Today, monitoring of patient complaints in healthcare services is being used as a tool for quality assurance systems and in the future development of services. This nationwide register study describes the number of all complaints processed, number of complaints between different state provinces, healthcare services and healthcare professionals, and outcomes of complaints in Finland during the period 2000–2004. All complaints processed at the State Provincial Offices and the National Authority for Medicolegal Affairs were analysed by statistical methods. Complaints about mental healthcare were explored in greater detail. The analysis showed that the number of patient complaints increased considerably during the study period. There were changes in the number of complaints between study years in different provinces. Out of different healthcare services, an especially marked increase was seen in private healthcare. Nearly all complaints were lodged against physicians, and over half of the complaints were made because of medical error. In mental health care, patients more often complained about unsatisfactory certificates and statements and the use of compulsory hospital care. An analysis of the outcomes revealed that in mental health care complaints more seldom led to consequences. The results need to be utilised when planning interventions for advanced supervision, prevention of adverse events and patient safety in healthcare, and especially in mental health care. From the patients’ perspective, it is important to create a culture where most problem situations are handled where the treatment was provided, thus avoiding a complex complaints process.
Statistics from Altmetric.com
The right to make a complaint is a core element of patients’ rights,1 2 and a complementary source of information on patient safety.3 4 Further, the monitoring of patient complaints in health services is a part of quality assurance.5 Therefore, all information related to patients’ complaints needs to be utilised in the governance and planning of healthcare organisations by learning from mistakes and adverse events.6
Patients’ right to lodge complaints is ensured by various pieces of legislation, for example, in Denmark,7 The Netherlands8 and Sweden.9 In general, there are major differences between the European Union Member States in the way complaint systems are organised.10 In Finland, according to the Act on the Status and Rights of Patients (789/1992, chapter 3, section 10)11 patients not satisfied with the quality or content of the healthcare services can file a complaint to the chief medical officer of the healthcare institution in question. The patient ombudsman may help in the preparation of the complaint. The goal is to prevent difficult and protracted complaint processes, and to handle problems in the organisation about which they were made.
When problems cannot be resolved immediately or almost immediately in the organisation, a patient can make a complaint to the national healthcare authorities: The State Provincial Offices of Finland and National Authority for Medicolegal Affairs (Terveydenhuollon Oikeusturvakeskus, TEO).12 In addition, there are several different options for a patient to make a complaint or apply for compensation in the Finnish system (see table 1). There are no formal requirements for complaints, and they may be filed by the patient her/himself, relatives or other concerned parties. Patients legally incompetent due to their illness may be helped in filing a complaint by their legal guardians, although the interest of legal guardians is often biased towards financial interests of the patients. In general, most patients lodging a complaint in Finland are judged as being with full capacity.12
The great variety of different ways to make a complaint may make the complaints process complicated and not always accessible to patients with severe illnesses, for example, patients with mental health problems.17 Patients with cognitive disabilities or psychotic symptoms especially may have problems in understanding complex regulations,18 or have problems in formulating the complaint. In addition, after making their complaints, patients may be afraid of impaired quality of care, or of retribution.19 Moreover, attitudes towards the complaint process may be pessimistic because of unbalanced power structures between staff and patients.20 21 In Finland, mental health patients’ complaints rarely lead to consequences.22 This was also found in a study about two decades ago: none of the complaints made by patients with mental health problems led to any consequences.23
In the future, as Finnish people are likely to become more aware of their rights as patients, and as more patients are treated with modern medical technology, more complaints will occur.4 Indeed, in light of TEO memoranda, the number of complaints has increased in Finland in recent years.22 24–27 A similar trend can also be seen in other Nordic countries.28 29 Therefore, it is important on a national level to monitor long-term trends in the number of complaints. This information is needed in the planning of interventions for advanced supervision, prevention of adverse events and patient safety.3 4 As people with mental disorders have the same human rights as everyone else, and as they are a particularly vulnerable group in healthcare,30 it is justifiable to have a special focus on complaints made by them.
The purpose of this study was to examine complaints lodged by patients in Finland from 2000 to 2004. Complaints about mental health services were explored in detail when possible. The following research questions were addressed: (1) are there changes in the overall number of complaints and especially complaints about mental health services, (2) what is the difference in the number of complaints between provinces, healthcare services and healthcare professionals, (3) what are the reasons for complaints in general and especially in mental health care, and (4) how many of the complaints in general, and especially in mental health care, lead to measures being taken?
MATERIALS AND METHODS
In this retrospective register study all complaints between 2000 and 2004 processed by the five State Provincial Offices of Finland (representing five provinces; South, West, East, Oulu and Lapland) and the TEO were included.
The register data
The register data used in this study is public, and can be accessed from the TEO where it is administrated. Systemised data is available from the beginning of 2000. It includes information from both State Provincial Offices and TEO. Number of complaints in different provinces of Finland can be found from State Provincial Offices’ information. TEO’s information is nation wide. The data includes information about total number of lodged and processed complaints, number of complaints about different healthcare services (public healthcare, specialised healthcare, private healthcare, psychiatric care), and healthcare professionals (39 officially registered healthcare professionals). In addition, the data contains information on the outcomes of complaints. In this study only resolved complaints were analysed, because on average 19% of lodged complaints were transferred to other authorities.22 24–27
The study proposal was evaluated by the ethical committee of the Hospital District of Southwest Finland, and permission for data collection was obtained from the National Authority for Medicolegal Affairs. The basic principles of research ethics were followed.31 32 There are no personal patient or healthcare professional details in the data.
Number of complaints about different health professionals, and number of complaints leading to measures are described in frequencies and percentages. When comparing changes in the number of all complaints and complaints about mental health care, and number of complaints between provinces and healthcare services, Poisson regression analysis was used.33 The year 2000 was used as a reference category, in order to explore possible changes in the number of complaints between study years. Results are expressed using risk ratios (RR) with their 95% CIs (confidence interval). p Values lower than 0.05 were considered significant. Statistical analyses were made using SPSS for Windows V.15.0.
Number of complaints
Altogether 4645 complaints were processed by State Provincial Offices in Finland and TEO between 2000 and 2004. Complaints increased by 90%, and the number of complaints/100 000 inhabitants by 88% between 2000 and 2004. Compared to 2000, the number of complaints increased statistically significantly every year. In mental health care, complaints increased by 47%, and complaints/100 000 inhabitants by 45%. There was a statistically significant increase in the number of complaints between 2000 and 2004 (table 2).
Number of complaints between different provinces
The number of complaints/100 000 inhabitants increased statistically significantly between 2000 and 2004 in every state province, except Oulu. Mean incidence/100 000 population was highest in eastern Finland and lowest in western Finland (table 3).
Complaints about different healthcare services
The annual increase in patient complaints was greatest in private healthcare (213%), where the increase was statistically significant every year. In public healthcare and in specialised healthcare services the increase on average was 71%, and statistical significance was found between the reference class and years 2003 and 2004. The smallest increase was found in mental health services (45%). There was a statistically significant increase in the number of complaints between 2000 and 2004 (table 4).
Complaints against different healthcare professions
There were only a few complaints lodged against most of the 39 officially registered healthcare professions. A majority (80%) of the processed complaints concerned physicians. Of the rest of the complaints, 8% were against nursing staff and 5% against dentists.
Reasons for complaints
During the study period 2000–2004, over half of the complaints were made because of medical error. Complaints related to prescription, professional’s behaviour, certificates and statements, and closed hospital care. In mental health care, patients more often complained about unsatisfactory certificates and statements and compulsory hospital care. On the other hand, fewer complaints about medical errors occurred in the area of mental health care (fig 1).
Outcomes of complaints
The number of complaints leading to measures increased from 35% in 2000 to 43% in 2004. On average, 39% of all complaints in Finland between 2000 and 2004 led to measures being taken. Of the outcomes, 92% were classified as administrative reprimand, which is the mildest form of reprimand. In mental health care, the number of measures taken increased from 19% of all complaints lodged in 2000 to 28% of all complaints lodged in 2004. On average 21% of complaints lodged about mental health care led to measures during the study period (table 5). In practise, all (99%) of the outcomes were classified as administrative reprimand. Restrictions on practice and warnings were used only in a few cases.
The number of complaints against Finnish healthcare services and the number of complaints leading to measures increased between 2000 and 2004. This raises the question whether the quality of care has deteriorated during the 20th century. Although, this is not supported by international comparisons where Finns are more satisfied with their healthcare than people in many other OECD countries,34 the results are important for Finnish healthcare quality review and in the designing of policies for quality improvement,35 36 and ethical standards in healthcare.
One probable explanation for our finding is that Finnish people have become more aware of their rights, the level of education has risen, and physicians’ authority has diminished. Moreover, patients are better equipped to formulate the complaint, and they know to what authority to address it.37 In addition, Finland adopted the Act on Patients’ Rights11 in 1992, at that time one of the most radical of its kind, which may have influenced citizens’ awareness of their rights as patients. The increased number of complaints can also be seen as an indicator of better recognition of patients’ rights in Finnish healthcare organisations.
Especially strong increase in the number of complaints was seen in the area of private healthcare. This possibly relates to the marked increase of private health services in Finland.38 It is also possible that in private healthcare patients are more aware of their role as healthcare consumers, and personnel may consider patients’ requests as having a more positive effect on patient care.39 In mental health care, the number of complaints has been quite stable. It is possible that special legislation in the area of mental health care40 41 has improved the realisation of rights of people with mental health problems. On the other hand, it is possible that patients treated especially in psychiatric hospitals and in-patient units are not aware of their possibilities to complain about care.42 Patients with mental health problems may also have difficulties in understanding the complex complaint process,13 or be afraid that making complaint affects their care in negative way.15
Our findings show that out of nearly 40 healthcare professions registered in Finland, most received very few or no complaints during the study period. In general, most of the complaints were lodged against physicians. This can be explained through Finnish legislation, where diagnosis and treatment is physicians’ responsibility.43 It is also possible that as physicians’ workload has increased and work has become very hectic,44 their opportunities to discuss difficult situations with patients may have deteriorated. Further, we found that in the area of mental health care, complaints more rarely led to measures being taken. It is possible that some of the complaints made by mental health patients are formulated in a way that it is not possible to process them due to patients’ psychotic illness or cognitive disabilities. Further, it is possible that these patients have received insufficient guidance from personnel or the patient ombudsman in formulating the complaint.
Overall, patient complaints in Finnish healthcare have increased vastly. During the study period more difficult and more complex situations were handled and treated in healthcare and a greater number of patients used the healthcare services of the private sector.4 38 These changes may have served to increase the number of complaints. As the complaints process is emotionally demanding for both complainants45 and personnel,46 it is very important that the increase in the number of patient complaints could be slowed down or stopped in the future. The capacity of healthcare personnel, and especially of physicians to resolve difficult situations in healthcare needs to be supported. It is moreover important to increase the patient ombudsmans’ activity in those areas where vulnerable patients are treated, for example, in mental health services. Information about patients’ rights needs to be essential part of patient education, especially during compulsory psychiatric care.42 In addition, as information about regulations and legislation more often can be found from the internet, patients’ possibilities to use information technology need to be supported.
There is a need to develop organisations’ own feedback mechanisms, so that patients have the means to process problems in the organisation where the problem occurred.47 Professionals need systematic education about procedures that make the processing of complaints easier and more effective.46 As in the future it is possible that patients will have access to healthcare across abroad, all development of complaints processes needs to be done in collaboration between European Union Member States.10
This study is funded by The Academy of Finland (213440), The Jalmari and Rauha Anokas foundation and The Finnish Cultural Foundation Uusimaa Regional Fund.
Competing interests: None declared.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.