Emotions in Decision-Making - Hindrance or Help?

Contents

Acknowledging the Limitations of Data

The demographic profile is our equivalent of knowing the date and place of our philosophers' meeting. People have a choice whether or not to share their personal data and if they choose to do so, we may presume they have no interest in giving false information. The question here is not then about the validity of the data but of deciding what to make of that information.

We certainly need to be cautious when using the demographic data. In complainant surveys, 'representativeness' can be a red herring.

Complainants need not be representative of anyone but themselves. However here it was clear that we were hearing from a very particular part of the population. For example, 91% of those who returned a questionnaire were female. Over half owned their own homes. Most were British-born Christians. This is not a mirror of the part of London where the hospital is situated.

The findings confirm that the people who chose to take a complaint on up the ladder in any environment and 'market' are on the whole amongst the more socially confident and articulate members of our society. We must acknowledge that the information has its limitations and cannot be used to understand the experience of a wider set of patients. It is however ok for our purposes which was to gather some information about users of the escalated complaint system.

Cross Checking for Validity

Prior to our survey, the management had no complainant-based data at all and so these findings gave them information that they had never had before. However can they be confident that the data represent reality if so few have provided it?

Here there was a way to check validity. The hospital had been gathering 'cause' data from the complaints handled. These confirmed our findings from the survey. 33% of the people who answered felt that the doctors had made a a mistake in diagnosing or had missed what was wrong. The next most important problem chosen by 21% was the poor attitude of staff (doctors, nurses). The hospital data confirmed that these causes are, sadly, the hardy perennials of health services complaints.

But cross-checking the survey findings against internal information gives an important reassurance that we are on the right track. What the quality manager needs to understand now is whether easier victories are available - the smaller, apparently less important problems that could well be easier to fix?

Multiple Problems in one Complaint

People ticked the boxes for 23 other problems indicating the multi-dimensional problem mix in the complex hospital environment revealed in these comments "in this year (2005) you have had the following continuing problems. your disabled toilet facilities for outpatient are excellent but those for inpatients are largely of an unacceptable standard. There are still not bath (bathing) facilities for disabled inpatients. 50% of the inpatient toilet/bathrooms are of poor standard + some frankly unhygienic. The refurbished ones are lovely. in February your kitchen ran out of kosher food. Your healthcare assistants do not care enough about whether a patient is fed; can eat unaided; can open food package; have fresh water or other fluids if recommended by dr. There are shortages of pillows. linen comes back from laundry with old dressings and excrement still on it."

Not Definitive but Indicative

The numbers of people in our survey are too few for quality managers to be absolutely certain that the problems mentioned by our sample are those that would be picked by all. But they now have a shape to the consumer experience and can start accumulating data on those other problems where progress is possible. The longer catalogue of 'smaller' quality failures as perceived by the patient offer richer and potentially more productive pastures for service quality improvement action. The complaints that go on to become escalated complaints concentrating as they do on clinical matters are not the best platform for a comprehensive service quality programme that seeks to tackle problems over a broad front.

Glimpses of Process

What about the process itself? What guidance does the complaint manager get? In contemplating the findings about the narrative of this particular escalated process, we were reminded how little of the process the complainant actually sees or is involved in as opposed to being present as a patient or a frequent visitor to a ward or clinic. They had to guess what was going on and cannot answer questions about parts of the process they have not experienced.

The really useful data from this part of the survey came on that complaint process stage prior to its escalation to the complaints office as a formal written complaint. When asked whether they had talked to anyone about their most serious problem before coming to the Complaints Department, 77% said they had. Some had gone to sources outside the hospital such as a solicitor or the Minister of Health and their MP but for the most part, they went to someone in the hospital. The hospital has a chance of pulling the complainant back from the formal procedure. 19 of the 26 people who answered this question said they had contacted someone at least and 4 of that number up to three times.

Identifying Opportunities for Resolution

The opportunities for resolution opened up by this data are important and a valuable insight into how hospitals can work with patients to minimise escalation and how much faith patients continue to have in a system that they abandon reluctantly to take up their complaint formally. Again the numbers are less important than the general guidance on behaviours and the definition of an opportunity to intervene.

We have now seen that feeling strongly about a problem does not impede people from giving a good account of what happened. Did the survey offer a comparable insight into what the complainant felt about the process as a whole?

I don't believe it!

The feeling that came through most strongly was the disenchantment and disbelief of the complainant in regard to what the NHS complaint literature and information describe as the central premise and promise of the NHS complaints system - that a complaint would help ensure that things would be improved as a result of complaining. Complainants want to believe this but the system does nothing to reassure them and this arouses strong feelings.

In my view, the NHS complaint process is an investigation-based process that seeks to establish 'facts' by going back and taking acounts from clinicians and others involved. In doing so, it disguises and hides the emotional aspects by throwing the fire blanket of process over the blaze of feeling. This may dampen feelings down - it rarely extinguishes them; rather banks them up - so making things more comfortable for the managers and clinicians involved - the dispassionate path of process can reassure those whose conduct and judgements are being challenged. They feel safer if the process looks even-handed and 'fair'. (We can discuss another time whether things have to be this way.)

But to the complainant of course, whose feelings are being ignored and tidied away in the interests of process, this looks like indifference, condescension or at worst total exclusion from an approach which is then seen as favouring the insiders. The dispassionate process disarms the consumer whose major weapon is emotion. Can it be a surprise then if satisfaction is so low with a process that puts them through a lot and apparently delivers so little?

Continued: Learning Points & Questions for Readers