Feedback

Thank you for the replies to last month's in tray. Further feedback is given in emjonline (www.emjonline/contents/SIMS3).

The strategic reports were very interesting and many had similar ideas to Dr York's own analysis (detailed feedback on internet). Some of you suggested that the report should be shared with the chief executive. This is a high risk strategy but with a possibility of gaining influence in high places. Most of you identified the accident and emergency (A&E) staff as key stakeholders and suggested a “time out” with the staff. This was successful and a brief report of this meeting is appended. Unfortunately Sister Oak was on annual leave and Mr London did not come as it was his half day (file note of this meeting on the internet). The next stage is to formulate a project plan for the major objectives. Aspiration is easy, realisation is difficult.Emerg Med J 2001;18:283–284

The complainant is still very unhappy and is asking for an independent review. Her letter and the response are on the internet. This complaint is not going well and we will take a “time out” to examine the reasons and see if lessons can be learned.

Some of you acted on the results that were in the first “in tray” but many did not. A letter from a solicitor has arrived and likely to result in a claim for damages.

Letter has arrived from Sister Oak who has seen a copy of your strategy and is not happy with some aspects of it and is also unhappy she was not consulted.

Your report has also ruffled more feathers. The medical director is not happy that the chief executive has been sent a report without his input.

A letter of response to Mr Glasgow shows you are willing to discuss such issues in a constructive manner but need some evidence to base this practice.

Time out

ATTITUDES

The complaint by Mrs Green is not going well. Let us examine the response so far and look at some of the attitudinal problems that are developing.

Everyone would agree that this is a serious complaint. Dr York has done all the right things so far.^{1, 2} She asked a senior colleague for advice but was given a very pragmatic, if terse and unhelpful response. We need to examine Mr London's attitude in some detail in a later issue. She then sought evidence on the complaint, first from the medical notes and then by interviewing the doctor involved and confirming the nursing view. Her reply showed appropriate empathy for the complainant and at the same time support for her staff who she judged had acted appropriately. She gave a clear invitation to the complainant to meet and discuss the issues.

However, this is obviously a complex complaint involving more than one department. It seems that she did not discuss the issue with the physician. The letter of reply did not address one of the complainant's key worries that her daughter's learning problems had resulted in poor treatment. The final letter of reply from the trust also omitted the offer to meet and discuss this issue and on the whole was rather defensive.

Let us examine the attitudes of the main players in this complaint.

The complainant is obviously angry. She has lost a daughter, probably she has put a great deal of effort into her care over 35 years. However, she may also be feeling guilty (although she has no real reason) as she left her daughter to go home when she thought she was being admitted to hospital. It is inevitable that she will be thinking “what if I had stayed and been able to challenge the doctors at that time”. She will also feel afraid that she is taking on a huge organisation and criticising doctors.³ These negative feelings may be sublimated and repressed by the complainant or are manifest by increased hostility.

Dr York is obviously concerned about this serious setback so early in her post. She will feel rebuffed by her senior colleague. She obviously empathises with the complainant yet equally wants to support her staff. A complaint can certainly have major effects on staff⁴ who may well need support. However, support can easily turn into hostility and denial and these emotions may intrude on a balanced reply. There will probably be some hostility to the medical team who might be viewed as the villains by the A&E staff. The medical team will have corresponding feelings towards A&E. Often there is hostility towards the complaints department of the hospital.

The key problem in this complaint at this stage looks like poor communication at the time of the clinical incident. Poor communication in the handling of the complaint is compounding the problems.

If all the complainant's concerns had been addressed, if A&E and the physicians had discussed the response, if the reply had offered a meeting to discuss the complaint then it might have been settled.

There is no right and wrong in many of these matters but judgement is often helped by self knowledge and appreciation of these powerful human feelings, the feelings both of ourselves and others.

Time out—Strategic decision making

WAITING TIME PROBLEM

It might be appropriate to examine our feelings about waiting time complaints and waiting time problems but perhaps we have had enough self analysis for one issue. We will use the waiting time problem to look at the steps in planning and effecting change, using decision management⁵ and change management tools.^{6, 7}

Decision management is commonplace in all types of management. The design of a new car, new timetables for the BBC, and even waiting time problems in A&E can be tackled using this approach. This is usually one of the first lessons on any management course where teams are given a project to complete and then reflect on the processes (for example, in five minutes build the tallest tower possible using plain paper and paper clips).

Try to apply this structure to the waiting time problem. One common response to waiting problems is “we need more staff”. In real life this is often the case but within the resources available it should be possible to make some impact. Therefore at the beginning of the exercise take it as one of the objectives that any plans must be within current resources.

Waiting time figures are on the internet as are SHO rotas (emjonline/contents/SIMS3 and emjoline/eduction/).

In tray

INFORMATION

• Complainant response requesting an independent review.

• Hospital response to request.

• Two letters of complaint about waiting time at the weekend.

• Letter from Sister Oak about your strategy.

• Letter from medical director about the strategy.

• Note from Sister Ash—ECG machine broke last night. The back up machine is so obsolete they cannot find any recording paper for it! She wants urgent action as she says it is unsafe to care for patients with chest pain.

• Letter from deputy chief executive regarding legal claim.

• CVs and request to shortlist.

• Waiting time figures.

TASKS

• Outline the project plan that might deliver some of the aspirations revealed by the SWOT analysis. Take each of the major objectives and decide how urgent each is, how much effort is going to be needed, who might be the best person to “lead” the initiative and which ones you are going to “champion” (see Cole).⁸

• What is the procedure for an independent review? What preparation is needed? Should you consult the Trust's solicitors? (For those who have not already done so).

• Write a short paper on how you are going to approach the waiting time problem.

• This is the start of the business planning season. Outline the main headings of a business plan for St Jude's (or patient services plan as they are sometimes called).

• How are you going to deal with the medical director and Sister Oak?

• What are you going to do about the ECG machine?

• What actions are needed over the legal claim?

• Shortlist the candidates (four posts).

Disclaimer

The characters and incidents in this series are mostly fictional and any resemblance to persons or departments is coincidental. Some situations are based on real problems but in no case have names or details been used that might identify a department or person.