Listening and learning

1. Listening and learning Dorothy Armstrong Clinical Adviser Scottish Public Services Ombudsman Patient Opinion Event I 14th March 2012 I Glasgow

3. Compu’er says NO But things do go wrong..

4. Dispelling the myths • Drive improvement • Public servants • Users of the NHS • Impartial • External ‘ a critical friend ‘

5. So perhaps they really should be treasured • Complaints are a key source of feedback from users. • And can be used to drive service improvement. • Good complaints mechanisms can stop disputes escalating – saving time and money.

6. Themes from spso • Communication • Documentation • Care and compassion • End of life care • Transitions and discharge • Technical care

7. ‘Although his proper name was John, he was known as Jack all his life. The name above his bed was John and staff called him John. This added to his confusion.’

8. ‘He needed help to eat and drink. There seems to have been a total breakdown of communication regarding his blindness and his nutritional needs. A member of staff should have been assigned to help him eat and drink.’

9. Mid Staffordshire report

10. Reasons why people complain • Don’t want the problem to happen again • Lessons to be learned • A full explanation • Commit to feedback • They feel humiliated, betrayed and hurt • Explain what happens next • An apology

11. Frontline resolution For issues that are straightforward and easily resolved, requiring little or no investigation • On the spot apology • Explanation or other action to resolve • Addressed by any member of staff or referred appropriately • Recorded – actions taken • Feedback used for service improvement

12. Investigation For issues that have not been resolved at the frontline, or are serious or high risk • Encourage face to face / telephone contact as early as possible • Responses within 20 days or communication • Consider internal review / significant events analysis • Consider mediation / advanced interview techniques • Responses signed off by senior managers • Complaints valued as part of the feedback process • Links to governance including Board reporting (Mid Staffs)

13. Empowering staff ‘Disclosure is not about apportioning or accepting blame It is about being truly professional. The NHS needs to learn to apologise more often. And it needs to learn to mean it.’ Sir Liam Donaldson, Chief Medical Officer for England. BBC Feb 09

14. ‘an apology is the superglue of life..it can repair just about anything’New South Wales Ombudsman, (2009).

15. There were eleven patients given a contaminated solution which had been injected into the heart during cardiac surgery. Five of the eleven patients died following this error. One of the senior staff recalls the events: ‘ One of my senior colleagues called all the families together and he and I sat down with the eleven families and said “This is terrible thing that has happened. It is awful. We are truly sorry that this has happened. We are not going to do another operation until we have got these patients out of the woods.” And we did not. We said “We are going to leave no stone unturned until we find out what the cause was.” We knew it was an infection, we knew it had occurred somewhere in the processing of that solution, which was beyond our control as individual clinicians. But we said sorry. None of those patients took legal action. Australian Ombudsman 2009

16. The power of apology - The 3 R’s • REGRET • Sorry, unreserved, meaningful, genuine ‘I am so sorry.’ • REASON • Explain, not defensive ‘This is what happened.’ • REMEDY • YOUR commitment to put things right, next steps. ‘This is what I will do to prevent this happening again.’

17. An apology ‘your complaint has made me reflect on what I did and here is what I have learned from it. Here is what I’m going to do and I apologise unreservedly.’

18. Recommendations • Organisation • Apology and/or explanation • Evidence of education and training • Strategy / lessons learned • Team / Department • External peer review • Leadership • Individual • Appraisal / feedback • Rarely Regulator informed

19. Driving change • nutritional care in hospitals • dementia care • end of life care • hospital cleanliness

20. Top ten tips • Create the culture – role model behaviours • Early resolution – empower your staff at all levels • Early escalation – manage the risk • Value feedback – drive improvement • Little things make a big difference • 3 R’s - regret, reason, remedy • Older people – if we get it right for them we will get it right for all! • Documentation – if it isn’t written it didn’t happen • We are all users of the NHS - we want the same things • It’s everyone’s business

21. 4 Melville Street EDINBURGH EH3 7NS Phone + 44 (0) 800 377 7330 Email darmstrong@spso.org.uk Website www.spso.org.uk