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BMJ Qual Saf. 2020 Feb 4. pii: bmjqs-2019-009704. doi: 10.1136/bmjqs-2019-009704. [Epub ahead of print]

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights.

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Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, UK.
Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK.



A global rise in patient complaints has been accompanied by growing research to effectively analyse complaints for safer, more patient-centric care. Most patients and families complain to improve the quality of healthcare, yet progress has been complicated by a system primarily designed for case-by-case complaint handling.


To understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement.


Literature screening and patient codesign shaped the review's aim in the first stage of this three-stage review. Ten sources were searched including academic databases and policy archives. In the second stage, 13 front-line experts were interviewed to develop initial practice-based programme theory. In the third stage, evidence identified in the first stage was appraised based on rigour and relevance, and selected to refine programme theory focusing on what works, why and under what circumstances.


A total of 74 academic and 10 policy sources were included. The review identified 12 mechanisms to achieve: patient-centric complaint handling and system-wide quality improvement. The complaint handling pathway includes (1) access of information; (2) collaboration with support and advocacy services; (3) staff attitude and signposting; (4) bespoke responding; and (5) public accountability. The improvement pathway includes (6) a reliable coding taxonomy; (7) standardised training and guidelines; (8) a centralised informatics system; (9) appropriate data sampling; (10) mixed-methods spotlight analysis; (11) board priorities and leadership; and (12) just culture.


If healthcare settings are better supported to report, analyse and use complaints data in a standardised manner, complaints could impact on care quality in important ways. This review has established a range of evidence-based, short-term recommendations to achieve this.


adverse events, epidemiology and detection; governance; health policy; patient safety; patient-centred care

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Competing interests: None declared.

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