How to Encourage Hospital Patients to Speak Up About Concerns

Many hospitalized patients are reluctant to raise concerns about their care, which reduces opportunities for improvement.

Encouraging patients to speak up about problems that occur during hospitalizations can improve patient experience and safety, recent research indicates.

Patients are uniquely qualified to raise concerns about care because they are present for the entire episode of care. Earlier research has shown most patients do not raise concerns or file formal complaints, with hesitancy to speak up linked to several factors such as an expectation that complaining will not make a difference.

The lead author of research published this month in BMJ Quality & Safety told HealthLeaders that health systems and hospitals have nothing to lose in asking patients about their concerns.

"From an institutional perspective, I don't think there is a downside to encouraging patients to speak up. However, institutions that do this should be prepared to take the next step and respond to patients who bring up concerns," said Kimberly Fisher, MD, an associate professor in the Department of Medicine at the University of Massachusetts Medical School in Worcester, Massachusetts.

Fisher's research team, which examined data from more than 10,000 patients, published several key findings.

• 48.6% of patients reported experiencing a problem during their hospitalization
   
• 30.5% of patients did not always feel comfortable raising concerns
   
• Patients who had the highest likelihood of not speaking up were older, had worse overall and mental health, were admitted from the emergency department, and did not speak English at home
   
• Mental health was a strong predictor of unlikelihood to speak up, with patients who had poor mental health nearly four times as likely to not feel comfortable raising concerns compared to patients who had excellent mental health
   
• Patients who were not always comfortable raising concerns gave lower ratings for nurse communication, physician communication, and the hospital overall

"The most common type of problem that patients report is inadequate communication—they didn't get the information that they wanted, they didn't get their questions answered, or things were not explained to them in a way that they could understand," Fisher said.

Taking an active approach
 

To maximize the number of patients who raise concerns, health systems and hospitals should take an active approach, she said.

"Directly asking patients whether they have any concerns and conveying a sincere desire to hear from patients is essential in encouraging patients to speak up. We learn about many more—by an order of magnitude—concerns and problems in care with an 'active outreach' approach in which someone inquires of patients as to whether they've had any problems, as compared to just setting up and publicizing mechanisms—websites, phone numbers, or email addresses." 

Care team members are well-positioned to ask patients whether they have concerns, Fisher said. "If it comes from someone on the care team, you are not fragmenting care by introducing yet another cook into the kitchen."

Health systems and hospitals need to be prepared for patient feedback, Fisher said. "When you ask a patient if there is a problem and a concern is raised, the response cannot be saying nothing. You can't ask people to raise their hands and speak up about something and not be ready to respond."

Rising to mental health challenge
 

Encouraging patients with poor mental health to speak up is daunting and will require further research, she said.

"In conditions that require patient activation and engagement, it's clear that poor mental health can be a barrier to doing what they need to do to take care of themselves. It's a cross-cutting problem. It's not just about speaking up—it affects managing diabetes, heart failure, and other conditions. Mental health can impact many health management behaviors."

Enlisting friends and family members could be an effective technique to help patients with poor mental health speak up, Fisher said.

"One approach that we have found helpful in getting patients' concerns heard that could be useful for patients who have a mental health barrier to speaking up is having friends or family members involved and available to speak up on their behalf."

In earlier research that she conducted, Fisher found patients were much more likely to express concerns if a friend or family member was in the room than if the patient was alone.

"We often think of people who are unable to advocate on their behalf as impaired, but there are a lot of people who are not particularly impaired but still find speaking up a hard thing to do."