It is inevitable that in any busy dental practice the standard of treatment or other work will sometimes fall below a patient’s expectations. This can result in a complaint. The Citizen’s Charter Complaints Task Force defines a complaint as: ‘An expression of dissatisfaction requiring a response’ ¹. Patients have the right to raise concerns about any aspect of the dental service that they receive and to expect a satisfactory resolution when things go wrong. In response, any complaint must be handled in accordance with a robust complaints system. The General Dental Council (GDC) states: ‘Make sure that there is an effective complaints procedure readily available for patients to use, and follow that procedure at all times’². To this end, this article will look at why patients complain and how to handle complaints to the standards expected by the Care Quality Commission (CQC) in Outcome 17 ³.
To complain or not to complain?
Whether a patient complains or not falls into the realms of psychology. A patient’s personality as much as their assertiveness will often determine whether they decide to complain or walk away quietly. Some patients will choose to reward your hard work and their satisfaction with gifts. Others will opt to complain about even minor issues despite having received the same level of service. Most patients are generally silently satisfied or silently dissatisfied. Perhaps this is due to people’s typically busy lives and the perceived effort involved in complaining - or maybe they do not know how to go about filing a complaint or think complaining will not make a difference. It is in our professional interest to receive complaints, as a lack of feedback results in us continuing to do our work in exactly the same way every day. Receiving complaints should be seen as a positive and should be welcomed as an opportunity to explore where we can improve skills and the service we offer. Satisfied, happy patients are in turn less likely to complain or sue and more likely to generate word-of-mouth referrals for your practice.
Why do patients complain?
According to the Dental Defence Union (DDU)4, the most common reasons for complaints are dissatisfaction with the administration and outcome of treatment. However, the other most widespread causes are:
- Failed/delayed diagnosis, most often of dental decay.
- An adverse incident during treatment.
- An adverse reaction to treatment.
Having worked in practice for many years, I have personally also received complaints about the following:
- The layout of reception and the waiting area.
- The time patients have waited to go into surgery.
- Patients not being treated as urgent cases (despite failing to fall within the urgent category).
- Waiting list times.
- The differences between NHS and private provision for dentistry.
- The telephone on reception always clicking to answer machine.
The list goes on and on. Further research needs to be done to fully understand the drivers behind the recent increase in complaints. It is also unclear why patients are complaining to the GDC rather than to their dental practices, but this may be due to increased awareness via the internet and advertising, as well as the impact of changes to ‘no win, no fee’ rules. It is essential to manage complaints in-house in an effective and timely way to prevent an escalation of the complaint to the GDC in the first instance.
How do NHS and private complaints procedures vary?
All dental practices that have secured NHS contracts are required to have a complaints-handling procedure in place that operates at a practice level. Specific requirements within complaints procedures vary across England, Scotland, Wales and Northern Ireland. However, the generic requirements are that:
- There is a named complaints officer/manager in the practice.
- All dental team members fully understand the complaints procedure in their practice and take ‘ownership’ of it in their area of work. Individuals must receive inductions and training regarding complaints handling.
- Website pages, leaflets and posters are accessible to all patients and provide thorough information about the practice’s complaints procedure.
- Any complaint is handled by instigating a full investigation of the complaint, including holding interviews with the complainant and any staff involved in the alleged incident.
- Information about how to access independent advice and support and additional ways of resolution via other organisations such as the Scottish Public Services Ombudsman (SPSO)5 or Parliamentary and Health Services Ombudsman in England (PHSO)6 is offered.
- Independent organisations may advise the escalation of a complaint to the GDC.
Any complaints procedure and a point of contact must be visible to patients and leaflets must be easily accessible. The process must ensure both ease of use and robust, timely and fair investigation of the complaint. Patient confidentiality must be respected at all times and any written documents generated during the process must be clear and written without any complicated language. The outcomes of any investigation should be clearly explained to the complainant with any resolution used to help improve future service provision.
In England, dental practices are obliged to provide the NHS area team with an annual report detailing any complaints handled during the financial year. The main reason for complaints and any changes made in practice to improve the dental service should be disclosed, as should any referrals to the PHSO.
Complaints can be instigated by a patient or someone with authority to act on their behalf. In England, complainants have 12 months to act following the occurrence of the incident that gave rise to the complaint or from the time the complainant became aware of the incident. In Scotland, Wales and Northern Ireland, complaints should be filed within 6 months of the incident or within 6 months of the time of discovery as long as it is within 12 months of the event.
A private dental practice should equally have a handling complaints policy and procedure that fall within the prerequisites of the CQC’s Outcome 17. Complaints should be dealt with at the practice level as with NHS practices. However, if the complaint remains unresolved patients are advised to contact the Dental Complaints Service (DCS)7. The DCS is an independent body funded by the GDC to assist non-NHS dental professionals and their patients to find a solution to complaints and disputes. In their intermediary capacity, the DCS may invite the complainant and respective dental team members to a complaints panel in order to discuss the complaint and resolve the situation. Panels are usually held locally and made up of three volunteers. The volunteers are normally members of the public and dental practitioners. They make recommendations regarding a resolution and of ways to avoid similar occurrences in the future.
What is the process of handling complaints?
On receiving a complaint, always accept it politely and acknowledge the fact that an issue has been highlighted. At this point, give the complainant a copy of the practice’s complaints procedure and explain the stages and timescales involved. For difficult complaints, invite the patients to put their issues in writing to the complaints manager, who should then respond by telephone or in writing as soon as possible. In this event, it is prudent to contact your defence organisation to ask for advice and support through the process. If an investigation is warranted, the complainant must be informed and an idea of timescales given. If the investigation is lengthy due to exceptional circumstances, the patient must be updated with a progress report at least every 10 days.
Every point raised in a written complaint must be addressed individually, with a possible solution offered for each. An apology should be offered to show reassurance and understanding, but it should be clear that this does not mean that you are necessarily accepting liability. Following an investigation, the patient should be sent a letter explaining the outcomes of the process and the solutions that are being proposed.
It is crucial to the outcome of an investigation to adopt a positive and open-minded attitude. As human beings we all make mistakes and can learn from them to improve what we do. Explaining this to the complainant and not apportioning blame to either party maintains a level playing field from which to achieve a balanced solution. Always be open and honest and listen to what the patient has to say. Many complaints take too long to be resolved or are not resolved at all because the simple act of communication is lacking. Listening is an active process and can take time. It is useful to allow your patient a ‘magic minute’ (Lazoritz, 2004)8; that is, let them voice their concerns for at least a minute without interruption. Follow this with open questions to gain a thorough understanding of what has occurred and then recap on what has been said and confirm with the patient that the information is correct. This method can help to alleviate negative emotions and focus discussions on the facts.
Record-keeping and complaint files
In its Standards for the Dental Team², the GDC states: ‘You should keep a written record of all complaints together with your responses. This record should be separate from your patient records’. In addition, records should be comprehensive and well-organised. This is particularly important if a patient wishes to refer their case to an independent party such as the Ombudsman. Rapid retrieval of records is essential so that information can be reviewed in a timely manner. If easily accessible, complaints can also be audited in order to make improvements to the service provided.
Complaints files should be kept and updated by the complaints manager and stored away from dental records. They are classed as public documents and their contents should remain confidential. The CQC has recommended that files should contain:
- A summary of significant events within the complaint process, including dates and names.
- Complete and legible copies of clinical notes, past and present, relevant to the case.
- Copies of all written correspondence pertinent to the complaint.
- Any notes made during meetings or interviews throughout the complaint process.
- A report of the investigation.
- A summary of the resolution of the complaint and any action taken to make improvements to future service provision.
What does the patient expect?
Patient complaints do not usually highlight a system failure but are more about the patient’s experience. In view of this, psychology is highly relevant when dealing with complaints. The outcome very much depends on the psychology of the individuals involved and the psychological techniques used to resolve the issue. Irrespective of this fact, good customer service dictates that a resolution is achieved whereby both parties (but particularly the patient) are satisfied with the outcome. Dental practices require patient loyalty and word-of-mouth referrals to thrive, so ensuring that the patient is content with the end result is crucial. So what do patients want? Most of the time they simply wish to be heard and have an acknowledgement made that something has gone wrong. They want to know why a situation happened and be given reassurance that it will not happen again. If a dental practice can demonstrate that a patient’s wishes have been heard by implementing visible improvements then they will be more than happy with the result. Ensuring sound communication at every stage of the complaints procedure in addition to bearing in mind the points above can often prevent escalation to a formal complaint.
The importance of practice meetings following a complaint
Dealing with complaints is a stressful process for all those involved. Learning from previous incidents cannot only improve dental service provision but can avoid staff members facing a similar nerve-wracking experience in the future. Staff meetings offer a perfect opportunity to analyse complaints and why things went wrong in the first place. It is wise to approach complaints analysis in a strategic manner and plan what action to take to rectify any problems as a team. The following method is simple and effective:
- Identify the cause of the complaint.
- Discuss with the staff involved what, when and how things went wrong.
- Identify what improvements need to be made and whether staff members require any further training to achieve these amendments.
- Set SMART objectives to ensure that improvements are achievable and implemented within a specific timeframe.
- Delegate responsibilities to individual team members to ensure the improvements are maintained.
- Review and audit the improvements made on a regular basis to identify whether they are effective and making a difference to your service.
- Communicate any improvements made to your patients and ask for their feedback as part of the monitoring system.
Teamwork is essential to handling complaints, rectifying mistakes and avoiding similar occurrences. It strengthens not only the common bond between individual staff members but also the framework within which these individuals need to work.
Levels of litigation are exceptionally high in this country. Patients seem to be more willing to complain and sue than ever before so it is paramount to have a robust in-house complaints procedure. Patients should be made fully aware of the complaints system and the process and timescales involved. Not only is this a GDC standard, but giving clear instructions avoids patients turning to the internet or the General Dental Council! Furthermore, it offers the transparency that patients require to trust and loyally continue to visit their dentist.
References and bibliography
1. Bhugra, D. et al. Management for Psychiatrists. R C Psych Publications. 2007, p 224.
2. General Dental Council. Standards for the Dental Team. 2013, p47.
5. Scottish Public Services Ombudsman. Valuing complaints: principles of good complaint management (leaflet). October 2006.
8. Lazoritz, S. ‘Dealing with angry patients’. Physician Executive. 2004, May-June.