Many patients are dissatisfied with the way in which their complaints about health care are handled, a phenomenon that exists in a number of countries and is not well understood [1–3]. The assumption – tested in this study – is that patient dissatisfaction with complaints handling consists of unmet expectations; if patients' expectations are not met or not met in full, they may feel disappointed or even frustrated . Fair complaints handling is highly significant in restoring patients' trust in health care and in renewing patients' commitment to the health care provider or organisation. Any effort to restore patient satisfaction with complaints handling is not only an ethical issue, therefore, it also provides practical advantages, while knowing the main components of dissatisfaction may lead to successful approaches to preventing dissatisfaction .
This article endeavours to explain patient (dis)satisfaction by comparing patients' expectations at the time they filed a complaint, with the outcome of the complaints handling process. The setting of the study was hospitals in the Netherlands and the subjects were patients who had lodged a complaint with the complaints committees of the participating hospitals.
Patient dissatisfaction with complaints handling
Complainant dissatisfaction is a common finding in many studies [1, 2, 6]. Daniel evaluated the experiences of 290 patients whose complaints were finalised by the Health Care Complaint Commission of New South Wales (HCCC) and nearly two-thirds of these patients (61%) appeared to be dissatisfied with the complaints handling by the time the complaint file was closed. All but two people said they would never consult the doctor involved again, while many respondents remained angry and most wanted stern measures to be taken. Satisfaction was significantly more likely if strong action had indeed been taken against the doctor . In business research, little is also known about people's behavioural and emotional responses to complaints handling .
Patients' motives for complaining
An important motive for patients to lodge a complaint is to prevent the same incident from happening to others [7–9]. Complainants experienced strong feelings of having been wronged and many felt it was their duty to complain, because they experienced a sense of moral duty or justice having been violated. They reacted out of a basic feeling that something had gone wrong in how things should be arranged that had to be set right . Some patients said they owed it to their deceased partner or child to lodge a complaint, while Bark et al.  found that the majority of patients wanted staff to be aware of what had happened and the effect it had had on the patient; "I wanted doctors to realise what they had done." .
Patients' expectations of complaints handling
Some studies focused on what patients expect from the health care provider (or the accused) in response to their complaint. According to Gallagher, patients want full disclosure of the incident , which is likely to increase patient satisfaction . Bark et al.  and Vincent et al.  found that many patients wanted an explanation from their doctor and/or a detailed account of what had happened. Half of the patients wanted an apology (as well), while less than 10% of the complainants attempted to obtain financial compensation [6, 7]. Bismark et al.  found that most patients do not seek monetary compensation when given a choice, but appreciate other forms of accountability, like explanations or lessons learned. They state that "the offering of apologies, explanations and assurances of system change, where appropriate, may address many patients' true concerns...". Only in the case of patients who had sued their doctor, did two thirds want to receive financial compensation .
Complaints are handled by patient ombudsmen or (hospital) complaints committees in some countries. Committees of this kind, which are required by law in the Netherlands, act as intermediaries between the hospital and the complainant and are responsible for a careful and independent handling of patients' complaints [13, 14]. What patients expect of the complaints committee differs from what they expect of the hospital or the doctor who gave rise to the complaint .
Hypothesis and research questions
The study is based on the underlying hypothesis that patient satisfaction with complaints handling is based on the extent to which their expectations regarding the conduct of the committee, the hospital and the professional are met. This hypothesis will be tested by answering the following research questions in succession.
1. What is the association between patients' initial expectations of the complaints handling process and their final experiences of the complaints committee, the medical professional, and the hospital management?
2. What factors in the conduct of the committee, the professional, and the hospital management predict patients' satisfaction with the complaints handling process?
3. Does satisfaction with complaints handling contribute to the feeling that justice was done through the complaints handling procedure?
The hypothesis on fair complaints handling stems from the core concepts in both Fairness and Justice Theories [4, 15]. According to these theories, patient satisfaction depends on the perceived fairness of a) the complaint procedures, b) the interpersonal communication, and c) the outcome.
The fairness of the complaints procedures is related to procedural justice, which is mainly expected of the complaints committee . The fairness of the communication is related to interpersonal behaviour, treating people with dignity and respect for example, i.e. interactional justice, which is expected of the members of the committee and the medical professional as well . The fairness of the outcome relates to the final decision, or what the patient "gets out of" the complaints handling process, i.e. distributive justice. Three types of outcome can be distinguished, viz. the committee's decision on the complaint, the doctor's explanation or apology, and the hospital's corrective measures or changes .
Fair outcomes alone do not determine patient satisfaction. It is often how (in terms of process and interpersonal style) the outcome is communicated, rather than what is communicated that seems to matter , which means that interpersonal communication plays a dominant role in a person's decision to remain loyal or to discontinue the relationship . Satisfaction will also depend on the remedial options available, which are naturally restricted in health care, where it usually is not possible to undo what has happened to the patient. Patients will judge fairness against the efforts of the hospital to make amends for the incident . If people feel that feasible remedial options exist (changes at the hospital, for example), but the provider does not use any of these options, the provider will be perceived as not caring and not caring is likely to evoke negative emotions and to result in anger and dissatisfaction .