EUROPEAN PRESSURE ULCER ADVISORY PANEL

Dealing with complaints well can have a positive impact on culture if staff are supported in a way that helps them respond to complaints in a positive way. No-one is under any misapprehension about the way it feels when the copy of a letter of complaint lands in the ward or department office. Clinicians are their professional practice and criticism from patients wounds (almost as much a self criticism). But things can be done that can help it from becoming a bad experience. Some are very simple -tell the practitioner about the complaint, ask them to comment, and tell them about the outcome. Failing to do these basic things is not very common now, but it can happen. Others things, which can make it a productive experience for practitioners, patients and organisations, take more time and planning. For example:

1. Helping people spot the things that lead to complaints - there are many and common triggers for complaints - and either intervene early or take corrective action immediately.
2. Making the time to consider and respond to a complaint comprehensively - perhaps through an internal case discussion of all concerned rather than several bilateral exchanges of correspondence between clinicians and a complaints manager.
3. A determination to make the outcome of investigations count - from the personal - I am never going to postpone doing a Waterlow assessment again; I am always going to read the lab results before I see the patient; to the organisational - if I can't staff the extra beds, I'm not going to open them. Three real commitments to recent recommendations in our reports.

The final condition is also to do with making the outcome of investigations count - if action on a complaint includes co-ordinated effort to make a reoccurrence of the problem complained about less likely. The product could be a change in procedures or guidance, new education or induction programmes. The responses to our recommendations provide wide ranging examples - from introducing a nutrition policy for elders wards, to a new protocol for responding to ketoacidosis, to a complete change in management arrangements for a key service. None of these are straightforward matters, but an organisation that has a mechanism for acting on complaints - a key feature of its clinical governance arrangements - is also saying something about the importance it attaches to patients' experience of the service, and their safety; about its expectations of its staff and of those also involved in supporting them, including professional and educational organisations.

A phrase often used when people are talking about dealing with complaints - 'learning lessons' - is missing so far. Although almost all the foregoing has been about learning from the experience of dealing with complaints, and making personal and organisational changes, the phrase 'learning the lessons' is one I try to avoid. Failure to 'learn the lessons' is a frequently heard criticism of health services - whether that is failure to act on the recommendations of several public enquiries, or to change clinical practice - for example hand washing. I try to avoid the phrase because it evokes in me a feeling of personal incompetence and hopelessness in the face of enormity, and I imagine it does for others too.

A more productive question, and a more interesting one in my view than 'why have you failed to learn the lessons?' is 'why are some lessons so difficult to learn?' Of course, it may come to the same thing, but the first invites defence (e.g., too little time and too few resources), while the second might invite inquiry.
There is only time to propose three things that seem to me to make some lessons hard to learn - by which, incidentally, I think we usually mean 'fix things'.

The first is to do with complexity. Very few 'lessons' are to do with the practice of an individual, or a single source for a type of mistake that can be eliminated. Addressing errors of connection and disconnection (e.g., enteral feed to a central line) is not so much a simple design issue as a matter of international commercial interests. I think I can illustrate another sort of complexity from our recent experience. It is only recently that three things have come together which means that we can play a credible part in discussions about improving practice in pressure area care and wound management. First, our office reviewed its criteria for investigating a complaint and, as a result, looks more often than it had in the past at the quality of nursing care. Second, the Department of Health in England published 'Essence of Care' which established nursing care benchmarks in a number of areas - including nutrition, hydration and pressure area care. Third, we had a cluster of cases which illustrated the result of inadequate assessment, care and monitoring patients at risk of pressure ulcers. These developments arose separately, and from different sources, on the face of it. I think that they have contributed to the slightly higher political profile fro pressure ulcer management, and, locally, my colleagues are able to make better and more relevant recommendations as part of our reports. Why has it happened now? Was it chance that three developments were linked together by people focused on improving care, who happened to come into contact with each other at the right moment? Or are there people who are always watching for the sorts of connections that can advance an important issue and promote improvements in care?

The fact is that clinical care, clinicians, patients - life - are complex, so there often has to be a complex (not complicated) response when something goes wrong, which can be daunting - and people shy away.
The second is that some lessons are too big to 'learn' easily. For example, writing decent clinical notes, an essential part of effective clinical practice. Poor record keeping is a feature of almost every case we investigate. If people are taught that they are personally responsible for the care of an individual (and their personal right to practice will be removed if they make a serious mistake), we cannot be too surprised if they make notes in the form of a personal aide memoire. If we taught people that they were one of a team providing care we might more often see notes written for the purpose of communication - but we (i.e., society) may have to forego the 'pleasure' of insisting that an individual bears the consequences if something goes wrong.

The third is to do with leadership. The literature on error in medicine and other industries refers often to the emergence of leaders who invest energy in eliminating sources of error, or to the absence of leadership, which contributes to continued problems. The latter may be a simple matter of '… there was no head of service for the nine months between the departure of the former manager and her successor taking up post'.
There are other possibilities, of course - perhaps finding a different focus for discussion. If 'eternal vigilance' for problems featured in undergraduate, postgraduate and continuing programmes of education; if errors were talked of as the consequences of problems, rather than the cause of them; if variability was talked of as an asset, rather than a cause for concern - would people not think about problems in health care differently, and about how best to 'learn lessons'?

Experience and common sense tells us that a single complaint can have the effect of a short sharp shock to the system, and evoke both an immediate and sustained response. A series of similar complaints, and not necessarily about the same service, can lead people to look for the source of the problem, and go on to think about why some problems are hard to resolve - that some lessons are hard to learn; and what it is that makes individual and organisational behaviour change. But a system for dealing with complaints that is detached from other care management and improvement systems -audit, education, performance review - will provide none of these benefits for practitioners and patients. I believe it is clinical governance arrangements in the NHS that have had the strongest impact on 'the way we do things around here' - when they connect research and education to appraisal and supervision, and serious incident reports and complaints to performance review and audit. NHS organisations have been working to make those connections, and so shift their cultures, for the past two and more years. The government bodies working in similar fields to the Ombudsman's office - the Commission for Health Improvement, the National Institute for Clinical Excellence, the National Patient Safety Agency and others, are working to make the same connections at national level. Will we, collectively, get it right? Feel free to check our website (http://www.Ombudsman.org.uk) for details of our investigations and their impact, for evidence both of trying to do so and, I hope, succeeding.

September 2001