Handling orthodontic complaints

The basic principles of managing dissatisfaction with effective complaint handling are well recognised and applicable across a wide variety of fields. Transactions that primarily regard goods and those that pertain to the provision of services differ in terms of the levels of human interaction they involve, as well as the subjectivity of subsequent complaints. By their very nature, many healthcare complaints are highly personal and subjective, and can therefore introduce some specific considerations. Dental complaints can be highly nuanced, with complaints relating to orthodontic treatment often having even more specific characteristics.

Most negligence claims, disciplinary or regulatory investigations start out as a simple complaint. While these can be hurtful, stressful and demoralising, we should not lose sight of the opportunities that complaints represent. Many problems can be sorted out in relative privacy before other parties become involved, such as lawyers, the GDC, or other external agencies (including social media), while you still have some control of events. Paradoxically, it is well recognised that the successful management of dissatisfaction and complaints can actually enhance and strengthen the relationship between the organisation and the customer (a process known as ‘service recovery’).¹ We can often learn valuable lessons from complaints and they can be a tool for improvement and development.

The context and setting of a complaint impact its management. Some readers of this article will work in NHS Trusts, hospitals or other environments where the complaints handling structure and processes are determined by others, but many will spend part of or all their time in NHS or private orthodontic practice (general or specialist) and are therefore able to influence or control how complaints are dealt with in their working environment. Whether or not money has changed hands, also makes a difference to how complaints are managed.

Complaints in orthodontics

Like any other area of dentistry, orthodontics raises some issues that apply throughout dentistry, alongside some more specific issues that are specific to the nature of the specialty and the procedures involved. The human and medicolegal complexities that arise when treating children can obviously present particular issues, while orthodontics can also share some of the risks that are associated with elective, cosmetic procedures carried out for adults – a rapidly growing area of dentistry. Some potential concerns arising from orthodontic treatment are immediately apparent, while others do not become apparent until much later – often, many years later.

There is a mistaken belief in some quarters that orthodontic treatment rarely results in complaints and litigation. It would be more accurate to say first, that while orthodontics may not be at the top of the leader board in terms of the number of complaints it generates, nor in terms of the costs incurred, it does currently represent a greater proportion of total complaints than in the past. Second, a disproportionate share of those cases involves non-specialist practitioners (i.e. those who have not undergone any recognised extended formal training in the field). Third, the fastest growing source of orthodontic complaints in recent years has been the involvement of non-specialists in treatments using clear aligners.

It is fair to say that specialists and non-specialists tend to have a different ‘mix’ of orthodontic cases and issues arising within them. In part, this reflects the fact that specialists, especially those who are hospital-based, deal with some especially challenging orthodontic situations and also have the most complex cases referred to them, creating a degree of risk transfer from generalists to orthodontic specialists.

Orthodontics can also present some challenging ‘shared care’ complaints arising at the interface between a general practitioner and an orthodontic specialist, or perhaps involving an orthodontic therapist. In these cases, all parties tend to get drawn into the complaint and its management. The same applies when a patient's treatment involves specialists from other disciplines as well as orthodontics. This can sometimes be further complicated when the parties have different indemnity providers, and views differ on the respective responsibilities of the clinicians involved.

In all ‘shared care’ situations, the role and responsibility of each party needs to be clearly established at the outset. Every clinician involved owes a duty of care to the patient and although someone among them must accept overall responsibility for the patient's ongoing oral health, and while this is usually (but not always) the general dental practitioner, this does not mean that any other party can disregard caries, early decalcified areas, periodontal disease or other signs and symptoms on the assumption that this is somebody else's job. Good, regular mutual communication between all clinicians can avoid many of the problems seen in ‘shared care’ situations.

Paediatric orthodontic complaints

Orthodontic treatment for children is generally being provided in an ever-changing environment as the child continues to grow and develop. As a result, clinical decisions tend to have immediate short-term consequences as well as some broader and longer-term implications. Sometimes, this impacts a case by inviting the question of how things might have developed if a specific event had not happened, or if a certain treatment, which was not provided, had been provided.

These cases can often be fraught with conflict and hidden agendas. Paediatric orthodontic outcomes can represent yet another unwelcome complication at a stage of family life which is permanently juggling schooling and perhaps examinations, sports, extra-curricular activities and many other commitments for everyone involved. This invariably includes parents, and their attitudes and responses can become clouded by the stress of a full schedule, feelings of guilt, natural parental protectiveness (or on occasions, over-protectiveness), or frustration, anger, and sometimes a single-minded determination to hold a dentist accountable for some actual or perceived act or omission towards the child, or unnecessary inconvenience or expense for themselves or other family members. An additional complication may be that a child or teenage patient does not necessarily share the views of their parent(s) about their orthodontic treatment.

Rushing into managing a complaint without taking the time to understand the context and drivers for making the complaint is unwise and can impede any attempt at resolution.

Adult orthodontic complaints

Adult orthodontics can throw up different, but equally challenging problems. While it is generally easier to manage a single patient rather than multiple parties, undergoing orthodontic treatment as an adult can introduce different problems, demands and potential complications.

First, there may have been several other treatment options, including that of simply accepting a situation that has probably been present for many years, and doing nothing. The patient may impose constraints upon how the treatment is to be carried out (especially in terms of the type of appliance and its visibility), and the treatment plan may be complicated by previous orthodontic treatment, missing teeth, the presence of restorations or periodontal disease. On the other hand, adult patients who are prepared to commit themselves to orthodontic treatment will generally not do so lightly and may be highly compliant and co-operative with the treatment.

Complications

Many orthodontic complaints relate to concerns about progress, which can be exacerbated by differences of opinion between clinicians and/or between specialists and non-specialists that may come to light if and when the patient decides to seek a second opinion. The complainant is often prompted to question the appropriateness of the original treatment plan and possibly the training and competence of the first dentist. In these cases, three recurring problems are commonly encountered:

• The original clinician appears not to have identified and taken account of certain complicating factors; as a result of which, they embarked upon a course of treatment which was never likely to succeed or proceed as planned. The validity of the consent process may well have been undermined by this fact
• The clinician was too slow to realise that treatment was not progressing as planned and failed to take steps to reassess the case personally, or with the help of an appropriately trained colleague
• Irrespective of the above issues, the second dentist expresses the view that the original treatment plan was inappropriate in the first place.

8-step guide to successful complaint handling

Step 1: Consent and communication

A large proportion of complaints (and litigation) regarding orthodontic treatment include issues of consent and communication – so getting these right can prevent potential complaints, as well as making life a lot easier further down the track.

In any highly technical or specialist field, at the outset there is likely to be a significant imbalance of knowledge and understanding between the provider and recipient of the service. This certainly tends to be the case in orthodontics, with the added dimension that patients may think that they understand the treatment process better than they do. This can result in an under-appreciation of the factors that can impede a successful outcome, including the importance of patient compliance, commitment and co-operation.

The consent process is, at its heart, an exercise in communication. Many of those involved in healthcare make the mistake of thinking that it is simply a question of imparting information, although many legal advisers would add ‘….and being able to prove that you did so’. Predictably, the typical consent forms drafted by the lawyers advising NHS Trusts and other such bodies, are focused almost entirely upon this defensive, self-protecting approach. However, the patient needs more than standardised information and a blanket list of evidence-based facts about a given type of treatment; any lay person needs to be helped to understand the information you give them, and to internalise what it means for them personally, in the context of the particular treatment that they are being asked to consider. For example:

The purpose – what is being proposed and why? What is it designed to achieve?

The nature of the treatment in question – what does it involve? How long will it take? What level of commitment will be required in terms of frequency of attendance, what it will look and feel like, and are there any other demands it will place upon me?

The likely effects – what should be expected? Pain, discomfort, changes in appearance, speech or function? How long would these effects last? Can I still play contact sport (wear a mouth protector), or play a musical wind instrument?

The risks of the treatment – what are the material risks and what are the chances of them happening in my particular case? What are the immediate and longer-term consequences of those risks if they materialise? (Retention and the risk of relapse is important here)

The likelihood of its success and any limitations – what kind of result can the treatment achieve, and what can it not achieve? Realistically, what is the anticipated outcome in my situation? What does that depend on? What might prevent that happening?

Any alternatives and how they compare in each of the above respects – including the all-important option of accepting the status quo and doing nothing, which is a more active consideration in orthodontics than in most other areas of dentistry. It is crucially important that the patient makes a free, voluntary choice and decision about how and when to proceed, without any kind of pressure, coercion and/or manipulation by those providing both the information and the treatment itself, or by any other third parties.

This long-overdue shift of focus away from simply providing every patient with similar standard information and standard warnings (and getting their signature on a consent form), to providing much more meaningful, tailored information which is relevant and personalised to the individual patient, was underlined by the landmark UK consent law case of Montgomery v Lanarkshire Health Board in 2015.² This seminal Supreme Court judgement included some though-provoking comments (Case study 1).

Case study 1

Extract from Supreme Court judgement in the case of Montgomery v Lanarkshire Health Board [2015],² a medical (obstetric) case that concerned the validity of the patient's consent and the extent to which material risks were discussed with the patient.

“It follows ….. firstly that the assessment of whether a risk is material cannot be reduced to percentages. The significance of a given risk is likely to reflect a variety of factors besides its magnitude: for example, the nature of the risk, the effect which its occurrence would have upon the life of the patient, the importance to the patient of the benefits sought to be achieved by the treatment, the alternatives available, and the risks involved in those alternatives. The assessment is therefore fact-sensitive, and sensitive also to the characteristics of the patient.

Secondly, the doctor's advisory role involves dialogue, the aim of which is to ensure that the patient understands the seriousness of her condition, and the anticipated benefits and risks of the proposed treatment and any reasonable alternatives, so that she is then in a position to make an informed decision. This role will only be performed effectively if the information provided is comprehensible. The doctor's duty is not therefore fulfilled by bombarding the patient with technical information which she cannot reasonably be expected to grasp, let alone by routinely demanding her signature on a consent form”.

In many instances, where concerns are raised as part of complaints or litigation, the patient ends up saying something along the lines that they would never have agreed to go ahead with the treatment, had it been explained to them that a certain outcome might happen. This outcome can relate to some aspect of the finished result, or a subsequent deterioration in that outcome due to relapse, or to treatment taking longer than expected, to some other kind of unforeseen complication, or to a suggestion that doing things differently (or involving someone with greater skills and experience) might have avoided a problem or improved the outcome in some way.

The common feature is that orthodontic (and many other) complaints are often fuelled by surprise and/or disappointment with unexpected developments and outcomes, which can often be traced back to deficiencies in the pre-treatment consent and communication process. For example, many complaints in aligner cases relate to interproximal reduction (IPR), often because there is an unresolved difference in perspective between clinician and patient. The patient misinterprets what is being done and why, precisely because it has not been properly presented and explained to them at the outset. An inexperienced clinician may unquestioningly follow the IPR plan supplied by the aligner company, without applying the filter of their own knowledge and clinical experience, and without properly understanding the patient's possible concerns and taking them fully into account. Or the clinician might undertake too little IPR at the start, only to be forced to come back later for a second (or third) round of IPR when it is realised that the teeth don't have enough space to move into.

Within reason, patients are generally more willing to accept outcomes that they have been prepared for, however unfavourable or unwelcome. In this regard, the profession can be its own worst enemy because recent years have seen an increasing tendency to go somewhat over-the-top with promotional and marketing claims on websites and social media, resulting in ‘over-promising’ and ‘under-delivering’ –a trap described almost 40 years ago by the legendary business, management and customer care guru Tom Peters.³

Something as simple as a marketing tagline like ‘Six-month smiles’ can be a double edged sword; it might sound attractive to patients, but it also sets expectations that might not be achievable in all cases thereby sowing the seeds of a future complaint. Short-term orthodontics sounds a lot more alluring than making a commitment to long-term or lifetime retention.

Investing time and effort into managing expectations and getting the consent and communication process right is an important ‘upstream’ extension of any effective complaints handling procedure, especially in orthodontics, because it reduces the potential for complaints and makes life easier for anyone tasked with dealing with a subsequent complaint.

Step 2: People and processes – training and preparation

Unless the culture of your organisation, and its people and processes are prepared and equipped for the possibility of having to deal with patient dissatisfaction and complaints, practitioners can be taken by surprise.

Good communicators usually make the best complaints handlers. The best listener(s) and communicators in the team should ideally be the people in the front line of your complaints system (not necessarily the most senior person), and because relatively few dental health professionals have had any formal training in communication, or complaints handling, it is worthwhile to train them in these skills. In any event, they are both recommended areas for CPD activity which can deliver development outcome A of the GDC's ‘Enhanced CPD’ arrangements.

Every workplace should have a well-structured complaints system in place that every member of the team is aware of, understands and would be able to explain to a patient if necessary. This is also a GDC requirement.⁴ This makes it easier for those managing the complaint, and easier for patients to understand how the system works, and what to expect. It is important to incorporate clear time limits for each stage of the process – and to adhere to them. The ten key features of an effective complaints system can be summarised as follows (use this as a checklist against which to assess the strengths and weaknesses of your own system):

• Accessible: patients are able to raise concerns in whatever way is easiest for them
• Fair to all parties
• Simple and easy to understand and navigate.
• Non-threatening, either for the complainant, or for the subject of the complaint
• Confidential
• Responsive and fast
• Flexible (overly-rigid systems and processes can obstruct complaints resolution)
• Cost-effective
• Constructive: promotes improvement
• Cost-beneficial.

An effective complaints system is patient-centric. Patients should be able to raise concerns and complain in whatever way they find it easiest, whether face-to-face, or by phone, email or online. Having said this, a complaint raised in person at a busy reception desk, within earshot of other patients, can make it much more difficult to deal with – so it is often easier for all parties if alternative, less confrontational and more private channels are made available. Not every work environment includes a readily available private space which would be suitable for a private conversation without distractions or interruptions, but with a bit of creative thinking there is usually something better than a busy front desk with other patients waiting nearby.

When a complaint relates to orthodontic treatment provided to a minor (under the age of 16), it is important to respect the wishes of both the parents and the patient, as to the extent to which the patient will be involved in any discussions or meetings in relation to the complaint, and in any agreed resolution of the complaint - especially if ongoing treatment is involved. The principles of ‘Gillick Competence’ apply and the views of the patient must be listened to and taken into account.⁵

Step 3: Anticipate, recognise and accept complaints

Adopting a proactive approach to recognising and identifying complaints increases the chances of retaining some control over how a complaint progresses. Surprisingly, given the UK's well-recognised blame and litigation culture, there is compelling evidence that most dissatisfied dental patients do not actually complain at all: they simply leave and go elsewhere, and tell their friends and colleagues (and anyone else who will listen) about their bad experience. This has been made quick, easy and more likely by the growth in the use of social media. Voting with your feet isn't quite as easy in the middle of a course of orthodontic treatment, of course, but many patients do not like the confrontation of complaining face-to-face. Unvoiced dissatisfaction does not help the clinician or organisation that the complaint is about either, because the damage is done and they will not get a chance to repair it (and perhaps, learn from it).

There are many ways of identifying and recognising dissatisfaction:

• Openly invite and encourage comments and feedback
• Offer accessible, informal channels as well as more formal in-house complaints procedures. Make it easy for patients to express their concerns and dissatisfaction so they will feel able to tell you, rather than telling someone else first
• Train staff to identify the ‘body language’ associated with dissatisfaction (such as posture, facial expression, eye contact and blink rate, gestures), and the verbal clues in terms of the words people choose to use, the questions they ask, their tone of voice, and their tendency to interrupt and ‘talk over’ things that people are saying to them
• Be proactive. Never ignore the early signs of complaints or simply hope that they will go away.

The designated complaints handler needs to co-ordinate the ‘acceptance’, acknowledgement, investigation and response to the complaint. They do not necessarily have to provide the detailed response themselves, although they should ensure that an appropriate team member does respond within any agreed timescales. The quality and promptness of the initial response is particularly important as it colours the perceptions of the complainant as to whether their complaint is likely to be taken seriously and acted upon. ‘Accepting’ a complaint does not mean rolling over and pleading guilty to all charges – rather, being the opposite of ‘rejecting’ or fighting off a complaint; it respects the patient's right to feel dissatisfied.

All complaints should be acknowledged quickly, informing the patient when they might anticipate a formal response and ideally, giving them a clear written summary of how the process works and the timescales involved for each stage. When replying to complaints, avoid over-promising and under-delivering. If, for example, the dentist involved will be away from the practice for a couple of weeks, then inform the patient. A patient is more likely to react favourably if they know that their complaint has been accepted and is at least being listened to, taken seriously and dealt with - even if a slight delay is unavoidable.

In general, a willingness or refusal to apologise sets the tone for the progression of any complaint. You can (and should) apologise for the patient's disappointment or feelings, without necessarily admitting that anyone did anything wrong. While many people mistakenly believe that saying ‘sorry’ is an admission of fault, guilt or even liability, it is not, or at least, it does not need to be. That said, simply going through the motions of saying ‘sorry’ when you do not appear or sound sorry in your response, can make matters worse.

Wendy Leebov, an American researcher, was one of the most influential teachers of customer care principles in the healthcare setting for several decades; she described a very effective approach to the initial response to a complaint.^6,7 Whether the response is verbal, or in writing, her ‘sad but glad’ technique consists of saying something to the effect of “I am sad that you aren't happy but I'm glad you told me”, or “I am naturally disappointed to hear that you are not happy with the service we have provided, but we welcome this opportunity to respond to the concerns that you have raised. Thank you for bringing this to our attention.” This is an excellent example of a first response, because it gives the patient confidence right from the start that that their complaint is not being ignored, fought off or swept aside. It is also ‘neutral’ in terms of not taking one side or the other and is both conciliatory (soothing) and non-confrontational.

Step 4: Investigate thoroughly, maintain momentum

A balance needs to be struck between taking enough time to find out the facts and understanding the views, feelings and opinions of everyone involved, but not taking so much time that you give the impression that you are dragging your feet. A common error in complaints handling is trying to provide a detailed response too quickly, before investigating and gathering the facts. What everyone wants is to get the complaint resolved fairly and to everyone's satisfaction, allowing everyone to move on - but this should not be at the expense of understanding the facts of what led to the complaint.

It is important for the complaints co-ordinator to identify all the parties involved, in order to avoid confusion, assumptions and misunderstanding. Any attempt to generate an instant response on behalf of another person who may be unavailable, or who might have left a practice or clinic, should be resisted.

While you are obtaining the views of all the parties involved, keep everyone informed of progress and the timescale for the next stage. Doing so maintains the momentum even when there is relatively little to report.

It is important to remember that any response to a complaint could end up as part of the evidence under consideration as part of a subsequent process or hearing. The response that can be made following a proper investigation is likely to be more thorough and accurate, and indeed fairer to all parties involved.

However, not every patient wants (or needs) a prolonged and detailed full investigation and report, nor the additional time it involves. Sometimes all the patient wants is for someone to put things right, not understanding how and why it happened. It is their complaint, after all, so explain the options and let them decide. This is an example of the need for flexibility in any complaints process.

Step 5: Explore possible solutions

Many people become defensive when they receive a complaint, particularly if they regard it as unreasonable, spurious or without foundation. While that may be understandable, defensiveness can obstruct good complaints handling and at worst it tends to result in the dentist's response sounding more like a justification (or a counterattack) than an explanation.

Instead of rushing to ‘defend’ ourselves against complaints and allegations made about us, and perhaps assuming that all the patient wants is money, a more constructive strategy is to find out what the patient is looking to achieve, and this in turn provides the clue to what we need to do in order to resolve the complaint. Patients are generally looking for a combination of the outcomes listed below:

• Outlet: reducing frustration, being taken seriously and listened to
• Apology: recognising their feelings; it does not always need to be an admission of fault
• Explanation: but only if that is what the patient wants
• Remedy: only the patient knows what will put things right in their eyes
• Redress: compensation does not always need to be monetary
• Retribution: settling the scores, resolving any interpersonal conflicts. Prominent among the drivers here are any perception of arrogance, a lack of respect or rudeness, or a lack of care and/or concern.

Don't be afraid to ask the important question: “What can I do to put this right for you ?”, or “I realise we can't undo what has happened, but is there something else you would like me to do…?”.

Ask yourself: what have you got to lose? The sooner you can find out what the patient wants, the sooner you can start resolving the complaint – the solution may be a lot quicker and easier to achieve than you had imagined. Even if you don't think you can give them exactly what they want (or this might be inappropriate anyway), you can at least start to think about what you can give them in order to move towards a mutually satisfactory resolution. Complaint handling is sometimes a negotiation involving compromises and trade-offs on both sides, but ultimately the patient holds more cards than we do because they can always take it further and involve other bodies if we don't resolve the issues to their satisfaction.

During this stage, it is important to stay calm and professional, demonstrate your concern and give the patient choices and a sense of control. Do not attribute any blame to the patient, even if they are partly at fault, as this is likely to escalate the patient's dissatisfaction and block the path to resolution. Keep your professional cool and do not get drawn into any unpleasantness or pick a fight – resolving a complaint isn't the same as winning the argument. Preventing escalation is a victory in its own right.

Step 6: Resolution

Complaints are best resolved at the lowest possible level, which is normally within the setting where the treatment was originally delivered - within a practice, for example. This ‘resolution’ does not always imply a detailed written response. Many minor complaints can be resolved informally on a one-to-one basis without anything being put in writing, although a short letter can still be sent to the patient confirming your concern and hoping that the complaint is now resolved. This sympathetic contact takes very little time and effort, but can make a significant difference in terms of patient loyalty.

In most cases, however, a written response is likely to be appropriate. This may include an explanation, reassurance, an apology, an offer of compromise or giving the patient options as to alternative ways forward. It is important to decide in advance exactly what message you wish to convey in a letter, bearing in mind the possibility that others might come to see it if the patient takes things further and involves other bodies. The GDC's published guidance sets out minimum standards for complaints handling, their ‘Standards for the Dental Team’ state: ‘You should respond to the patient in writing, setting out your findings and any practical solutions you are prepared to offer. Make sure that the letter is clear, deals with the patient's concerns and is easy for them to understand’.⁴ Therefore, you would need to have adequate justification when choosing not to respond to a patient's complaint in writing.

Not everyone is skilled at letter writing, but it is wise always to choose your words carefully. The more reasonable and professional your written response, the more credit you will be given at any subsequent review or hearing of the complaint if it progresses. Always involve your indemnity/defence organisation, as they will be very experienced in drafting letters of response to complaints and are further removed from those involved in the complaint, making it is easier to be more balanced and objective.

Step 7: Following-up

For some people, it can feel like an intimidating prospect to make further contact with the patient to ensure that the complaint has been satisfactorily resolved. This may not be appropriate in all cases, but it can be extremely helpful, particularly when you want to retain the confidence of the patient.

There is really no difference between this and a dentist contacting a patient after a difficult procedure to enquire about their wellbeing. Even if the patient is not completely satisfied, it provides a further opportunity to identify any residual complaints and deal with that dissatisfaction. It also demonstrates respect and concern, care and consideration. An effective follow-up is what most complaint systems lack, yet it is the last memory that the person takes away from their experience, so make it a positive one and reinforce the professionalism with which you handled their complaint, in case the patient decides to take things further still. It is good practice, and also a GDC requirement, that patients be provided with contact details of organisations to whom they can escalate their complaint if they are not satisfied with the resolution that you have been able to achieve through local/in-house complaints procedures.

Step 8: Learning, sharing lessons and improving

All complaints can teach us something. It can be constructive to consider:

• How and why the complaint arose
• What steps could have been taken to avoid the complaint in the first place?
• Was the complaint handled effectively?
• Did the practice/patient achieve the desired outcome? If not, why not?
• Has the clinician learned anything useful from reflecting on the experience?
• Could this help to avoid the same things happening in the future?

It is important to remember that complaints can alert you to areas of service delivery that, if not addressed, could lead to a more serious complaint in the future. When reasonable patients complain, they are doing us a favour because we can take steps to avoid the same thing happening when a less reasonable patient is involved.

A patient is more likely to accept the eventual outcome if they can see that a complaint has been taken seriously, and time and effort has been put into investigating it fairly, so this should be demonstrated to the patient. Although research shows that patient expectations of complaints handling are often quite low, never ignore or dismiss any complaint or delay your response to a complaint, as this can be interpreted as arrogant, disinterested or a dismissive approach on the part of the healthcare professional. A perceived lack of respect can transform a dissatisfied patient into an angry one, seeking ‘punishment’ of the practitioner.

Conclusions

One of the hallmarks of any professional is the pride they take in what they do. Nobody likes to be criticised or complained about, but another important facet of professionalism is the way we react and respond to adverse events and negative feedback.⁸ We do not need to agree with criticism in order to learn from it: by re-framing how we view complaints and ensuring that we invest time and effort into maintaining quality complaints procedures, we can use complaints constructively as a tool for improvement and personal development, as well as a risk management strategy to prevent and effectively manage potential dento-legal challenges and threats.