Driving positive change: what can we learn from compliment letters?

Patient perceptions of care have been recognized as a key component of healthcare quality for over 30 years.1 Patient satisfaction began being reported at the hospital level in the US in 2007.2 However, despite recent institutional and governmental emphasis on satisfaction measures, studies have not shown consistent ways in which using these results can drive improvement at the clinician, hospital, payor, or policy levels.3 Instead, many authors have questioned the fairness of such satisfaction measures, as they may be associated with factors other than healthcare and may widen inequities if used as part of provider performance review or pay.4,5

Even with such concerns, understanding the views of patients and families remains important to identify safety issues and opportunities. Often, complaints are reviewed in detail. However, rather than focusing on patients’ perspectives of safety events or overall satisfaction with care, Gillespie and Reader recently reviewed over 1,200 letters of compliment sent to 54 English hospitals (an estimated 2% of those received annually) to learn more about the routine successes of everyday work and what patients or their families value enough to acknowledge by sending an unsolicited message. The study’s goals included categorizing the focus of these letters (clinical, relationships or management), determining the aims of the letter as being either acknowledgment or reward, and determining if these aims differed by the intended recipient of the letter.

They found that 80% of compliment letters included a theme of gratitude, either for an individual, a care team or a unit. In 44% of the total letters, these sentiments were sent to a unit, departmental, or senior manager or were copied into such managers, presumably to ‘reward’ the person(s) named within the letter. In almost half of letters, specific behaviors were commended, presumably to promote these behaviors in the future.

While a general theme of gratitude may be unsurprising for compliment letters, the study suggests that patients seem to define specific goals for their letters by choosing to whom the letter is addressed. Letters sent to front-line workers are intended to thank them directly, while those sent to their managers are often meant to reward front-line individuals via additional recognition, to share ideas for improvement at a system or institutional level, or to promote behaviors that patients recognized as being outside the boundaries of ‘normal’ work. Specifically, almost 40% of letters referred to examples of an individual going ‘above and beyond’.

At the individual level, such positive feedback can increase the recipient’s work motivation and reduce burnout.6,7 However, the best way to use these compliments at the systems level is less clear. On the one hand, managers sharing such compliments may build better relationships with front-line staff while also allowing better understanding of, and improving the overall work culture of, an organization. On the other hand, officially tracking receipt of such compliments may create mistrust of managers if front-line workers then feel obligated to solicit compliments from patients. Sharing compliments may also be counter-productive if compliments recognize staff doing ‘extra’ work that covers for inadequate resources, leading to this being seen as an expectation that staff should to do this.

So, what are some takeaways from this work? First, thousands of patients are grateful for the care they have received and take time and effort to share this gratitude. The individuals and teams mentioned in these compliments should be notified of this recognition, as this can reinforce reasons that many chose such a career, around making a difference to those they care for. Second, there are significant risks to monitoring whether or not staff receive compliments or using compliments to justify staff going ‘above and beyond’ (such as in working additional hours) as a part of their normal work. These practices should be discouraged at the managerial and systems levels. Instead, managers ideally would identify opportunities for redirecting or adding resources through noting trends and themes within compliment letters. Ultimately, finding such ways to integrate selected complimented behaviors into healthcare workflows should improve the patient experience for everyone.

Joel Boggan



1.Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry 1988;25:25-36.

2.Center for Medicare and Medicaid Services. HCAHPS: Patients’ Perspectives of Care Survey (updated 11 February 2020). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS

3.Davidson KW, Shaffer J, Ye S, et al. Interventions to improve hospital patient satisfaction with healthcare providers and systems: a systematic review. BMJ Qual Saf. 2017;26:596-606.

4.Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012;172(16):1204-1210

5.Casalino LP, Elster A, Eisenberg A, Lewis E, Montgomery J, Ramos D. Will pay-for-performance and quality reporting affect health care disparities? Health Aff (Millwood).2007;26(3):w405-w414.

6.Aparicio M, Centeno C, Robinson C, et al. Gratitude between patients and their families and health professionals: a scoping review. J Nurs Manag 2019;27:286–300.

7.Converso D, Loera B, Viotti S, et al. Do positive relations with patients play a protective role for healthcare employees? effects of patients’ gratitude and support on nurses’ burnout. Front Psychol 2015;6:470.


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