Patients as Observers and Reporters in Support of Systems and Patient Safety

Chapter

Abstract

When patients and families observe and report their healthcare experiences, they can play important roles in promoting safety and improving quality. This chapter begins with the case of a busy, well regarded medical professional associated with a patient complaint. The complaint is a means by which patients and families can be “safety promoters”. While barriers to this role exist, they may be reduced or eliminated when organizations commit to assessing their readiness to invite and address patient concerns, and build a robust infrastructure to support the effort. This chapter discusses our experience using unsolicited (voluntary) patient complaints to address unsafe systems and behaviors. We use the physician and the physician’s practice group to illustrate implementation and outcomes of interventions designed to reduce unnecessary variation in healthcare professionals’ behavior and performance that undermine a healthcare organization’s culture of safety. The chapter concludes with guidance to hospital and healthcare systems on how best to develop, implement and sustain a patient and family experience program.

Keywords

Patient safety Patient engagement Patient empowerment Patient activation Patient centered care Risk management Professionalism Professional conduct Patient satisfaction Patient complaints Quality improvement 

References

  1. 1.
    Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient Complaints & Malpractice Risk. JAMA. 2002;287(22):2951–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76–80.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Hickson GB, Pichert JW. Identifying and Addressing Physicians at High Risk for Medical Malpractice Claims. In: Youngberg BJ, editor. Principles of Risk Management and Patient Safety. Sudbury: Jones and Bartlett Publishers, Inc; 2012. p. 347–68.Google Scholar
  4. 4.
    Vincent C, Davis R. Patients and families as safety experts. CMAJ. 2012;184(1):15–6.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Funnell MM, Anderson RM. Empowerment and self-management of diabetes. Clin Diabetes. 2004;22(3):123–7.CrossRefGoogle Scholar
  6. 6.
    Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff. 2013;32(2):207–14.CrossRefGoogle Scholar
  7. 7.
    Hickson GB, Pichert JW, Federspiel CF, Clayton EW. Development of an Early Identification and Response Model of Malpractice Prevention. Law Contemp Probl. 1997;60(1):7–29.CrossRefGoogle Scholar
  8. 8.
    Harbin T. Walking up blind – lawsuits over eye surgery. Blumenthal DR, editor. Minneapolis, MN: London Street Press; 2009.Google Scholar
  9. 9.
    Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, editor. From the front office to the front line: essentials issues for healthcare leaders. 2nd ed. Oakbrook Terrace: Joint Commission Recourses, Inc; 2012. p. 1–36.Google Scholar
  10. 10.
    Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3:e001570.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Pichert JW, Miller CS, Hickson GB, Hollo AH, Gauld-Jaeger J, Federspiel CF, Hickson GB. What health professionals can do to identify and resolve patient dissatisfaction. Joint Comm J Qual Improv. 1998;24(6):303–12.Google Scholar
  12. 12.
    Consuming health care. Lancet. 1994;344(8925):763–5. [No authors listed].Google Scholar
  13. 13.
    Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796–804.PubMedGoogle Scholar
  14. 14.
    Epstein RM, Street Jr RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. NIH Publ. 07:6225. Bethesda: National Cancer Institute; 2007.Google Scholar
  15. 15.
    Berwick DM. What ‘patient-centered’ should mean: confessions of an extremist. Health Aff. 2009;28(4):w555–65.CrossRefGoogle Scholar
  16. 16.
    Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff. 2010;29(8):1489–95.CrossRefGoogle Scholar
  17. 17.
    Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229–39.PubMedCrossRefGoogle Scholar
  18. 18.
    Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med. 2012;27(5):520–6.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Annandale E, Hunt K. Accounts of disagreements with doctors. Soc Sci Med. 1998;46(1):119–29.PubMedCrossRefGoogle Scholar
  20. 20.
    Allsop J. Two sides to every story: complainants’ and doctors’ perspectives in disputes about medical care in a general practice setting. Law Policy. 1994;16(2):149–83.CrossRefGoogle Scholar
  21. 21.
    Remmers C, Hibbard J, Mosen DM, Wagenfield M, Hoye RE, Jones C. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32(4):320–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Rogvi S, Tapager I, Almdal TP, Schiøtz ML, Willaing I. Patient factors and glycaemic control—associations and explanatory power. Diabet Med. 2012;29(10):e382–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Terry PE, Fowles JB, Xi M, Harvey L. The ACTIVATE study: results from a group-randomized controlled trial comparing a traditional worksite health promotion program with an activated consumer program. Am J Health Promot. 2011;26(2):e64–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Skolasky RL, Mackenzie EJ, Wegener ST, Riley LH. Patient activation and functional recovery in persons undergoing spine surgery. Orthopedics. 2011;34(11):888.PubMedCrossRefGoogle Scholar
  25. 25.
    Dentzer S. Rx for the ‘Blockbuster Drug’ of patient engagement. Health Aff. 2013;32(2):202.CrossRefGoogle Scholar
  26. 26.
    Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4 Pt 1):1005–26.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the patient assessment of chronic illness care (PACIC). Med Care. 2005;43(5):436–44.PubMedCrossRefGoogle Scholar
  28. 28.
    Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows J. Is patient activation associated with outcomes of care for adults with chronic conditions? J Ambul Care Manage. 2007;30(1):21–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Alexander JA, Hearld LR, Mittler JN, Harvey J. Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res. 2012;47(3 Pt 1):1201–23.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Maeng DD, Martsolf GR, Scanlon DP, Christianson JB. Care coordination for the chronically ill: understanding the patient’s perspective. Health Serv Res. 2012;47(5):1960–79.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Begum N, Donald M, Ozolins IZ, Dower J. Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes. Diabetes Res Clin Pract. 2011;93(2):260–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Shively MJ, Gardetto NJ, Kodiath MF, Kelly A, Smith TL, Stepnowsky C, et al. Effect of patient activation on self-management in patients with heart failure. J Cardiovasc Nurs. 2013;28(1):20–34.PubMedCrossRefGoogle Scholar
  33. 33.
    The Health Foundation: involving patients in improving patient safety, London, January 2013 http://www.health.org.uk/public/cms/75/76/313/3998/Involving%20patients%20in%20improving%20safety.pdf?realName=sVAlBL.pdf. Last accessed 25 May 2013.
  34. 34.
    Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med. 1998;47(3):329–39.PubMedCrossRefGoogle Scholar
  35. 35.
    Peat M, Entwistle V, Hall J, Birks Y, Golder S. Scoping review and approach to appraisal of interventions intended to involve patients in patient safety. J Health Serv Res Policy. 2010;15 Suppl 1:17–25.PubMedCrossRefGoogle Scholar
  36. 36.
    Hibbard JH. Engaging health care consumers to improve the quality of care. Med Care. 2003;41(1):1–61.CrossRefGoogle Scholar
  37. 37.
    Bernabeo E, Holmboe ES. Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health Aff. 2013;32(2):250–8.CrossRefGoogle Scholar
  38. 38.
    Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681–92.PubMedCrossRefGoogle Scholar
  39. 39.
    Charles C, Gafni A, Whelan T. Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651–61.PubMedCrossRefGoogle Scholar
  40. 40.
    Burton D, Blundell N, Jones M, Fraser A, Elwyn G. Shared decision-making in cardiology: Do patients want it and do doctors provide it? Patient Educ Couns. 2010;80(2):173–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Fowler Jr FJ, Levin CA, Sepucha KR. Informing and involving patients to improve the quality of medical decisions. Health Aff. 2011;30(4):699–706.CrossRefGoogle Scholar
  42. 42.
    Friedberg MW, Van Busum K, Wexler R, Bowen M, Schneider EC. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Aff. 2013;32(2):268–75.CrossRefGoogle Scholar
  43. 43.
    Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff. 2013;32(2):276–84.CrossRefGoogle Scholar
  44. 44.
    The Joint Commission: facts about the joint commission’s complaint process. http://www.jointcommission.org/GeneralPublic/Complaint/oqm.htm. Last accessed 26 May 2010.
  45. 45.
    Department of Veterans Affairs, Veterans Health Administration. Service Recovery in the Veterans Health Administration. 2004 [cited 2010 May 26]. Available from: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=433.
  46. 46.
    Society for Healthcare Consumer Advocacy (SHCA). In the name of the patient: consumer advocacy in health care. Chicago: SHCA (American Hospital Association); 2009.Google Scholar
  47. 47.
    Hayden AC, Pichert JW, Fawcett J, Moore I, Hickson GB. Best Practices & Advanced Skills in Healthcare Service Recovery Programs. Joint Comm J Qual Improv Patient Saf. 2010;26(7):310–8.Google Scholar
  48. 48.
    Reinhard EH. Medicine and the crisis in confidence. Pharos. 1974;37:117–23.Google Scholar
  49. 49.
    Haug MR, Lavin B. Public challenge of physician authority. Med Care. 1979;17(8):844–58.PubMedCrossRefGoogle Scholar
  50. 50.
    Greaves F, Ramirez-Cano D, Millett C, Darzi A, Donaldson L. Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Qual Saf. 2013;22(3):251–5.PubMedCrossRefGoogle Scholar
  51. 51.
    National Patient Safety Foundation. National Agenda for action: patients and families in patient safety. Nothing about me, without me. http://www.npsf.org/wp-content/uploads/2011/10/Nothing_About_Me.pdf. Last accessed 3 June 2013.
  52. 52.
    Frosch DL, May SG, Rendle KAS, Tietbohl C, Elwyn G. Authoritarian physicians and patients’ fear of being labeled “difficult” among key obstacles to shared decision making. Health Aff. 2012;31(5):1030–8.CrossRefGoogle Scholar
  53. 53.
    Donovan-Kicken E, Mackert M, Guinn TD, Tollison AC, Breckinridge B. Sources of patient uncertainty when reviewing medical disclosure and consent documentation. Patient Educ Couns. 2013;90:254–60.PubMedCrossRefGoogle Scholar
  54. 54.
    Cruess SR, Cruess RL. The medical profession and self-regulation: a current challenge. Virtual Mentor. 2005;7(4). Available from: http://virtualmentor.ama-assn.org/2005/04/oped1-0504.html. Accessed 28 Feb 2014.
  55. 55.
    Hickson GB, Entman SS. Physicians influence the malpractice problem. Obstet Gynecol. 2010;115(4):682–6.PubMedCrossRefGoogle Scholar
  56. 56.
    Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, Meyer GS, Healy GB. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845–52.PubMedCrossRefGoogle Scholar
  57. 57.
    Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, Meyer GS, Healy GB. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Sawer G, Glendon MA, Alford WP. Legal profession. In: Encyclopædia Britannica. 2013. http://www.britannica.com/EBchecked/topic/334873/legal-profession/65821/Characteristics-of-the-profession. Accessed 16 Jan 2013.
  59. 59.
    Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med. 2002;77(6):502–15.PubMedCrossRefGoogle Scholar
  60. 60.
    Accreditation Council for Graduate Medical Education (ACGME). Outcome project: general competencies. 1999. Available online at: http://www.acgme.org/outcome/comp/compFull.asp. Accessed 15 Jan 2013.
  61. 61.
    *Board of Regents, American College of Surgeons. Code of Professional Conduct. Approved June 2003. http://www.facs.org/memberservices/codeofconduct.html.
  62. 62.
    Canadian Medical Association. Code of ethics. Ottawa: Canadian Medical Association; 2004. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf. Accessed 3 Mar 2014.
  63. 63.
    Canadian Medical Association Conjoint Accreditation Services. Guiding principles for national entry-level competency profiles used in the Canadian Medical Association conjoint accreditation process. Ottawa: Canadian Medical Association; 2010. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Accreditation/pdf/2010_guiding_principles_profile.pdf. Accessed 3 Mar 2014.
  64. 64.
    General Medical Council. Good medical practice. London: General Medical Council; 2013. http://www.gmc-uk.org/guidance/good_medical_practice.asp. Accessed 3 Mar 2014.
  65. 65.
    Royal College of Physicians. Medical professionalism and leadership. London: Royal College of Physicians; 2010. http://www.rcplondon.ac.uk/policy/physician-development/medical-professionalism-and-leadership. Accessed 3 Mar 2014.
  66. 66.
    Scottish Medical and Scientific Advisory Committee. Promoting professionalism and excellence in Scottish medicine. Edinburgh: Scottish Medical Association; 2009. http://www.scotland.gov.uk/Resource/Doc/275420/0082599.pdf. Accessed 3 Mar 2014.
  67. 67.
    Van De Camp K, Vernooij-Dassen MJ, Grol RP, Bottema BJ. How to conceptualize professionalism: a qualitative study. Med Teach. 2004;26(8):696–702.CrossRefGoogle Scholar
  68. 68.
    Samenow CP, Swiggart W, Spickard Jr A. A CME course aimed at addressing disruptive physician behavior. Physician Exec. 2008;34(1):32–40.PubMedGoogle Scholar
  69. 69.
    Moran SK, Sicher CM. Interprofessional jousting and medical tragedies: strategies for enhancing professional relations. AANA J. 1996;64(6):521–4.PubMedGoogle Scholar
  70. 70.
    Phillips RL, Harper DC, Wakefield M, Green LA, Fryer Jr GE. Can nurse practitioners and physicians beat parochialism into plowshares? Health Aff. 2002;21(5):133–42.CrossRefGoogle Scholar
  71. 71.
    Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Health Care. 2001;10 suppl 2:ii26.Google Scholar
  72. 72.
    Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44:350–83.CrossRefGoogle Scholar
  73. 73.
    Becker ER, Roblin DW. Translating primary care practice climate into patient activation: the role of patient trust in physician. Med Care. 2008;46(8):795–805.PubMedCrossRefGoogle Scholar
  74. 74.
    Fiscella K, Meldrum S, Franks F, Shields CG, Duberstein P, McDainel S. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42(11):1049–55.PubMedCrossRefGoogle Scholar
  75. 75.
    Danis M, Solomon M. Providers, payers, the community, and patients are all obliged to get patient activation and engagement ethically right. Health Aff. 2013;32(2):401–7.CrossRefGoogle Scholar
  76. 76.
    Garbutt J, Bose D, McCawley BA, Burroughs T, Medoff G. Soliciting patient complaints to improve performance. Jt Comm J Qual Saf. 2003;29(3):103–12.PubMedGoogle Scholar
  77. 77.
    Burroughs TE, Waterman AD, Gallagher TH, Waterman B, Jeffe DB, Dunagan WC, et al. Medication safety: patients’ concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5–14.PubMedGoogle Scholar
  78. 78.
    Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267–76.PubMedCentralPubMedCrossRefGoogle Scholar
  79. 79.
    Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007;335(7609):24–7.PubMedCentralPubMedCrossRefGoogle Scholar
  80. 80.
    Stone S, Kontowski G, Gallagher R, Storr J, Teare L. Keeping hand hygiene high on the patient safety agenda. BMJ. 2013;346:f2699.PubMedCrossRefGoogle Scholar
  81. 81.
    Haines S, Warren T. Staff and patient involvement in benchmarking to improve care. Nurs Manage. 2011;18(2):22–5.CrossRefGoogle Scholar
  82. 82.
    Daniels JP, Hunc K, Cochrane D, Carr R, Shaw NT, Taylor A. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ. 2012;184(1):29–34.PubMedCentralPubMedCrossRefGoogle Scholar
  83. 83.
    Brown M, Frost R, Ko Y, Woosley R. Diagramming patients’ views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research. Patient Educ Couns. 2006;62(3):302–15.PubMedCrossRefGoogle Scholar
  84. 84.
    Schwappach DLB. “Against the silence”: development and first results of a patient survey to assess experiences of safety-related events in hospital. BMC Health Serv Res. 2008;8(1):59.Google Scholar
  85. 85.
    Wallace LM, Spurgeon P, Benn J, Koutantji M, Vincent C. Improving patient safety incident reporting systems by focusing upon feedback – lessons from English and Welsh trusts. Health Serv Manage Res. 2009;22(3):129–35.PubMedCrossRefGoogle Scholar
  86. 86.
    Gaal S, Hartman C, Giesen P, van Weel C, Verstappen W, Wensing M. Complaints against family physicians submitted to disciplinary tribunals in the Netherlands: lessons for patient safety. Ann Fam Med. 2011;9(6):522–7.PubMedCentralPubMedCrossRefGoogle Scholar
  87. 87.
    Millman EA, Pronovost PJ, Makary MA, Wu AW. Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf. 2011;7(2):106–8.PubMedCrossRefGoogle Scholar
  88. 88.
    de Feijter JM, de Grave WS, Muijtjens AM, Scherpbier AJ, Koopmans RP. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PLoS One. 2012;7(2):e31125.PubMedCentralPubMedCrossRefGoogle Scholar
  89. 89.
    Frost J, Okun S, Vaughan T, Heywood J, Wicks P. Patient-reported outcomes as a source of evidence in off-label prescribing: analysis of data from PatientsLikeMe. J Med Internet Res. 2011;13(1):e6.PubMedCentralPubMedCrossRefGoogle Scholar
  90. 90.
    Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405–11.PubMedCrossRefGoogle Scholar
  91. 91.
    Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–31.PubMedCrossRefGoogle Scholar
  92. 92.
    Jayadevappa R, Schwartz JS, Chhatre S, Wein AJ, Malkowicz SB. Satisfaction with care: a measure of quality of care in prostate cancer patients. Med Decis Making. 2010;30(2):234–45.PubMedCrossRefGoogle Scholar
  93. 93.
    Glickman SW, Boulding W, Manary M, Satelin R, Roe M, Wolosin R, et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;3(2):188–95.PubMedCrossRefGoogle Scholar
  94. 94.
    Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41–8.PubMedGoogle Scholar
  95. 95.
    Tehrani AB, Feldman SR, Camacho FT, Balkrishnan R. Patient satisfaction with outpatient medical care in the United States. Health Outcomes Res Med. 2011;2(4):e197–202.CrossRefGoogle Scholar
  96. 96.
    Manary P, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;17(368):201–3.CrossRefGoogle Scholar
  97. 97.
    Bendall-Lyon D, Powers T. The role of complaint management in the service recovery process. Jt Comm J Qual Improv. 2001;27(5):278–86.PubMedGoogle Scholar
  98. 98.
    Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126–33.PubMedCrossRefGoogle Scholar
  99. 99.
    Levtzion-Korach O, Frankel A, Alcalai H, Keohane C, Orav J, Graydon-Baker E, et al. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Jt Comm J Qual Patient Saf. 2010;36(9):402–10.PubMedGoogle Scholar
  100. 100.
    Fullam F, Garman AN, Johnson TJ, Hedberg EC. The use of patient satisfaction surveys and alternative coding procedures to predict malpractice risk. Med Care. 2009;47(5):553–9.PubMedCrossRefGoogle Scholar
  101. 101.
    Cydulka RK, Tamayo-Sarver J, Gage A, Bagnoli D. Association of patient satisfaction with complaints and risk management among emergency physicians. J Emerg Med. 2011;41(4):405–11.PubMedCrossRefGoogle Scholar
  102. 102.
    Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file malpractice claims following perinatal injuries. JAMA. 1992;267(10):1359–63.PubMedCrossRefGoogle Scholar
  103. 103.
    Murff HJ, France DJ, Blackford J, Grogan EL, Yu C, Speroff T, Pichert JW, Hickson GB. Relationship between patient complaints and surgical complications. Qual Saf Health Care. 2006;15(1):13–6.PubMedCentralPubMedCrossRefGoogle Scholar
  104. 104.
    Hickson GB, Federspiel CF, Blackford JU, Gaska W, Merrigan MW, Miller CS. Patient complaints and malpractice risk in a regional healthcare center. South Med J. 2007;100(8):791–6.PubMedCrossRefGoogle Scholar
  105. 105.
    Hickson G, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040–8.PubMedCrossRefGoogle Scholar
  106. 106.
    Pichert JW, Hickson GB, Moore IN. Using patient complaints to promote patient safety: the patient advocacy reporting system (PARS). In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches. Bethesda: Agency for Healthcare Research and Quality (AHRQ); 2008. p. 421–30.Google Scholar
  107. 107.
    Moore IN, Pichert JW, Hickson GB, Federspiel CF, Blackford J. Rethinking peer review: detecting and addressing medical malpractice claims risk. Vanderbilt Law Rev. 2006;59:1175–206.Google Scholar
  108. 108.
    Pichert JW, Moore IN, Karrass J, Jay JS, Westlake MW, Catron TF, Hickson GB. An intervention model that promotes accountability: Peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435–46.PubMedGoogle Scholar
  109. 109.
    Sage WM. Putting the patient in patient safety: linking patient complaints and malpractice risk. JAMA. 2002;287(22):3003–5.PubMedCrossRefGoogle Scholar
  110. 110.
    Sheppard F, Williams M, Klein V. Team STEPPS and patient safety in healthcare. J Healthcare Risk Manage. 2013;32(3):5–10.CrossRefGoogle Scholar
  111. 111.
    Hsieh SY, Thomas D, Rotem A. The organisational response to patient complaints: A case study in Taiwan. Int J Health Care Qual Assur. 2005;18(4):308–20.CrossRefGoogle Scholar
  112. 112.
    Stimson CJ, Pichert JW, Moore IN, Dmochowski RR, Cornett MB, An AQ, Hickson GB. Medical malpractice claims risk in urology: an empirical analysis of patient complaint data. J Urol. 2010;183(5):1971–6.PubMedCrossRefGoogle Scholar
  113. 113.
    Mukherjee K, Pichert JW, Cornett MB, Yan G, Hickson GB, Diaz JJ. All trauma surgeons are not created equal: Asymmetric distribution of malpractice claims risk. J Trauma. 2010;69(3):549–56.PubMedCrossRefGoogle Scholar
  114. 114.
    Pichert JW, Johns JA, Hickson GB. Professionalism in support of pediatric cardio-thoracic surgery: A case of a bright young surgeon. Prog Ped Card. 2011;32(2):89–96.CrossRefGoogle Scholar
  115. 115.
    Hickson GB, Moore IN. Risk prevention, risk management, and professional liability. In: Rock JA, Jones III HW, editors. TeLinde’s operative gynecology. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 1991 (in press).Google Scholar
  116. 116.
    The Joint Commission. Behaviors that undermine a culture of safety. Sentinel event alert #40. Oakbrook Terrace: The Joint Commission; 2008.Google Scholar
  117. 117.
    Pichert JW, Hickson GB, Vincent C, Pinto A. Communicating about unexpected outcomes and errors. In: Carayon P, editor. Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety. 2nd ed. Boca Raton, FL: CRC Press; 2012. p. 401–22.Google Scholar
  118. 118.
    Reiter CE, Pichert JW, Hickson GB. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Ped Card. 2012;33(1):37–45.CrossRefGoogle Scholar
  119. 119.
    Samenow CP, Worley LL, Neufeld R, Fishel T, Swiggart WH. Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study. Aca Med. 2013;88(1):117–23.CrossRefGoogle Scholar
  120. 120.
    Smith RC, Dwamena FC, Grover M, Coffey J, Frankel RM. Behaviorally defined patient-centered communication – a narrative review of the literature. J Gen Intern Med. 2011;26(2):185–91.PubMedCentralPubMedCrossRefGoogle Scholar
  121. 121.
    Roseman D, Osborne-Stafsnes J, Amy CH, Boslaugh S, Slate-Miller K. Early lessons from four ‘aligning forces for quality’ communities bolster the case for patient-centered care. Health Aff. 2013;32(2):232–41.CrossRefGoogle Scholar
  122. 122.
    Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J Qual Improv. 2000;26(7):400–9.PubMedGoogle Scholar
  123. 123.
    Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, Vincent C, et al. Patient reports of preventable problems and harms in primary health care. Ann Fam Med. 2004;2(4):333–40.PubMedCentralPubMedCrossRefGoogle Scholar
  124. 124.
    Taylor BB, Marcantonio ER, Pagovich O, Carbo A, Bergmann M, Davis RB, et al. Do medical inpatients who report poor service quality experience more adverse events and medical errors? Med Care. 2008;46(2):224–8.PubMedCrossRefGoogle Scholar
  125. 125.
    Catron TF, Guillamondegui OD, Karrass J, Cooper WO, Martin BJ, Dmochowski RR, Pichert JW, Hickson GB. Surgical risk moderates the relationship between patients’ observations of care and surgical outcomes. Manuscript submitted for publication.Google Scholar
  126. 126.
    Entman SS, Glass CA, Hickson GB, Githens PB, Whetten-Goldstein K, Sloan FA. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994;272(20):1588–91.PubMedCrossRefGoogle Scholar
  127. 127.
    Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, et al. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994;272(20):1583–7.PubMedCrossRefGoogle Scholar
  128. 128.
    Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff. 2013;32(2):223–31.CrossRefGoogle Scholar
  129. 129.
    Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L (American Institutes for Research, Washington, DC). Guide to patient and family engagement: environmental scan report [Internet]. Rockville: Agency for Healthcare Research and Quality; 2012 [cited 2013 Jan 8]. Available from: http://www.ahrq.gov/qual/ptfamilyscan/ptfamilyscan.pdf.
  130. 130.
    Johnson B, Abraham M, Conway J, Simmons L, Edgman-Levitan S, Sodomka P, et al. Partnering with patients and families to design a patient- and family-centered health care system: recommendations and promising practices. Bethesda: Institute for Patient and Family-Centered Care, Institute for Healthcare Improvement; 2008. http://www.ipfcc.org/pdf/PartneringwithPatientsandFamilies.pdf. Accessed 25 May 2014.
  131. 131.
    Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, et al. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA. 2007;298(9):993–1001.PubMedCrossRefGoogle Scholar
  132. 132.
    Entwistle VA, McCaughan D, Watt IS, Birks Y, Hall J, Peat M, et al. Speaking up about safety concerns: multi-setting qualitative study of patients’ views and experiences. Qual Saf Health Care. 2010;19(6):e33.PubMedGoogle Scholar
  133. 133.
    Schwappach DLB, Wernli M. Chemotherapy patients’ perceptions of drug administration safety. J Clin Oncol. 2010;28(17):2896–901.PubMedCrossRefGoogle Scholar
  134. 134.
    Schwappach DL, Hochreutener MA, Wernli M. Oncology nurses’ perceptions about involving patients in the prevention of chemotherapy administration errors. Oncol Nurs Forum. 2010;37(2):E84–91.PubMedCrossRefGoogle Scholar
  135. 135.
    Schwappach DLB, Frank O, Davis RE. A vignette study to examine health care professionals’ attitudes towards patient involvement in error prevention. J Eval Clin Pract. 2012;19:840–8.PubMedGoogle Scholar
  136. 136.
    Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010;85(1):53–62.PubMedCentralPubMedCrossRefGoogle Scholar
  137. 137.
    Mira JJ, Guilabert M, Pérez-Jover V, Lorenzo S. Barriers for an effective communication around clinical decision making: An analysis of the gaps between doctors’ and patients’ point of view. Health Expect. 2012; doi: 10.1111/j.1369-7625.2012.00809.x.Google Scholar
  138. 138.
    Davis RE, Sevdalis N, Jacklin R, Vincent CA. An examination of opportunities for the active patient in improving patient safety. J Patient Saf. 2012;8(1):36–43. Epub 2012 Jan.PubMedCrossRefGoogle Scholar
  139. 139.
    Jordan JE, Briggs AM, Brand CA, Osborne RH. Enhancing patient engagement in chronic disease self-management support initiatives in Australia: the need for an integrated approach. Med J Aust. 2008;189(10):9–S13.Google Scholar
  140. 140.
    Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff. 2010;29(7):1310–8.CrossRefGoogle Scholar
  141. 141.
    Kravitz RL, Epstein RM, Feldman MD, Franz CE, Azari R, Wilkes MS, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293(16):1995–2002.PubMedCentralPubMedCrossRefGoogle Scholar
  142. 142.
    Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997;315(7117):1211–4.PubMedCentralPubMedCrossRefGoogle Scholar
  143. 143.
    Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and 2-week outcome. Arch Intern Med. 1997;157(13):1482–8.PubMedCrossRefGoogle Scholar
  144. 144.
    Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972–81.PubMedCentralPubMedCrossRefGoogle Scholar
  145. 145.
    Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75–81.PubMedCrossRefGoogle Scholar
  146. 146.
    Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillment in office practice: antecedents and relationship to outcomes. Med Care. 2002;40(1):38–51.PubMedCrossRefGoogle Scholar
  147. 147.
    Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use. Can patient expectations be altered? Arch Intern Med. 1987;147(1):141–5.PubMedCrossRefGoogle Scholar
  148. 148.
    Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Mastat ASJ, et al. Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? J Gen Intern Med. 2004;19(11):1080–7.PubMedCentralPubMedCrossRefGoogle Scholar
  149. 149.
    Pfifferling JH. The myth of telling patients “No.” Protector. Spring 2012, http://www.medpro.com/the-myth-of-telling-patients-no.
  150. 150.
    Audet AM, Davis K, Schoenbaum SC. Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med. 2006;166(7):754–9.PubMedCrossRefGoogle Scholar
  151. 151.
    Carroll KN, Cooper WO, Blackford JU, Hickson GB. Characteristics of families that complain following pediatric emergency visits. Ambul Pediatr. 2005;5(6):326–31.PubMedCrossRefGoogle Scholar
  152. 152.
    Papanicolas I, Cylus J, Smith PC. An analysis of survey data from eleven countries finds that ‘satisfaction’ with health system performance means many things. Health Aff. 2013;32(4):734–42.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Medical Education and Administration, Center for Patient and Professional AdvocacyVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of Quality, Safety & Risk Prevention, Center for Patient and Professional AdvocacyVanderbilt University Medical CenterNashvilleUSA

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