By Gloria Salazar, MD, Keith Quencer, MD, Shima Aran, MD, Hani Abujudeh, MD, MBA Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
This article was originally published in the Journal of the American College of Radiology - Volume 10, Issue 7, Pages 513-517, July 2013 www.JACR.org
The aims of this study were to review patients' complaints about their care in radiology and to determine key areas for improvement.
An institutional review board–approved, HIPAA-compliant study was conducted to retrospectively evaluate all radiology-related patient complaints received by the authors' institution's Office of Patient Advocacy from April 1999 to December 2010. The internal review classified the complaints into those that concerned medical complications, radiology staff members, failure to provide patient-centered care, and those that related to quality on the basis of radiologic benchmarks of safety, systems, and professionalism. The rate of successful complaint resolution was also tallied. The incidence of complaints per modality was calculated as a fraction of the total number of radiologic examinations performed.
A total of 153 radiology-related complaints were identified. The majority of complaints (60.1% [92 of 153]) described a failure to provide patient-centered care. Of the remaining complaints, 26.2% (40 of 153) reported physical discomfort, 10.5% (16 of 153) reported a combination of both physical discomfort and lack of patient-centered care, and 3.2% (5 of 153) were not related to either category. Of the complaints regarding quality, 44.5% (68 of 153) were associated with operational systems, 24.2% (37 of 153) with safety, 17% (26 of 153) with professionalism, and 14.3% (22 of 153) with multifactorial events. Delays accounted for 20.2% of complaints (31 of 153), and 49.6% of complaints (76 of 153) concerned radiology staff members. Complaint resolution was achieved in 83.6% of cases (128 of 153). The overall incidence of complaints per radiologic procedure was 0.238 per 10,000. The incidence of complaints associated with interventional procedures (3.26 per 10,000) was significantly (P < .05) higher than the incidence of those associated with noninterventional examinations (0.138 per 10,000).
Failure to provide patient-centered care was the most common complaint; most of these complaints could be attributed to systems issues. There was a higher incidence of complaints related to interventional procedures than diagnostic examinations. Delays and providers' interactions with patients were identified as key areas for improvement.
Patient satisfaction is an important metric for health care improvement. Since the publication of the Institute of Medicine  report Crossing the Quality Chasm: A New Health System for the 21st Century in 2001, recommendations have been made to specifically focus on delivering patient-centered care. The Institute of Medicine  defined patient-centered care as care that is responsive and respectful of individual patients' preferences, needs, and values, as well as care that ensures that individual patients' values guide all clinical decisions. In radiology, patient-centered metrics are described in the literature and indicate patients' preferences in the timing of receiving radiology results , but to our knowledge, there are no qualitative data on patients' perceptions regarding coordination of care, communication of results, and staff members' attitudes toward patients.
Since the introduction of the Hospital Consumer Assessment of Healthcare Providers and Systems as a standardized tool to evaluate patient-centered care and to provide scores, hospitals are better able to address factors that interfere with a positive and satisfying patient experience . However, because there are several steps in the process of performing a radiologic procedure that may contribute to a patient's dissatisfaction , it is challenging to identify specific patient-centered practices that address key areas of the patient experience in radiology with the use of Hospital Consumer Assessment of Healthcare Providers and Systems surveys.
Qualitative data regarding patients' satisfaction and expectations can also be obtained by reviewing patients' complaints . At our institution, complaints regarding moral, ethical, operational, and care standards associated with patients' experiences are collected and evaluated by the Office of Patient Advocacy (OPA), which acts as an intermediary between patients and the Massachusetts General Hospital. By addressing and investigating patients' complaints related to care, outcomes, and experiences, the OPA allows us to identify key areas in patients' services that need improvement in our specialty.
To our knowledge, no recent data have been published that describe and analyze the causes of patient complaints in radiology. The purpose of this study was to address this gap by performing a qualitative review of complaints collected over a period of 10 years from patients undergoing radiologic examinations and to identify areas for improvements in delivering patient-centered care.
This retrospective evaluation of patient complaints received by OPA from April 1999 to December 2010 was approved by our institutional review board and compliant with HIPAA.
Complaints to OPA are sent by fax, e-mail, or written letter and include the following information: the nature of the patient's complaint, the patient's medical record number, the name(s) of the person(s) involved, the department in which the problem occurred, the date on which the problem occurred, and the patient's suggestions about how the problem could be resolved. OPA case files are reviewed and processed within a 30-day period, and a letter of resolution is then sent to the patient.
In cases in which another person complains on a patient's behalf, OPA first asks the patient's permission before starting an investigation. During an investigation, OPA talks with the family and patient about their concerns, contacts the person(s) named in the complaint, reviews all appropriate documents, and collaborates with patients on a possible resolution. Moreover, the department to which the complaint is directed is required to provide a response. Sometimes a root-cause analysis evaluation is performed. For this study, cases were deidentified by removing all personal data, and we evaluated the following information: category, description of event, and resolution or outcomes.
Review of Complaints
Because the largest number of complaints was categorized by the OPA as “not specified” (Fig. 1), we performed a qualitative evaluation of the event descriptions to obtain more information regarding patients' experiences. This included an internal review in which complications, if any, were identified, and we determined whether the complaint stemmed from failure to provide patient-centered care. The complaints were also categorized into quality areas on the basis of benchmarks of safety, systems, and professionalism.
Classification of complaints by Office of Patient Advocacy categories. ADA = Americans With Disabilities Act.
Categorization of complaints into quality areas was on the basis of the Institute of Medicine's  definitions for the 6 specific aims for improvement of care: safe, timely, effective, equitable, efficient, and patient-centered. We also used the classification scheme proposed by Johnson et al , which specifies 4 quality domains in radiology: safety, process improvement, professional outcomes, and satisfaction. With the goal of transforming descriptions of the events into objective metrics that could drive quality improvement changes in our department, we evaluated complaints on the basis of the available information. We identified 3 major quality factors associated with failure in addressing patients' needs: operational systems issues, patient safety, and professionalism of radiology department employees.
Definition of Objective Metrics
Our definition for systems issues included complaints that resulted from ineffective, untimely, inefficient, and inequitable care but did not result in objective patient harm.
These included complaints stemming from matters associated with the department or the hospital infrastructure facility conditions, management, and delay in the interpretation of a study or performance of a procedure. Operational systems issues were subclassified into coordination of care, financial matters, delays, scheduling problems, privacy, environment or equipment, and lack of support staff.
If a complaint concerned real or perceived physical harm or medical complications, the complaint was classified under the safety category. Safety complaints included any medical complication that occurred as a result of a radiologic procedure as well as events that had the potential to cause complications or injury to the patient. We also included some errors that come under the National Patient Safety Goals metrics from 2012 (identifying the right patient, controlling infection avoiding wrong-side surgery)  and contrast-related adverse events.
Complaints that concerned professionalism were defined as those directed to radiology department employees (clerical staff members, physicians, nurses, and technologists). These included complaints of poor communication, questioning of staff members' competence or experience, and instances of inappropriate, rude, or otherwise unprofessional behavior. These complaints were further analyzed according to the role of personnel involved (physicians, nurses, technologists, other). Multifactorial issues were defined when more than one quality factor was identified in the description of the complaint.
To further understand the patient's perspective, an overall analysis was performed to identify the cause of failure to provide patient-centered care. This was defined for the purpose of this study as any complaint that resulted in failure to be directly responsive to the patient's needs at the time of the radiologic procedure (eg, attitudes of providers, timely services, response to concerns and questions).
Incidence of Complaints Per Modality and Analysis
The total number of radiologic services provided to patients was obtained from a departmental database and categorized into different imaging modalities: ultrasound, CT, barium fluoroscopy, nuclear medicine, PET, mammography, interventional radiology, MRI, conventional radiography, and bone densitometry (dual-energy x-ray absorptiometry). Interventional radiologic procedures included all invasive procedures regardless of imaging modality or the clinical division (vascular, abdominal, thoracic, and musculoskeletal) performing the intervention. The incidence of complaints was analyzed per modality, and comparative analysis was performed using t tests and χ2 tests, with significance set at P = .05.
We identified a total of 153 complaints directed toward the Radiology Department in the period of interest, during which 6,428,403 radiologic examinations were performed. The overall incidence of complaints per total number of radiologic examinations was 0.238 per 10,000. Figure 1 shows the distribution of complaints by OPA categories. Qualitative evaluation and classification of the complaints demonstrated that 44.5% (n = 68) were associated with operational systems, 24.2% (n = 37) with safety, 17% (n = 26) with professionalism, and 14.3% (n = 22) with multifactorial events (Fig. 2). Many complaints were related to delays (20.2% [n = 31]), including delays in appointment availability, receiving test results or treatment, time taken to return pages, telephone wait time on hold, wait time to see a clinician, and difficulties in reaching a live person.
Rate of complaints by modality per 10,000 examinations or procedures performed. Dexa = dual-energy x-ray absorptiometry.
Other complaints involved the accuracy of test results and information given to the patient (20.2% [n = 31]), attitudes of radiology staff members (including alleged verbal abuse), appropriateness of staff member conduct, and overall customer service. The technical skills of the provider, monetary issues (including amount charged, clarity of bill, refusal to pay, and insurance coverage), and other unspecified events (29.4% [n = 45]) made up the remainder of the cases.
In another breakdown of the results, we found that 60.1% (n = 92) of the complaints described failures to provide patient-centered care, 26.2% (n = 40) involved physical discomfort, 10.5% (n = 16) were reported as both failures to provide patient-centered care and physical discomfort, and 3.2% (n = 5) were not related to either.
Incidence of Complaints Per Radiologic Modality
Interventional examinations and procedures accounted for 43.7% (n = 67) of all complaints. The incidence of complaints per modality demonstrated a significant difference between invasive and noninvasive radiologic examinations (P < .0001). There were 1,368,855 interventional examinations performed over the evaluation period, for a wide variety of purposes and using several different imaging modalities.
The majority of the 37 safety complaints concerned complications related to interventional radiologic procedures (62.2% [n = 23]). Those related to diagnostic examinations (37.9% [n = 14]) included discrepancies in dictation or interpretation of the examination (18.9% [n = 7]), fall or injury during the examination (8.1% [n = 3]), pain during intravenous line placement (2.7% [n = 1]), thrombophlebitis (2.7% [n = 1]), extravasation of contrast media (2.7% [n = 1]), and aspiration of barium (2.7% [n = 1]); 5.4% (n = 2) were complications related to a lack of postprocedural education of patients for infection control, resulting in infections at the site of venous access. One of these patients described being given the wrong instructions after port placement, which resulted in a port-related infection, delaying chemotherapy treatment. Other descriptions included performing the wrong MRI protocol, resulting in the need to perform a second MRI examination. One case of extravasation of contrast media resulted in admission to the hospital for monitoring.
Operational Systems Issues
A total of 68 complaints related to operational systems were identified, most of which were associated with delays (23.5% [n = 16]) or were multifactorial (26.4% [n = 18]). Delays included waiting for examination or procedure, scheduling an examination, reporting an examination, and sending reports to outside hospitals. Some complaints described difficulties scheduling examinations over the phone. Most complaints were resolved with patient clarification processes.
A total of 76 complaints (49.6%) were directed to radiology staff members, with the following distribution: 51.3% to doctors (n = 39), 28.9% to technologists (n = 22), 5.3% to nurses (n = 4), 5.3% to both physicians and technologists (n = 4), and 9.2% to others (n = 7), including administrators and secretaries. Of the complaints directed to physicians, 69% (n = 27) occurred in the setting of an interventional radiologic procedure, whereas 31% (n = 12) were associated with noninvasive diagnostic studies. Four complaints (10.2% [n = 4]) were directed at trainee physicians. Professionalism alone was cited in 26 complaints; 53.8% of these complaints (n = 14) were related to the attitudes of health care providers, 38.5% (n = 10) questioned the competence of staff members, and the remaining 2 (7.6%) were classified as other.
Of the 14 complaints that provided descriptions of unprofessional attitudes, 7 (50%) cited rough or insensitive behavior. Others described degrading behavior (7.1% [n = 1]), unpleasantness (7.1% [n = 1]), poor attitude (7.1% [n = 1]), rudeness (14.5% [n = 2]), feeling rushed (7.1% [n = 1]), and hurtful behavior (7.1% [n = 1]).
Of the 10 complaints that questioned employees' competence, 4 (40%) were related to trainees and 6 (60%) were related to staff physicians, technologists, or nurses. Our institution is an academic center in which residents and fellows work under the direct supervision of attending physicians, and some of the patients' complaints involved concerns regarding trainee involvement in procedures. For example, 1 patient complained to the attending physician because a trainee performed a portion of a procedure; another described feeling deceived because he had requested an attending physician to perform a procedure and instead a trainee had done so. In this case, the patient refused to pay for the procedure and attributed a complication as being secondary to a resident's performing the procedure. Even though the investigation performed by OPA in conjunction with the radiology staff deemed the care appropriate, the patient was still dissatisfied with the outcome. One patient (3.8%) reported inappropriate conduct during an ultrasound examination after she perceived unnecessary touching of her breast. And 1 patient (3.8%) complained because the examination results were not personally communicated to him by the interpreting radiologist.
Twenty-two complaints (14.3%) related to incidents that involved two or more quality issues. For example, one complaint was from a patient's mother, who complained about the physician's attitude when she was questioned about attention-seeking behavior. She also complained about delays and lack of privacy during the same encounter (professionalism and systems). Another patient complained about both the lack of support for patients with disabilities, as well as delays related to rescheduling the examination (systems and professionalism).
Resolution of Complaints
Satisfactory resolution of complaints was achieved after mediation by OPA in 83.6% of the cases (n = 128). Of the safety issues, 89.2% (33 of 37) were resolved. Of these, 64% (n = 21) were resolved through clarification processes, 15% (n = 5) required manager notification, 12% (n = 4) included rectification of medical bills, 3% (n = 1) led to a quality review, and in 6% (n = 2), second radiologic procedures were performed and resulted in changes in practice.
Of complaints that included the multifactorial issues, 86.3% (19 of 22) were resolved, including 31.5% (n = 6) in which an apology was given, 36.8% (n = 7) that were resolved with clarification processes, 10.5% (n = 2) that resulted in manager notification of the problem, and 5% (n = 1) that included rectification of a medical bill and the scheduling of another appointment.
Of the complaints that concerned operational systems issues, 77.9% (53 of 68) were resolved, including 30.2% (n = 16) in which apologies were given. In 35.8% (n = 53), the complaints were resolved through clarification processes, 9.4% (n = 5) required manager notification, and 3.8% (n = 2) included rectification of medical bills. In 7.6% (n = 4), another examination appointment was scheduled, in 9.4% (n = 5), second procedures were performed, and in 3.8% (n = 2), additional costs were reimbursed.
Of the professionalism issues, 84.6% (22 of 26) were resolved. In 59.1% (n = 13), apologies were accepted, 13.6% (n = 3) were resolved through clarification processes, and 18.2% (n = 4) required manager notification. One patient was granted a request for a different provider, and 1 patient postponed a procedure.
In this study, the qualitative evaluation of OPA files demonstrated that the majority (60.1% [92 of 153]) of complaints described failures to provide patient-centered care . The second largest category (49.6% [76 of 153]) related to the interpersonal skills of radiology staff members, most of which were complaints lodged against physicians. More than two-thirds of these complaints were related to interventional procedures (69% [27 of 39]), which is not surprising given that there is extensive physician-patient interaction in this setting. On the other hand, patients are more likely to interact with technologists and nurses during noninvasive diagnostic studies. Patients' satisfaction in interventional radiology may also be influenced by their perception of pain, although Mueller et al  demonstrated that patients' satisfaction does not necessarily correlate with procedural pain. Our study suggests that patients have high expectations regarding radiologists' role in their care.
The majority of complaints concerning operational systems issues were secondary to delays, including unanticipated waiting for a radiologic examination to be performed (invasive or noninvasive), waiting for an appointment for a radiologic examination, or waiting for test results. Long waiting times play a major role in patients' dissatisfaction in radiology . Studies have shown that anxiety about critical test results is maximized when patients are uncertain about their diagnoses , and delays are associated with great stress, even greater than that associated with more invasive procedures .
Finally, satisfactory resolution of complaints was obtained in the large majority of complaints, which was most commonly achieved through clarification and, in some cases, apologies. Our results suggest the importance of educating patients about technical factors and complex issues that influence the performance of radiologic examinations.
The limitations of this study include the retrospective nature of the analysis, the subjectivity of the patients' descriptions of events, and the lack of feedback from patients after OPA reviewed and responded to their complaints. The number of complaints received by OPA is likely to markedly underestimate the true degree of patient dissatisfaction with care received in our department because many patients are not likely to take the time to file formal complaints. The study lacked objective tools (such as root-cause analysis) to evaluate complaints, and because of recent technological advances, the findings here may not reliably represent the current standard of practice in our radiology department. Moreover, this was a single-institution qualitative review that does not necessarily correlate with the experiences of other institutions or settings.
- Knowledge of patients' needs during radiologic encounters is paramount to address and determine patient-centered metrics for quality improvement processes.
- The overall rate of complaints was low (1 complaint for every 6,600 services provided).
- Failure to deliver patient-centered care was present in 60% of the descriptions of complaints, with systems (such as delays) and individual issues (such as attitudes of providers) identified as key areas for improvement in our department.
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