.ie/wp-content/uploads/2017/05/Development-of-a-Patient-Safety-Complaints-and-Advocacy-Policy.pdf (accessed on 22 March 2019 ). 2. Mulcahy L , Tritter JQ . Pathways, pyramids and icebergs? Mapping the links between dissatisfaction and complaints . Sociol Health Illn 1998 ; 20 ( 6): 825 – 47 . Google Scholar Crossref Search ADS WorldCat 3. Clwyd A , Hart T. A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture. Final Report . UK: National Health Service , 2013 . Google Preview WorldCat COPAC 4. Allsop J , Mulcahy L . Dealing with clinical complaints . Qual Health Care 1995 ; 4 : 135 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Francis R. Independent Inquiry Into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 . London: The Stationery Office , 2010 . Google Preview WorldCat COPAC 6. Reader TW , Gillespie A , Roberts J . Patient complaints in healthcare systems: a systematic review and coding taxonomy . BMJ Qual Saf 2014 ; 23 : 678 – 89 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Weingart SN , Pagovich O , Sands DZ et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents . J Gen Intern Med 2005 ; 20 : 830 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Newdick C , Danbury C . Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire . J Med Ethics 2015 ; 41 : 956 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 9. The Health Foundation. Evidence Scan: Levels of Harm in Primary Care . 2011 ; https://www.health.org.uk/publications/levels-of-harm-in-primary-care (accessed on 15 March 2019 ). 10. Esmail A. Measuring and Monitoring Safety: A Primary Care Perspective . London, UK : Health Foundation , 2013 . Google Preview WorldCat COPAC 11. Douw K , Nielsen CP , Pedersen CR . Centralising acute stroke care and moving care to the community in a Danish health region: challenges in implementing a stroke care reform . Health Policy 2015 ; 119 : 1005 – 10 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Sibbald B , Pickard S , McLeod H et al. Moving specialist care into the community: an initial evaluation . J Health Serv Res Policy 2008 ; 13 : 233 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Starfield B , Lemke KW , Bernhardt T et al. Comorbidity: implications for the importance of primary care in ‘case’ management . Ann Fam Med 2003 ; 1 : 8 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Rubin G , Berendsen A , Crawford SM et al. The expanding role of primary care in cancer control . Lancet Oncol 2015 ; 16 : 1231 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Madden C , Lydon S , Cupples ME et al. Safety in primary care (SAP-C): a randomised, controlled feasibility study in two different healthcare systems . BMC Fam Pract 2019 ; 20 : 22 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Panesar SS , deSilva D , Carson-Stevens A et al. How safe is primary care? A systematic review . BMJ Qual Saf 2016 ; 25 : 544 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Samra R , Bottle A , Aylin P . Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews . BMJ Open 2015 ; 5 : e008128 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Tang N , Meyer GS . Ambulatory patient safety: the time is now: comment on ‘patient perceptions of mistakes in ambulatory care’ . Arch Intern Med 2010 ; 170 : 1487 – 9 . Google Scholar PubMed WorldCat 19. Gandhi TK , Kachalia A , Thomas EJ et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims . Ann Intern Med 2006 ; 145 : 488 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 20. Liberati A , Altman DG , Tetzlaff J et al. . The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration . PLoS Med 2009 ; 6 : e1000100 . Google Scholar Crossref Search ADS PubMed WorldCat 21. The PME. Best practice in systematic reviews: the importance of protocols and registration . PLoS Med 2011 ; 8 ( 2): e1001009 . Crossref Search ADS PubMed WorldCat 22. Wallace E , Lowry J , Smith SM , Fahey T . The epidemiology of malpractice claims in primary care: a systematic review . BMJ Open 2013 ; 3 ( 7): e002929 . Google Scholar Crossref Search ADS PubMed WorldCat 23. Shea BJ , Grimshaw JM , Wells GA et al. . Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews . BMC Med Res Methodol 2007 ; 7 : 10 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Sirriyeh R , Lawton R , Gardner P , Armitage G . Reviewing studies with diverse designs: the development and evaluation of a new tool . J Eval Clin Pract 2012 ; 18 : 746 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 25. O’Dowd E , Lydon S , O’Connor P , Madden C , Byrne D . A systematic review of 7 years of research on entrustable professional activities in graduate medical education, 2011-2018 . Med Educ 2019 ; 53 : 234 – 49 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Lydon S , Cupples ME , Murphy AW , Hart N , OʼConnor P . A systematic review of measurement tools for the proactive assessment of patient safety in general practice . J Patient Saf 2017 ; Apr: publish ahead of print . WorldCat 27. Baxter R , Taylor N , Kellar I , Lawton R . What methods are used to apply positive deviance within healthcare organisations? A systematic review . BMJ Qual Saf 2016 ; 25 : 190 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 28. Gillespie A , Reader TW . The healthcare complaints analysis tool: development and reliability testing of a method for service monitoring and organisational learning . BMJ Qual Saf 2016 ; 25 : 937 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Carroll C , Booth A , Leaviss J , Rick J . ‘Best fit’ framework synthesis: refining the method . BMC Med Res Methodol 2013 ; 13 : 37 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Abrecht CR , Brovman EY , Greenberg P et al. . A contemporary medicolegal analysis of outpatient medication management in chronic pain . Anesth Analg 2017 ; 125 : 1761 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Barragry RA , Varadkar LE , Hanlon DK et al. . An analytic observational study on complaints management in the general practice out of hours care setting: who complains, why, and what can we do about it? BMC Fam Pract 2016 ; 17 : 87 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Birkeland S , Christensen Rd , Damsbo N , Kragstrup J . Process-related factors associated with disciplinary board decisions . BMC Health Serv Res 2013 ; 13 : 9 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Birkeland S , Depont Christensen R , Damsbo N , Kragstrup J . Characteristics of complaints resulting in disciplinary actions against Danish GPs . Scand J Prim Health Care 2013 ; 31 : 153 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Cowan J , Wilson J . Clinical risk management. Complaints in primary care arising from bereavement . Clin Gov 2007 ; 12 ( 4): 296 – 304 . Google Scholar Crossref Search ADS WorldCat 35. Cox SJ , Holden JD . Presentation and outcome of clinical poor performance in one health district over a 5-year period: 2002-2007 . Br J Gen Pract 2009 ; 59 : 344 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Esmail A . Patient safety–what claims against the NHS can teach us . J Health Serv Res Policy 2010 ; 15 ( suppl 1) : 33 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Flannery FT , Parikh PD , Oetgen WJ . Characteristics of medical professional liability claims in patients treated by family medicine physicians . J Am Board Fam Med 2010 ; 23 : 753 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Gaal S , Hartman C , Giesen P et al. . Complaints against family physicians submitted to disciplinary tribunals in the Netherlands: lessons for patient safety . Ann Fam Med 2011 ; 9 : 522 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 39. Harris JM Jr . Papanicolaou smear recommendations, patient complaints, and patient satisfaction in managed-care medical organizations . Med Care 1995 ; 33 : 272 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 40. Hart J , Weingarten MA . A procedure for handling complaints against general practitioners . Fam Pract 1986 ; 3 : 107 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 41. Lim HC , Tan CB , Goh LG , Ling SL . Why do patients complain? A primary health care study . Singapore Med J 1998 ; 39 : 390 – 5 . Google Scholar PubMed WorldCat 42. Mack JW , Jacobson J , Frank D et al. Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery . Jt Comm J Qual Patient Saf 2017 ; 43 : 498 – 507 . Google Scholar Crossref Search ADS PubMed WorldCat 43. Nettleton S , Harding G . Protesting patients: a study of complaints submitted to a family health service authority . Sociol Health Illn 1994 ; 16 ( 1): 38 – 61 . Google Scholar Crossref Search ADS WorldCat 44. Owen C . Formal complaints against general practitioners: a study of 1000 cases . Br J Gen Pract 1991 ; 41 : 113 – 5 . Google Scholar PubMed WorldCat 45. Phillips RL Jr , Bartholomew LA , Dovey SM et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States . Qual Saf Health Care 2004 ; 13 : 121 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 46. Pietroni PC , de Uray-Ura S . Informal complaints procedure in general practice: first year’s experience . BMJ 1994 ; 308 : 1546 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 47. Quinn GR , Ranum D , Song E et al. Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data . Jt Comm J Qual Patient Saf 2017 ; 43 : 508 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 48. Rodriguez HP , Rodday AM , Marshall RE et al. Relation of patients’ experiences with individual physicians to malpractice risk . Int J Qual Health Care 2008 ; 20 : 5 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 49. Wallace E , Cronin S , Murphy N et al. Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland . Br J Gen Pract 2018 ; 68 : e860 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 50. Sowka M. Malpractice Claims: Final Compilation . Brookfield, WI: National Association of Insurance Commissioners , 1980 . Google Preview WorldCat COPAC 51. Hageman MG , Briët JP , Bossen JK et al. Do previsit expectations correlate with satisfaction of new patients presenting for evaluation with an orthopaedic surgical practice? Clin Orthop Relat Res 2015 ; 473 : 716 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 52. Mohammed K , Nolan MB , Rajjo T et al. Creating a patient-centered health care delivery system: a systematic review of health care quality from the patient perspective . Am J Med Qual 2016 ; 31 : 12 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 53. Williams S , Weinman J , Dale J , Newman S . Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract 1995 ; 12 : 193 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 54. Fletcher-Lartey S , Yee M , Gaarslev C , Khan R . Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study . BMJ Open 2016 ; 6 : e012244 . Google Scholar Crossref Search ADS PubMed WorldCat 55. Curran C , Lydon S , Kelly ME , Murphy AW , O’Connor P . An analysis of general practitioners’ perspectives on patient safety incidents using critical incident technique interviews . Fam Pract 2019 ; Mar: epub ahead of print . WorldCat 56. Gillespie A , Reader TW . Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety . Milbank Q 2018 ; 96 : 530 – 67 . Google Scholar Crossref Search ADS PubMed WorldCat 57. de Wet C , Black C , Luty S et al. . Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement . BMJ Qual Saf 2017 ; 26 : 335 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 58. Cunningham W . The immediate and long-term impact on New Zealand doctors who receive patient complaints . NZ Med J 2004 ; 117 : U972 . WorldCat 59. D’Cruz L . The successful management of complaints–turning threats into opportunities . Dent Update 2008 ; 35 : 182 – 4, 186 . Google Scholar Crossref Search ADS PubMed WorldCat 60. Gurung G , Derrett S , Gauld R , Hill PC . Why service users do not complain or have ‘voice’: a mixed-methods study from Nepal’s rural primary health care system . BMC Health Serv Res 2017 ; 17 : 81 . Google Scholar Crossref Search ADS PubMed WorldCat 61. Berwick DM , Nolan TW , Whittington J . The triple aim: care, health, and cost . Health Aff (Millwood) 2008 ; 27 : 759 – 69 . Google Scholar Crossref Search ADS PubMed WorldCat 62. Mehta SJ . Patient satisfaction reporting and its implications for patient care . AMA J Ethics 2015 ; 17 : 616 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 63. Vincent C , Amalberti R. Safer Healthcare . Cham, Switzerland : Springer International Publishing , 2016 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 64. Martin JL , Pérez V , Sacristán M , Alvarez E . Is grey literature essential for a better control of publication bias in psychiatry? An example from three meta-analyses of schizophrenia . Eur Psychiatry 2005 ; 20 : 550 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 65. Morrison A , Polisena J , Husereau D et al. . The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies . Int J Technol Assess Health Care 2012 ; 28 : 138 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

A systematic review of patient complaints about general practice

Download PDF
9 pages

Loading next page...
 
/lp/oxford-university-press/a-systematic-review-of-patient-complaints-about-general-practice-CmSFhXt2as

References (60)

Publisher
Oxford University Press
Copyright
© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0263-2136
eISSN
1460-2229
DOI
10.1093/fampra/cmz082
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Health care complaints are an underutilized resource for quality and safety improvement. Most research on health care complaints is focused on secondary care. However, there is also a need to consider patient safety in general practice, and complaints could inform quality and safety improvement. Objective This review aimed to synthesize the extant research on complaints in general practice. Methods Five electronic databases were searched: Medline, Web of Science, CINAHL, PsycINFO and Academic Search Complete. Peer-reviewed studies describing the content, impact of and motivation for complaints were included and data extracted. Framework synthesis was conducted using the Healthcare Complaints Analysis Tool (HCAT) as an organizing framework. Methodological quality was appraised using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Results The search identified 2960 records, with 21 studies meeting inclusion criteria. Methodological quality was found to be variable. The contents of complaints were classified using the HCAT, with 126 complaints (54%) classified in the Clinical domain, 55 (23%) classified as Management and 54 (23%) classified as Relationships. Motivations identified for making complaints included quality improvement for other patients and monetary compensation. Complaints had both positive and negative impacts on individuals and systems involved. Conclusion This review highlighted the high proportion of clinical complaints in general practice compared to secondary care, patients’ motivations for making complaints and the positive and negative impacts that complaints can have on health care systems. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice is required. Access to care, community medicine, doctor–patient relationship, medical errors, patient safety, primary care, quality of care Key Messages Clinical and safety issues are prevalent in general practice complaints. Patients can be motivated to complain to improve quality of care. Further research on reliably coding general practice complaints is required. Background Health care complaints are formal expressions of dissatisfaction regarding any action or care by the health service or a health care provider that is perceived to be suboptimal and to have an adverse impact on patients and their families (1). The submission of a complaint indicates that a threshold of dissatisfaction has been crossed during the process of care (2). Health care complaints are recognized as an underutilized resource for quality and safety improvement (3). Complaints are traditionally addressed on an individual basis, typically by responding to the patient and resolving the issue identified in that specific complaint (4). However, there is recognized value to analyzing complaints at the systems level by aggregating the data from multiple complaints and utilizing the learning from this process (5,6). Patients often have insight into issues and problems that providers themselves do not recognize or are not exposed to (e.g. problems prior to admission and following discharge) (7). The knowledge gained from patient complaints could be particularly important when a culture exists in a system whereby staff are unwilling or unable to raise quality and safety issues themselves (8). Most research on health care complaints is focused on care delivered in the hospital setting (6). This is unsurprising given that the study of safety and quality in general practice lags far behind that in hospital settings (9). Typically, general practice has been considered relatively low risk (10). However, as services are increasingly being diverted from a hospital setting to the community (11,12), there is a greater need to consider quality and safety in this domain of health care. Patients interact more frequently with their General Practitioner (GP) than hospital doctors (13,14) and, with this increase in volume of interaction, the risk of errors occurring also rises (15). Adverse events have been found to occur in 2–3% of general practice appointments (16). However, despite recognition of the growing complexity and potential for error in general practice, GPs report that they find it difficult to know where to start with implementing quality and safety improvement practices (17). Health care complaints could serve as one source of data for informing quality and safety improvement in general practice. Serious issues occur in general practice, which patient complaints could identify, such as treatment delays, difficulty accessing treatment or delays in diagnosis (18). Using complaints to access patient insights into safety and quality issues in general practice could provide valuable learning, given the frequency of contact and the privileged viewpoint that patients have within the health care system (7). This systematic review aimed to synthesize the extant research on health care complaints and medicolegal claims in general practice. Medicolegal claims are defined as a written demand for compensation for medical injury (19), and complaints are formal expressions of dissatisfaction with health care (1). For the purpose of this review, both will be, hereafter, referred to using the umbrella term ‘complaints’. Specifically, we examined the following: (i) the content of complaints described in included studies; (ii) what motivated the individual to make the complaint; (iii) the impact of the complaints on the health care providers and systems involved and (iv) the harm experienced by the patients in the incident that led to the complaint. It was intended that this review would offer an understanding of the nature and impact of health care complaints in general practice and facilitate comparison between the content of health care complaints in primary and secondary care. The review also considers the potential for adapting existing complaint taxonomies to make these more readily applicable to general practice. Method This systematic review was conducted with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (20). In accordance with best practice in systematic reviews (21), a protocol for the review was registered on the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42019123245). Search strategy Five electronic databases were screened to identify relevant papers for inclusion in this review—Medline, Web of Science, Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO—between October and November 2018 and updated in March 2019. The search strategy was developed with the assistance of a research support librarian and was based on the strategy used by Reader et al. (6). The search comprised of medical subject headings (MeSH terms) and other keywords relating to patient safety or experience (e.g. ‘patient satisfaction’ and ‘safe*’), complaints (e.g. ‘malpractice’ and ‘complain*’) and primary care (e.g. ‘general practice’ and ‘primary care’). The full electronic search strategy used for Medline can be found in Supplementary Data 1. This search strategy was adapted as necessary for the other electronic databases. The search strategy included terms relating to health care practitioners and services other than general practice (e.g. dentistry, physiotherapy and pharmacy) as this review was part of a larger community care-focused project. However, for the purposes of this review, the authors only included studies that focused on general practice. In each database, search returns were limited to English language results only. There was no limit placed upon publication year. Following the electronic searches, the reference lists of studies that were identified as suitable for inclusion, and those of related review papers (6,22), were screened to identify any additional relevant studies. This search strategy complied with best practice for systematic reviews as laid out in the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) checklist (23). Study selection Inclusion criteria To be eligible for inclusion, studies were required to be peer-reviewed and to present original, empirical data on health care complaints that related to poor care experiences in general practice. Studies were required to have a focus on one or more of the following: (i) patients’ motivation for making the complaint; (ii) the content or nature of complaints; (iii) the impact of the complaint on the patient, health care provider or system or (iv) the harm experienced by patients in the event leading to the complaint. For the purposes of this review, it was considered necessary that the complaints described within studies were instigated by the patient/service user, or someone acting on their behalf, rather than being solicited by researchers through surveys, interviews or otherwise. Exclusion criteria Studies that were focused on health care complaints relating to secondary care settings were excluded along with studies that provided no original, empirical data on health care complaints (e.g. review papers, editorials or commentaries). Studies were also excluded if: (i) they were focused on the analysis of incident reports from health care professionals; (ii) complaints were solicited using a survey or qualitative methodology and (iii) they focused on community health services other than general practice. Screening process The title and abstract of all search returns in each of the five databases were screened by the first author (EOD). The full text of any study that appeared relevant was screened in order to confirm its suitability for inclusion. Further, if it was unclear from the examination of the title and the abstract whether or not the study fit the inclusion criteria, the full text of the article was also screened. A second author (SL) reviewed any article for which there remained uncertainty. Data extraction and synthesis Data extraction was conducted independently by two authors (EOD and CM). Any disagreements were resolved through discussion until consensus was achieved. Agreement was calculated as an average of 95% across all studies, ranging from 89% to 100% for individual studies. A third author (SL) was consulted in the event that consensus could not be achieved. A standardized form was used by the two authors to extract data from studies that fit the inclusion criteria. Extracted information included general characteristics of studies (e.g. year of publication, country of study, individual making the complaint and methods used) along with the data under the headings below. Methodological quality The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) (24) was used to assess the methodological rigour of the included studies. This tool was considered appropriate as the studies included in this review were heterogeneous in design. The QATSDD is a 16-item scale developed for use by health service researchers, which has been used successfully in other systematic reviews (25–27). Each QATSDD item is scored on a scale ranging from 0 (e.g. ‘no mention at all’) to 3 (e.g. ‘detailed description of each stage of the data collection procedure’), with a maximum possible score of 42 for qualitative or quantitative studies and 48 for mixed-method studies. Two authors (EOD and CM) applied the QATSDD to included studies, and disagreements were resolved through discussion until consensus was achieved. Content and categorization of complaints Data on the content of complaints (i.e. the issue[s] described) were extracted from the studies. These data took the form of raw complaints extracted from either text or tables within the included studies and/or the interpretations of complaints made by the authors of individual studies. These data were synthesized by four authors (EOD, SL, POC and CM) using the Healthcare Complaints Analysis Tool (HCAT) (28). The HCAT is a tool that allows for the systematic coding and categorization of health care complaints in a hospital setting (28). The HCAT has been found to be statistically reliable and valid and there is no suitable tool designed specifically for use in general practice. A framework synthesis approach was taken to coding the complaints with the HCAT. Framework synthesis is a structured, deductive approach to collating data, often used when there is an existing theory (29). Data were coded into the HCAT framework using an iterative process. This allowed the researchers to determine how the general practice complaints can fit under the HCAT tool, which was developed for hospital complaints. Complaints were categorized using domains (‘Clinical’, ‘Management’ and ‘Relationships’) and categories within those domains, such as ‘Quality’, ‘Safety’, ‘Listening’ and ‘Environment’. Motive for making a complaint If available, information on the reason(s) why the patient was motivated to make a complaint was extracted. Impact of complaint Where possible, the impact of the complaint on the patient, providers or health care service was extracted from studies. Harm to patient in events leading to complaint When available, the harm caused to patient in the event leading to the complaint was extracted. Results A total of 2960 records were identified from the databases screened, with further papers identified from hand searches of reference lists. Figure 1 presents the PRISMA flow diagram. A total of 21 papers (19,30–49), published between 1986 and 2018, were deemed eligible for inclusion in the review. Figure 1. Open in new tabDownload slide PRISMA flow diagram. Figure 1. Open in new tabDownload slide PRISMA flow diagram. Methodological quality (n = 21) Overall, the quality of included studies was found to be variable, with 14 studies scoring 50% or less (raw score of 24 or less) on the QATSDD (mean raw score = 19.8, range of scores = 8–29). One study was qualitative only, six were quantitative only and 14 were mixed methods. Studies scored well on items including ‘Fit between stated research question and method of data collection’, ‘Clear description of research setting’ and ‘Statement of aims/objectives in main body of report’. Studies received low scores on items including ‘Evidence of sample size considered in terms of analysis’, ‘Rationale for choice of data collection tool(s)’ and ‘Good justification for analytical method selected’. Characteristics of included studies (n = 21) Table 1 presents a summary of the characteristics of the studies that were included in this review. The majority were conducted in the USA (n = 8, 38%). Studies were also conducted in countries including the UK (n = 6, 29 %), Ireland (n = 2, 10%) and Denmark (n = 2, 10%). All studies took place in general practice settings, but varying terminology was used to describe these. As can be seen in Table 1, ‘General Practice’ was the most commonly used term (n = 14, 67%), amongst others (e.g. ‘ambulatory care’ (n = 2, 10%) and ‘family medicine’ (n = 1, 5%)). There was some variation in the characteristics of individuals who made the complaints or claims. However, in the majority of the included studies, the complaints were made either by the patient themselves (n = 12, 57%) or by a family member (n = 10, 48%). Finally, studies utilized different methods to examine the complaints, including reviews of complaints databases (n = 15, 71%), observational studies with before/after designs (n = 1, 5%) and audits of informal complaints procedures (n = 1, 5%). Further information regarding the characteristics of included studies can be found in Supplementary Data 2. Table 1. Characteristics of included studies (dated 1986–18) Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% aColumn does not sum to 100% as some studies had more than one type of complainant. Open in new tab Table 1. Characteristics of included studies (dated 1986–18) Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% Characteristics n, % Country  USA 8, 38%  UK 6, 29%  Ireland 2, 10%  Denmark 2, 10%  Netherlands 1, 5%  Israel 1, 5%  Singapore 1, 5% Setting  General practice 14, 67%  Out of hours general practice 2, 10%  Ambulatory care 2, 10%  Outpatient chronic pain management 1, 5%  Family medicine 1, 5%  Outpatient general medicine 1, 5% Individual making complainta  Patient 12, 57%  Family members (including parent, son/daughter) 10, 48%  Non-family members 4, 19%  Partner of patient 3, 14%  Professional colleague 3, 14%  Solicitors/advocates 1, 5%  Health care inspector 1, 5%  Social worker 1, 5%  Warden of sheltered housing 1, 5%  Other 3, 14%  Not specified 8, 38% Method used  Review of claims/complaints database 15, 71%  Analytic observational study with before/after design 1, 5%  Audit of medical records 1, 5%  Description of experience of handling complaints 1, 5%  Analysis of informal complaints made to a family health service authority 1, 5%  Audit of an informal complaints procedure 1, 5%  Retrospective cohort study of patient complaints to an out of hours service provider 1, 5% Motive for making complaint  Wish for explanation 1, 5%  Wish for placement of responsibility 1, 5%  Wish for quality improvement for future patients 2, 10%  Review of GPs competence 1, 5%  Economic compensation 1, 5%  Better level of general service 1, 5%  Professional discipline 1, 5%  Feeling devalued 1, 5%  Other sanction 1, 5% aColumn does not sum to 100% as some studies had more than one type of complainant. Open in new tab Content of complaints (n = 18) The content of complaints was synthesized using the HCAT framework. The existing HCAT framework did not require adaptations in order to code and synthesize the content of complaints in included studies. Figure 2 presents how the complaints (n = 235) were organized into different categories using the HCAT framework. Of the total number of complaints, 54% (n = 126) were categorized as Clinical, 23% (n = 55) were categorized as Management and 23% (n = 54) were categorized as Relationships. Exemplar complaints that were synthesized using the HCAT framework can be found in Table 2. Figure 2. Open in new tabDownload slide Number of complaints in included studies as classified into HCAT domains and categories. Figure 2. Open in new tabDownload slide Number of complaints in included studies as classified into HCAT domains and categories. Table 2. Exemplar complaints from included studies (dated 1986–2018) categorized under HCAT HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) Open in new tab Table 2. Exemplar complaints from included studies (dated 1986–2018) categorized under HCAT HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) HCAT Domain HCAT Category Exemplar complaints from included studies (n) Clinical problems  Quality Inadequate patient assessment (29) Failure to supervise or monitor care (36) Unsatisfactory treatment (43) Problems with records (45)  Safety Wrong patient or body part (45) Misdiagnosis (43) Drug allergy missed (41) Incorrect interpretation of diagnostic or laboratory tests (38) Management  Environment Physical environment (41) Telephone system (46) Poor administration (44) Inadequate disposal of drugs (43)  Institutional processes/health system processes Length of NHS waiting lists for treatment (46) Surgery cancelling appointments (43) Patient access to care (39) Cost (30) Relationship  Respect and patient rights Alleged assault (40) Impolite behaviour (37) Breach of confidentiality (36) Discrimination (49)  Listening Not taken seriously (43) Unmet patient expectations/requests (41) Doctor not investigating symptoms as much as the patient wanted (40)  Communication Inadequate explanation (41) Poor explanation of illness and of prescription (30) Inadequate explanation of diagnosis or management plan (49) Poor spoken English (43) Open in new tab Motives for making complaint (n = 2) Two of the included papers (33,44) described patients’ motives for making a complaint. Motivations included a desire for placement of responsibility, economic compensation, and professional disciplining of the practitioner involved. In both studies, ‘preventing the same thing happening to other people’ or ‘quality improvement for future patients’ also emerged. Impact of the complaints (n = 16) Studies described a number of outcomes of health care complaints for the patient, providers and wider health service. At an individual patient level, the award of monetary compensation was described in four papers (19%). Other outcomes included an apology or explanation being provided to the patient (n = 4, 19%) or the patient changing doctors (n = 3, 14%). A number of outcomes were described for health care providers in the included studies, such as the disciplining of doctors (n = 5, 24%) or complaints against them being dropped (n = 9, 43%). Disciplinary measures included reprimands, fines or removal from performers list. System-level outcomes, such as an investigation by an external body (e.g. committee, ombudsman and governmental department; n = 4, 19%) and the implementation of an intervention or audit (n = 2, 10%), were also described in some of the included studies. Further detail of the impact of complaints can be found in the data extraction table in Supplementary Data 2. Harm to patients in events leading to complaints (n = 14) Of the included studies, 14 (67%) made some attempt to classify the harm to the patients in the event leading to the complaint. There was heterogeneity in the classification of harm across the included studies; however, it typically ranged from ‘minor temporary harm’ or ‘insignificant injury’ to ‘grave injury or death of a patient, depending on the scale that was used for classification. The National Association of Insurance commissioners severity scale (ranging from 1 ‘Emotional only’ to 9 ‘Death’) (50) was utilized in four papers (19%). Other studies developed severity scales (42) or adopted other systems (49) to measure the level of harm. Discussion There is increasing recognition of the importance of assessing, and improving, quality and safety in general practice. Health care complaints are an underutilized data source for informing such efforts. This review examined the content of complaints in included studies, the motive and harm that led to making these complaints and the impact of the complaints on patients, providers and the wider system. Key findings included the fact that there was a higher proportion of clinical complaints compared to relationship or management issues, that patients can be motivated to complain with the intent of making service improvements and that complaints had positive and negative impacts for all those involved in the process. A large proportion of complaints in the included studies were found to focus on quality and safety issues. In the past, issues around error and safety in primary care and general practice have been somewhat neglected, with the focus being on quality and safety in secondary care (9). However, the data from this review emphasize that greater attention must be given to addressing safety in general practice. Many of the complaints in this review related directly to clinical issues, which included errors, poor care and safety incidents (e.g. ‘Drug allergy missed’ (41) and ‘Failure to supervise or monitor care’ (37)). Patient expectations could have some role to play in these findings, particularly with regards to quality complaints as health care has moved to a more consumer-based model (51–54). However, patient expectations aside, it is evident from this synthesis that safety issues must be considered more seriously in general practice research. The proportion of general practice complaints in the included studies related to quality and safety was greater than has been found in a review of secondary care complaints (53.6% in general practice as compared to 33.7% in secondary care (6)). This somewhat surprising result could be because patients have more frequent contact with GPs than hospital doctors and are increasingly seeing multiple GPs (55). Lack of continuity in GP care has been flagged by practitioners as a factor leading to error (55). It is evident, therefore, that there should be an increased focus on complaints relating to safety issues in general practice research. Currently, complaints data in general practice is severely underutilized as a means of identifying issues (3). Using this aggregated data, rather than addressing individual complaints, could allow researchers to develop a broader understanding of what patients are complaining about and enable these to be addressed at a higher level, contributing to system-level organizational learning (56). GPs are competent in developing solutions to address problems around safety and quality in their own practice (15,57) and should be encouraged to examine these problems using their complaints data. However, the large body of complaints data could also be used to move beyond that, placing more emphasis on changing the system-wide problems as well as individual practices (6). Only two papers discussed the motives that led to patients making a complaint and, as such, there are limits to the conclusions that can be drawn. However, the fact that one of these motives was to improve the health care experience for other patients warrants further discussion. Motives including ‘wish for quality improvement for future patients’ (33) and ‘to prevent the same thing happening to other people’ (44) were identified in the two studies that examined this aspect of complaints. While complaints are often viewed by practitioners as negative, and individuals who made these complaints are sometimes distrusted in their motives (58,59), this review indicates that patients can desire to be agents for change. Complaints are one way through which patients and family members can feel they are contributing to service improvement (7). It has previously been identified that patients have a privileged viewpoint within the health system, which could help increase understanding of systemic issues that occur during the process of care (56). For example, in this synthesis, complaints around institutional processes were often regarding ‘blind spots’ that only patients could identify, such as not being able to access appointments (43) or the cost of an appointment being a barrier to accessing health care (31). Future research should focus on exploring patients’ motivations for complaining and engage with their wish to contribute by using complaints data and other tools, such as patient surveys. The focus of this review was on complaints made by patients. However, there is also likely a proportion of patients who may be dissatisfied with their GP care but do not complain. Previous research has found that people might not complain for reasons including power imbalances, lack of understanding of the complaint channels and a lack of responsiveness on the part of the provider (60). It is important, therefore, for GPs to proactively engage with patients who already complain and remove the barriers that may prevent others from complaining. For example, practitioners could ensure that patients receive clear information on where to complain (60). The availability of this information would be an effective way of improving patient experience, quality and safety and could ensure that the viewpoints of all patients are represented (56,61,62). The data synthesized in this review on the impact of complaints highlighted how complaints can have positive and negative impacts on the system as a whole, not just on individuals. Only two of the included studies reported practices making changes following the analysis of complaints (31,34). Included studies more often described the impact of complaints on the patient themselves, for example, ‘payment to patient’ (37) or ‘changing doctor’ (43), and on the provider involved in the events leading to complaints, such as ‘disciplinary action’ (33) or ‘complaint successfully defended’ (49). This focus on the negative impacts of complaints on individuals is reflected in how complaints are often framed as punitive, causing stress, anger and even depression for the providers (58). However, potentially more important is how complaints can impact positively on the system as a learning tool for safety improvement (e.g. ‘engaging in risk reduction’ (31)). Reframing complaints as learning opportunities, and analyzing them collectively, could benefit practices, and also the health care system as a whole, by moving away from complaints as a negative experience targeting individual providers (6,63). Limitations There are a number of limitations to the current review. First, the studies included were heterogeneous in nature. They used different methods (e.g. review of database, audit of medical records and retrospective cohort study), categorized complaints in a variety of ways (e.g. HCAT and systems developed by the authors) and focused on different outcome variables (e.g. impact, motive and content). This heterogeneity is both a limitation and strength. The heterogeneity increased the complexity of synthesizing the data and, as a result, it was challenging to derive learning from the data. On the other hand, this variation served to clarify the need for a reliable and standardized system for analyzing GP complaints moving forward. Inclusion of a wide range of studies allowed for a broad overview of the existing research on complaints about GP. By highlighting the heterogeneity within the canon of knowledge on complaints, this review has set the stage for future work to focus on more specific research questions. There was also considerable variation in the methodological quality of the included studies. Second, raw complaints from the included studies were unavailable. Therefore, the synthesis of complaints is based upon the study authors’ interpretations of the complaints rather than on the actual patient complaints. However, in most cases, the authors of the included studies did provide examples of the raw data, which facilitated the synthesis. Third, it was initially intended to examine the frequency of GP complaints. This intention was included in the PROSPERO protocol. However, during the data extraction, it became apparent that it was not possible to synthesize the data on frequency given the different methods authors used to calculate and present this data. As a result, it was necessary to amend the PROSPERO protocol. It is, therefore, recommended that some consistency is established for calculating and presenting frequency data in future studies, at which point this could be reviewed. Finally, this review only included studies that were peer reviewed and published in English. There is a lack of best-practice guidelines for searching grey literature, and it is often difficult to interpret data included in grey literature due to poor reporting (64). There is also some evidence to demonstrate that limiting the language does not negatively impact a review (65). Future research and application to practice This review has highlighted areas for future research and changes to practice. First, the use of the HCAT as an organizing framework for synthesis has indicated that it can be successfully used to classify general practice complaints. However, future work is necessary to validate the tool in primary care. The use of a standardized tool that is reliable and valid would reduce the heterogeneity of data available on complaints and facilitate quality and safety improvements in general practice (28). Standardisation in the analysis of complaints would also facilitate comparisons between the different aspects of health care (such as primary and secondary care) regarding quality and safety (56). Utilising a standardized, reliable tool, such as the HCAT, could enable future research to apply the rigour of secondary care to the analysis of general practice complaints. Second, there is a relative lack of research on complaints in general practice as compared to secondary care. Moreover, the existing research is predominately limited to the UK and USA, and more research into GP complaints internationally is required to allow for further comparisons. This review of general practice complaints included 21 papers compared to the 59 included in the hospital care review by Reader et al. (6). This finding is at odds with the high volume of contact that patients experience with general practice, indicating a need for more research on general practice complaints. Third, more research is required on how patients can contribute to improving safety and quality in general practice. It is evident from this review that patients are motivated to improve the health care system at large and, therefore, integrating patients’ experiences must be prioritized in patient safety research moving forward. Finally, there is a need for learning from this systematic review to be applied by GPs to their work. The small number of practices utilizing the complaints data to make system improvements indicate that this is an area to be further explored. By collating complaints and framing them as learning opportunities, GPs could use them to identify improvements and reduce the number of complaints they receive (15,57). Conclusion The data which emerged from this review highlighted the high proportion of quality- and safety-related complaints in general practice, patients’ motivations to improve the health care system and the various positive and negative impacts that complaints can have on individuals and systems involved. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice would be of much interest. Declarations Funding: This study was funded by the National University of Ireland, Galway, Hardiman PhD scholarship programme. Ethical approval: not applicable. Conflicts of interest: none. References 1. National Patient Safety Office. Summary—Introduction of a Patient Safety Complaints and Advocacy Policy. 2017 ; https://health.gov.ie/wp-content/uploads/2017/05/Development-of-a-Patient-Safety-Complaints-and-Advocacy-Policy.pdf (accessed on 22 March 2019 ). 2. Mulcahy L , Tritter JQ . Pathways, pyramids and icebergs? Mapping the links between dissatisfaction and complaints . Sociol Health Illn 1998 ; 20 ( 6): 825 – 47 . Google Scholar Crossref Search ADS WorldCat 3. Clwyd A , Hart T. A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture. Final Report . UK: National Health Service , 2013 . Google Preview WorldCat COPAC 4. Allsop J , Mulcahy L . Dealing with clinical complaints . Qual Health Care 1995 ; 4 : 135 – 43 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Francis R. Independent Inquiry Into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 . London: The Stationery Office , 2010 . Google Preview WorldCat COPAC 6. Reader TW , Gillespie A , Roberts J . Patient complaints in healthcare systems: a systematic review and coding taxonomy . BMJ Qual Saf 2014 ; 23 : 678 – 89 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Weingart SN , Pagovich O , Sands DZ et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents . J Gen Intern Med 2005 ; 20 : 830 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Newdick C , Danbury C . Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire . J Med Ethics 2015 ; 41 : 956 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 9. The Health Foundation. Evidence Scan: Levels of Harm in Primary Care . 2011 ; https://www.health.org.uk/publications/levels-of-harm-in-primary-care (accessed on 15 March 2019 ). 10. Esmail A. Measuring and Monitoring Safety: A Primary Care Perspective . London, UK : Health Foundation , 2013 . Google Preview WorldCat COPAC 11. Douw K , Nielsen CP , Pedersen CR . Centralising acute stroke care and moving care to the community in a Danish health region: challenges in implementing a stroke care reform . Health Policy 2015 ; 119 : 1005 – 10 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Sibbald B , Pickard S , McLeod H et al. Moving specialist care into the community: an initial evaluation . J Health Serv Res Policy 2008 ; 13 : 233 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Starfield B , Lemke KW , Bernhardt T et al. Comorbidity: implications for the importance of primary care in ‘case’ management . Ann Fam Med 2003 ; 1 : 8 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Rubin G , Berendsen A , Crawford SM et al. The expanding role of primary care in cancer control . Lancet Oncol 2015 ; 16 : 1231 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Madden C , Lydon S , Cupples ME et al. Safety in primary care (SAP-C): a randomised, controlled feasibility study in two different healthcare systems . BMC Fam Pract 2019 ; 20 : 22 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Panesar SS , deSilva D , Carson-Stevens A et al. How safe is primary care? A systematic review . BMJ Qual Saf 2016 ; 25 : 544 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Samra R , Bottle A , Aylin P . Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews . BMJ Open 2015 ; 5 : e008128 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Tang N , Meyer GS . Ambulatory patient safety: the time is now: comment on ‘patient perceptions of mistakes in ambulatory care’ . Arch Intern Med 2010 ; 170 : 1487 – 9 . Google Scholar PubMed WorldCat 19. Gandhi TK , Kachalia A , Thomas EJ et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims . Ann Intern Med 2006 ; 145 : 488 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 20. Liberati A , Altman DG , Tetzlaff J et al. . The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration . PLoS Med 2009 ; 6 : e1000100 . Google Scholar Crossref Search ADS PubMed WorldCat 21. The PME. Best practice in systematic reviews: the importance of protocols and registration . PLoS Med 2011 ; 8 ( 2): e1001009 . Crossref Search ADS PubMed WorldCat 22. Wallace E , Lowry J , Smith SM , Fahey T . The epidemiology of malpractice claims in primary care: a systematic review . BMJ Open 2013 ; 3 ( 7): e002929 . Google Scholar Crossref Search ADS PubMed WorldCat 23. Shea BJ , Grimshaw JM , Wells GA et al. . Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews . BMC Med Res Methodol 2007 ; 7 : 10 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Sirriyeh R , Lawton R , Gardner P , Armitage G . Reviewing studies with diverse designs: the development and evaluation of a new tool . J Eval Clin Pract 2012 ; 18 : 746 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 25. O’Dowd E , Lydon S , O’Connor P , Madden C , Byrne D . A systematic review of 7 years of research on entrustable professional activities in graduate medical education, 2011-2018 . Med Educ 2019 ; 53 : 234 – 49 . Google Scholar Crossref Search ADS PubMed WorldCat 26. Lydon S , Cupples ME , Murphy AW , Hart N , OʼConnor P . A systematic review of measurement tools for the proactive assessment of patient safety in general practice . J Patient Saf 2017 ; Apr: publish ahead of print . WorldCat 27. Baxter R , Taylor N , Kellar I , Lawton R . What methods are used to apply positive deviance within healthcare organisations? A systematic review . BMJ Qual Saf 2016 ; 25 : 190 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 28. Gillespie A , Reader TW . The healthcare complaints analysis tool: development and reliability testing of a method for service monitoring and organisational learning . BMJ Qual Saf 2016 ; 25 : 937 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat 29. Carroll C , Booth A , Leaviss J , Rick J . ‘Best fit’ framework synthesis: refining the method . BMC Med Res Methodol 2013 ; 13 : 37 . Google Scholar Crossref Search ADS PubMed WorldCat 30. Abrecht CR , Brovman EY , Greenberg P et al. . A contemporary medicolegal analysis of outpatient medication management in chronic pain . Anesth Analg 2017 ; 125 : 1761 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Barragry RA , Varadkar LE , Hanlon DK et al. . An analytic observational study on complaints management in the general practice out of hours care setting: who complains, why, and what can we do about it? BMC Fam Pract 2016 ; 17 : 87 . Google Scholar Crossref Search ADS PubMed WorldCat 32. Birkeland S , Christensen Rd , Damsbo N , Kragstrup J . Process-related factors associated with disciplinary board decisions . BMC Health Serv Res 2013 ; 13 : 9 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Birkeland S , Depont Christensen R , Damsbo N , Kragstrup J . Characteristics of complaints resulting in disciplinary actions against Danish GPs . Scand J Prim Health Care 2013 ; 31 : 153 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 34. Cowan J , Wilson J . Clinical risk management. Complaints in primary care arising from bereavement . Clin Gov 2007 ; 12 ( 4): 296 – 304 . Google Scholar Crossref Search ADS WorldCat 35. Cox SJ , Holden JD . Presentation and outcome of clinical poor performance in one health district over a 5-year period: 2002-2007 . Br J Gen Pract 2009 ; 59 : 344 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 36. Esmail A . Patient safety–what claims against the NHS can teach us . J Health Serv Res Policy 2010 ; 15 ( suppl 1) : 33 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Flannery FT , Parikh PD , Oetgen WJ . Characteristics of medical professional liability claims in patients treated by family medicine physicians . J Am Board Fam Med 2010 ; 23 : 753 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 38. Gaal S , Hartman C , Giesen P et al. . Complaints against family physicians submitted to disciplinary tribunals in the Netherlands: lessons for patient safety . Ann Fam Med 2011 ; 9 : 522 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 39. Harris JM Jr . Papanicolaou smear recommendations, patient complaints, and patient satisfaction in managed-care medical organizations . Med Care 1995 ; 33 : 272 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 40. Hart J , Weingarten MA . A procedure for handling complaints against general practitioners . Fam Pract 1986 ; 3 : 107 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 41. Lim HC , Tan CB , Goh LG , Ling SL . Why do patients complain? A primary health care study . Singapore Med J 1998 ; 39 : 390 – 5 . Google Scholar PubMed WorldCat 42. Mack JW , Jacobson J , Frank D et al. Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery . Jt Comm J Qual Patient Saf 2017 ; 43 : 498 – 507 . Google Scholar Crossref Search ADS PubMed WorldCat 43. Nettleton S , Harding G . Protesting patients: a study of complaints submitted to a family health service authority . Sociol Health Illn 1994 ; 16 ( 1): 38 – 61 . Google Scholar Crossref Search ADS WorldCat 44. Owen C . Formal complaints against general practitioners: a study of 1000 cases . Br J Gen Pract 1991 ; 41 : 113 – 5 . Google Scholar PubMed WorldCat 45. Phillips RL Jr , Bartholomew LA , Dovey SM et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States . Qual Saf Health Care 2004 ; 13 : 121 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 46. Pietroni PC , de Uray-Ura S . Informal complaints procedure in general practice: first year’s experience . BMJ 1994 ; 308 : 1546 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 47. Quinn GR , Ranum D , Song E et al. Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data . Jt Comm J Qual Patient Saf 2017 ; 43 : 508 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 48. Rodriguez HP , Rodday AM , Marshall RE et al. Relation of patients’ experiences with individual physicians to malpractice risk . Int J Qual Health Care 2008 ; 20 : 5 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 49. Wallace E , Cronin S , Murphy N et al. Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland . Br J Gen Pract 2018 ; 68 : e860 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 50. Sowka M. Malpractice Claims: Final Compilation . Brookfield, WI: National Association of Insurance Commissioners , 1980 . Google Preview WorldCat COPAC 51. Hageman MG , Briët JP , Bossen JK et al. Do previsit expectations correlate with satisfaction of new patients presenting for evaluation with an orthopaedic surgical practice? Clin Orthop Relat Res 2015 ; 473 : 716 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 52. Mohammed K , Nolan MB , Rajjo T et al. Creating a patient-centered health care delivery system: a systematic review of health care quality from the patient perspective . Am J Med Qual 2016 ; 31 : 12 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 53. Williams S , Weinman J , Dale J , Newman S . Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract 1995 ; 12 : 193 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 54. Fletcher-Lartey S , Yee M , Gaarslev C , Khan R . Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study . BMJ Open 2016 ; 6 : e012244 . Google Scholar Crossref Search ADS PubMed WorldCat 55. Curran C , Lydon S , Kelly ME , Murphy AW , O’Connor P . An analysis of general practitioners’ perspectives on patient safety incidents using critical incident technique interviews . Fam Pract 2019 ; Mar: epub ahead of print . WorldCat 56. Gillespie A , Reader TW . Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety . Milbank Q 2018 ; 96 : 530 – 67 . Google Scholar Crossref Search ADS PubMed WorldCat 57. de Wet C , Black C , Luty S et al. . Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement . BMJ Qual Saf 2017 ; 26 : 335 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat 58. Cunningham W . The immediate and long-term impact on New Zealand doctors who receive patient complaints . NZ Med J 2004 ; 117 : U972 . WorldCat 59. D’Cruz L . The successful management of complaints–turning threats into opportunities . Dent Update 2008 ; 35 : 182 – 4, 186 . Google Scholar Crossref Search ADS PubMed WorldCat 60. Gurung G , Derrett S , Gauld R , Hill PC . Why service users do not complain or have ‘voice’: a mixed-methods study from Nepal’s rural primary health care system . BMC Health Serv Res 2017 ; 17 : 81 . Google Scholar Crossref Search ADS PubMed WorldCat 61. Berwick DM , Nolan TW , Whittington J . The triple aim: care, health, and cost . Health Aff (Millwood) 2008 ; 27 : 759 – 69 . Google Scholar Crossref Search ADS PubMed WorldCat 62. Mehta SJ . Patient satisfaction reporting and its implications for patient care . AMA J Ethics 2015 ; 17 : 616 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 63. Vincent C , Amalberti R. Safer Healthcare . Cham, Switzerland : Springer International Publishing , 2016 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 64. Martin JL , Pérez V , Sacristán M , Alvarez E . Is grey literature essential for a better control of publication bias in psychiatry? An example from three meta-analyses of schizophrenia . Eur Psychiatry 2005 ; 20 : 550 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 65. Morrison A , Polisena J , Husereau D et al. . The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies . Int J Technol Assess Health Care 2012 ; 28 : 138 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Family Practice – Oxford University Press

Published: Dec 1, 2004

There are no references for this article.