Dealing with Complaints (01 Feb 2024)

SPEAKER_00 0:15

Hello and welcome everyone to this podcast on the topic of dealing with complaints. My name is Craig Thirtel. I'm a consultant physician in endocrinology and diabetes, working at University Hospital Monklins in Lanarkshire, Scotland. And I'm very lucky to be joined today by Dorothy Armstrong for this podcast on complaints. Dorothy has a background in senior nursing and education and formed her own company, DA Professional, in 2012. She has collaborated with the Royal College on a number of occasions, providing training and education on a number of topics, not just complaints. So welcome, Dorothy.

SPEAKER_01 1:00

Thank you. Thanks very much, Craig. Delighted to be here and thank you for the invitation to do this on behalf of the Royal College of Physicians of Edinburgh.

SPEAKER_00 1:09

Thank you. And would you like to take a minute or so just to explain a bit more about your own background?

SPEAKER_01 1:15

Sure. As you said, I continue to be on the nursing register. I worked as a vaccinator during COVID. But really around 11 years ago, I became interested in the topic of complaints and was one of the advisors for the Scottish Public Services Ombudsman, which we can talk a wee bit about later, but it's basically where the public can take their complaints once the complaint has gone through the process. So, really, since then I've developed a real interest in this topic. And as you said, through my company and through my work with the Ombudsman, I'm really keen to share this passion with primarily healthcare professionals about the importance of how we can manage complaints, how complaints are an opportunity for learning and improvement, but also what it's like to be on the receiving end of complaints. We know that clinicians who have been complained about or who are perhaps supporting a colleague, it can have a huge impact on themselves and their career. So really keen to thread through today not just about the managing of the complaint, but also how people can do that in the most effective way whilst caring for themselves.

SPEAKER_00 2:28

So the Royal College is hosting this podcast on behalf of the recently appointed Consultants Committee of which I'm a member. So this podcast is primarily targeted towards senior trainees and newly appointed consultants. We find that dealing with complaints, how to approach a complaint situation, is something that isn't often covered very much in our formal postgraduate medical education. So I'm very keen to have your insights on this topic in this podcast. So if we can just start off with a typical kind of word-based scenario, let's say that I've just completed a morning ward round and the nurse in charge comes up to me and says, Craig, the family of one of your patients isn't very happy and they'd like to make a complaint about an aspect of their relatives' care. So how do I start addressing that situation?

SPEAKER_01 3:21

Thanks, Craig. And I think I would start by saying around recognising that particularly in groups of either senior trainees or newly appointed consultants, this can cause a lot of grief. You know, when you're a trainee, you're kind of protected, and then suddenly you're it and you're asked, as you said, by the nurse in charge to speak to relatives or indeed patients. And I think I will share in the information a kind of seven A's, seven steps around complaints. I think the first thing is to do whatever you can to be prepared and to go into that conversation with a kind of positive mindset, recognising that the vast majority of people who are upset or who are complaining is often because of their vulnerability. It's very often around either miscommunication or an issue with communication. And therefore, as soon as you can have that conversation, then I would say absolutely kind of welcome that. It's also important to recognise that you may be nervous having that conversation if it's something you haven't done before, and look at it almost as a form of advanced communication skills, a bit like breaking bad news. You wouldn't expect to do that for the first time without giving it your consideration. So the first A around this would be appreciate. So going in and just thanking or making a connection with the person to say, you know, you're happy to give them this information, thank them for raising it or questioning what is something that's important to them. And accepting that's an issue because of that vulnerability, many clinicians become defensive immediately and think, goodness, what's going on? Or why have I been asked to do this? First one would be that appreciation, followed by acceptance around they're clearly upset, there's been something that's not kind of blanding with them. So there's some simple things like words like around thank you. So thank you, Craig, for asking to speak to me. I appreciate this is maybe a difficult time for you, etc. So a lot of it is that initial listening and communicating. So perhaps starting with after you've done your introduction, how can I help you? What would be useful? Remembering that in any form of communication, questions can be your friend. You know, you're opening up the dialogue and allowing the relative or the patient to speak. You know, people will often be emotional, they might be angry, they might be frustrated. So simply, how can I help? What would be useful for me to do in the time that we have? Often that includes an apology, a subject I'm really interested in, and we could talk about probably at another time. But it might be once you've heard them and allow them to speak, they might even need to rant for 10 minutes. And I know your time is hugely precious, but sometimes we need to let them speak and following that up with something really simple like, I'm really sorry to hear that was your experience. And it may not even be related to your care, it may be prior to coming into hospital, it could be to do with a whole range of issues. So that apology can be really helpful to de-escalate, to recognize that they are important and that you value their contribution. And then you can go into opening up the conversation a bit more to find out what it is they're looking for and give them a bit of choice. So one of the other is is that autonomy. You know, very often people complain because they feel that they have no decision making, they've lost any control over their situation, they're feeling very vulnerable, they feel frustrated. So again, asking them what would help, giving them choices and doing all that in an authentic way, which is another A. So there's no script for this, Craig. It's not about saying, right, say this, this, and this, but giving it some thought if you can, and it may be you've been asked to do it and you have to go in straight away, but if you know the situation, even asking their what are there a family like, what's going on, so that you're going in there with a little bit of information and you can take your best self to that conversation and be authentic, be meaningful, because people will pick it up if not. So there's no script, but there can be useful phrases which I can share alongside this podcast. And then the final seminar is around action. So what's the end of the conversation? It might only be short, it might be only 10-15 minutes, it might be longer, but towards the end of it, you're going to say, right, so here's what we've agreed, or this is what I'm going to do. You know, it's about that plea about please make sure you do it. Complaints often arise because healthcare professionals who are extremely busy may not follow through what has been agreed. I'll go and find this information out or I'll come back to you. When that happens, relatives and patients can feel that they're not being valued, and that can be the trigger. So the trigger point can be something like, you know, they don't care, nobody's actually doing what they've said they're going to do. So following up with those actions. But that early meeting, what I would call early resolution, is actually crucial in managing the complaint to prevent it from becoming a recognized complaint, if you like, and all the work that then goes into that.

SPEAKER_00 8:35

Yeah, I think something that takes a wee bit of time and experience is recognising the situations that patients and relatives are likely to make an issue of. And I think as a newly appointed consultant about four years ago now, that was something that I definitely struggled with. But with a little bit of time and experience, I think you do get a little bit better at being able to recognise the situations before they become something that becomes a lot harder and time-consuming to deal with. And you know, sometimes we can head these things off at an early stage, so-called early resolution of complaints before it reaches a more kind of formal stage. What sort of advice would you have about trying to head off these kinds of off-the-cuff complaints at an early stage, so-called early resolution?

SPEAKER_01 9:26

Sure. I think the majority of complaints are exactly that. You know, they can be a concern, there might be a criticism early on. And I would say probably my advice for that would be still it's around communication and the relationships that you have with your colleagues and probably particularly around the nursing team who may know and come across relatives more than you might do. So being aware of any concerns that they have and having that courage to have an early conversation so you're not waiting for them to get upset or angry. And I know there's lots of examples of that being done now in clinical practice across a whole range of medicine. I'm thinking particularly around medicine of the elderly, where we know there can be many complaints from sons and daughters of elderly patients, and that that can often be prevented by consultants or senior trainees having conversations very early, keeping them updated, asking them if they've got any questions, asking if they have any concerns. So you're being proactive in those conversations at a very early stage. For example, if a member of the team and that might be one of your junior trainees, is saying, Oh, this family is a bit tricky, or this is a bit difficult, this patient seems to be a bit annoyed, then having a proactive conversation by, you know, are you okay? Oh, you look like you're maybe a little bit concerned, or what can we do to help to have that conversation? So I know it's difficult, as I say, it's a resource, it's a time, but that initial conversation early on, what I would call nipping it in the bud can prevent you spending a lot of time later looking at a formal complaint.

SPEAKER_00 11:06

Yeah, and I think picking up something you said earlier about just not really taking it on a personal level, often these things aren't directly relating to you as an individual. It's more about the episode of care or maybe something that happens before the patient was admitted to hospital. And I think as a new consultant, it can be quite difficult, I think, just to get out of that mindset of thinking this is a personal attack against me as an individual, as a clinician and professional, and just to kind of put that mindset to one side and just try to put yourself in their shoes really and to gain an appreciation of what it is they're upset about and what you can do to help. These things often aren't complaints about you at a personal level, it's more about frustration, it's an aspect of their care. And modern healthcare is becoming incredibly complex now. You know, people have multiple contacts with quite a lot of different parts of the healthcare system, so it's no wonder really that patients often feel quite lost in that whole process and they feel quite disempowered at times that they're not having all the information shared with them that they think they should be, and then relatives can think that as well. So I think it is important just to try and you know consider things from the patient or the relative's perspective, isn't it?

SPEAKER_01 12:27

Yeah, absolutely. I think that's spot on, Craig. And one of the key issues, I think, is showing that empathy. And as you know, empathy, one of the key definitions is perspective taking, to see it as if you're in their shoes. And one of the ways to do that is again by asking them questions. You know, something that we think is really important may not be important to them. Something that they've raised may be trivial to us. So it is about understanding that perspective. Yeah, absolutely.

SPEAKER_00 12:54

Moving on, we can now have a discussion about dealing with the more formal written complaint. So these often arrive in your email inbox from Patient Affairs. The organization in your own health board will uh sort of vary in its name, but locally it's Patient Affairs, and one of their representatives will email you with a very sort of formal, rather intimidating looking email detailing the formal complaint asking various individuals to offer a reply. So, Dorothy, what advice would you have for a newly appointed consultant who is having to deal with their first formal written complaint?

SPEAKER_01 13:34

I think one of the things that's really important, Craig, is about getting some support when you're in that process for the first time. So speak to a more senior consultant, somebody who's maybe supported you, clinical director, etc., because I think it is crucial that you manage that situation in an open and transparent way. It can be easy to get caught up in defending yourself. And I think that's probably not always helpful. So be open to looking at, almost to look at what you've done as if you were kind of a fly-in-the-wall. Really that ability to think, well, you know, maybe that didn't quite go as well as I would have thought, or, you know, actually they're quite right. They have had to wait, you know, a lot of complaints are about delays or waiting times. It's okay to acknowledge that and to say that they are correct. So really seeing that complaint as an opportunity for your own learning to self-reflect, also as an opportunity for improvement, perhaps to your service or your own development. I think it can be easy to kind of put a barrier up and think about, well, you know, did this and did that. And perhaps looking at, I don't mean excuses, but you know, there is ways that may be helpful to explain why something happened and that may be useful. But remembering for most people who have made a complaint, it is actually about them. They're not really concerned about the ex 100 number of patients that you maybe have to see or the busy ward or whatever else is going on. So again, it goes back to that perspective taking, to be open and also to hold your hand up if there has been an issue or a mistake made. And so remembering about that ability to apologize for that, about whole duty of candor. Probably the third thing I would say about that situation, if you do have the opportunity, even when it is in writing, when it's a formal complaint and you've been asked to respond, is an opportunity to meet with the relative or the patient early on. You know, can you pick up the phone and say to them, you know, I've got your complaint here, you know, I had no idea, I'm really sorry that was your experience. How can we help? Because many, many people don't really want to complain. What they want is where whatever is their issue to be made right. They want opportunities to stop the same thing happening again to others. People are very motivated to complain because they care about the NHS, because they're proud of the NHS, and they actually want to prevent the same things happening again.

SPEAKER_00 16:01

Sure. And our regulator, the GMC, has outlined our duties in this respect in writing in the good medical practice documents that as healthcare professionals we have to have the ability to respond to and also reflect on complaints that we've received. And it does form part of our annual appraisal and revalidation as well. So these issues do provide a substrate for us to be able to reflect on our own practice and say where you have made improvements as well. And I'd just like to ask what your role has been with the Scottish Public Services Ombudsman, the Ombudsman being the body that can deal with complaints that's been taken to them by patients or relatives.

SPEAKER_01 16:46

Yeah, sure. I find it an absolutely fascinating role. People think complaints, is that not negative, but actually it can be really fascinating. It can be a huge way to learn as well for people's own practice. So yeah, we have over 80 professional advisors in Scotland, and these range across a whole number of the professions. And what happens is if a complaint comes in about healthcare and it's been through the process, so it's like a review, the public ask for a review of their complaint, then the ombudsman would consider whether or not they can do that, they can investigate that complaint. And many of the complaints are closed very early on because we would look to see whether it would be proportionate or not to investigate. For example, if a board has demonstrated that they have fully investigated the complaint, that they have held their hands up if there's been a mistake, if they've demonstrated reflection, learning, and improvement, then the ombudsman will think, well, what more can we achieve here actually? And that will be closed at that early resolution stage. If it does go to full investigation, then we have this team of advisors who would be asked for their view on the care and treatment. And it's really important to recognise that these advisors and the ombudsman in general is independent and partial. They're not there to protect patients, they're there to look at all sides of the complaint, to look at what would have been reasonable at that time within that particular context. So, for example, we're still seeing complaints that are being asked to be reviewed during COVID, during the pandemic. So it's really important that our advisors can help to interpret or set the scene about what was going on at the time. So, for example, visiting. There may be a complaint about visiting. And whilst yes, we recognize it was really challenging for relatives perhaps not to be able to visit, the reasons for that were absolutely valid. So these advisors would give their own view of that complaint, looking at the records and saying whether or not the care was reasonable at the time. So I guess the key thing for that as a clinician is to remember that when you are involved in a complaint within your board, to do the very best you can to investigate the complaint at the time, to ensure that your records are as clear as possible. And remembering too that all of the communication that's already in the file, whether it's a complaints file or the clinical records, will all be shared with the ombudsman. So being very aware of what is written in the records. But also remembering that the ombudsman, you know, we're all on the same page. It's not of them and us. The ombudsman is there to review complaints for the public, but also to ensure that there's learning and improvement for complaints around themes and around specific areas that might be in the public interest.

SPEAKER_00 19:42

Sure. So I suppose in conclusion, then, complaints aren't meant to be something that are scary or intimidating. And I really like the advice that you gave earlier that help and support is available, that just having a senior colleague have a look over your response and just to talk things through is immensely helpful. So, Dorothy, just as we kind of draw to a conclusion now, would you just like to take a little minute to kind of summarize what your key take-home messages are?

SPEAKER_01 20:08

Sure. Well, thank you. So, first of all, I would say first key message is that early resolution, nipping things in the bud, having the conversations, when folks have a concern, allowing them to speak, the power of listening and communicating that with patients and relatives, it's absolutely crucial. And when you do that, as you mentioned yourself, Craig, it's around showing that empathy and compassion, the human element. Secondly, I would say when you do hear of the complaint is using tools like the power of apology, about ability to de-escalate by listening, by recognizing, by appreciating their concerns, appreciating their vulnerability, and allowing them to speak and open up the dialogue. What is it they're looking for? What would be helpful? And thirdly, it would be around that self-compassion, recognizing it's really hard to be on the receiving end of a complaint, knowing the likelihood that you will be complained about as a consultant is pretty high at some point in your career, and not to take it personally, because it's usually not about you, it's usually all about them. But that you have an opportunity to engage with them to help them get through that. But for some patients, you will never fix it. Even if you manage the complaint really well, they will remain unhappy. And you have to care for yourself in that situation. I guess my final word is like the safety brief on the plane. Put your own oxygen mask on first before helping others. Get help, get support, and you know, really try as far as you can to see the opportunity to respond to the complaint as an opportunity for learning and improvement.

SPEAKER_00 21:51

Thank you very much, Dorothy. And you're going to signpost some online resources, aren't you, in the bio that accompanies this podcast?

SPEAKER_01 21:58

Yes, I've got a website as well. There's lots of information there. You know, you're very free to download information, tools, tips, there's a few videos, and I will share some specific handouts along with my bio. Thank you so much again for the opportunity, Craig. Lovely to talk to you today.

SPEAKER_00 22:16

You too. Thank you.