LSE researchers have developed a tool for systematically analysing patient complaints, helping healthcare organisations to reduce errors and improve outcomes.
What was the problem?
Healthcare complaints from patients (or someone speaking on their behalf) about failures in service provision are common. They might, for example, be about medical errors or poor-quality care. Complaints seek an institutional response to a failure, often in the form of an explanation, investigation, apology, or change of procedure.
NHS Trusts receive more than 130,000 written complaints each year. Around one in 10 patients experience unintended harm in hospital, and 14 per cent of such incidents lead to permanent disability or death.
Healthcare bodies often only assess these complaints in rudimentary and haphazard ways, focusing on individual cases or complaint volume rather than learning from the substantive issues they may raise. As a result, patients’ healthcare complaints have had minimal impact on improving services, which is a lost opportunity. If the information reported in complaints could contribute to reducing the number of adverse events, systematic problems could be identified and health outcomes improved.
What did we do?
In response to this problem, Dr Tom Reader and Dr Alex Gillespie undertook a systematic review of tools for analysing patient complaints, drawing on data from 59 studies and 88,069 patient complaints to outline the first taxonomy for analysing information in healthcare complaints.
From this, Reader and Gillespie developed the Healthcare Complaints Analysis Tool (HCAT), the world’s first empirically tested coding system for systematically analysing and aggregating written data provided by patients through complaints on poor-quality and unsafe healthcare experiences.
Freely available, the tool can be used for analysing the types of problems reported, their severity, their consequent harm, and where they occur in the healthcare service. Its key innovations include developing a method for quantifying this highly qualitative and unstandardised information, and for categorising the severity of problems reported, for example distinguishing between complaints about expensive parking compared to life-changing medication errors.
In 2017, Reader and Gillespie analysed 1,100 complaints made to the NHS, testing their analysis tool with a national sample of healthcare complaints. Their findings suggested two critical insights. Firstly, complaints can reveal “hot spots” of problematic care, showing patterns and causes of adverse events and near misses in a hospital or healthcare system. The second was that complaints also reveal “blind spots” in service provision. This refers to aspects of healthcare delivery that are difficult for hospitals to monitor. These can include problems in access to a hospital, systemic problems such as poor communication between units, and omissions in care, for instance when patients are not fed.
Analysis conducted in 2018 of healthcare complaints collated from 59 hospitals showed, for the first time, strong associations between patient reports of harm (including death) or severe clinical problems (such as cancer misdiagnoses) and hospital-level mortality rates. This association was stronger for healthcare complaints than for employee surveys, incident reports, and patient satisfaction surveys. Based on these results, Reader and Gillespie recommended that information provided by public complaints should be considered useful and supplementary for investigating hospital safety.
Reader and Gillespie’s novel Healthcare Complaints Analysis Tool (HCAT) has instigated a new body of research on the use of complaints to monitor safety in healthcare. It is now widely used by practitioners in healthcare and beyond.
In partnership with the National Institute for Health Research Patient Safety Translational Research Centre at Imperial College, a free online portal of HCAT resources – including the HCAT tool itself, along with an online training package, data visualisation tool, and benchmark dataset – has been created. Imperial College Healthcare Trust is driving the application of HCAT for improving patient safety. A leading NHS Trust, it treats over 1.5 million patients per year, and receives approximately 1,000 complaints annually. It uses HCAT to analyse and learn from these and identify areas for improvement. Imperial College has also established a new stream of research to test the effectiveness of HCAT as a potential alternative to the current UK complaints coding system.
In 2016/17, the UK Government Cabinet Office commissioned its Behavioural Insights Team to investigate the feasibility and benefits of applying this new analysis tool to complaints across the NHS, as well as the wider public sector. They piloted the tool in four healthcare trusts, and recommended that HCAT be adopted more widely, eventually replacing the existing national complaints coding system. Their report recommended both that health policymakers consider using HCAT and that the potential of such tools be explored beyond the health sector.
This report, and HCAT’s use by Imperial College Healthcare Trust, have been a catalyst for its adoption across more healthcare institutions, including Northern Ireland’s Southern Health and Social Care Trust, Great Ormond Street Hospital, and across NHS Scotland. LSE researchers were also invited to meet former Department of Health and Social Care Minister Nadine Dorries to develop policy for better managing complaints in NHS hospitals.
In line with the Cabinet Office recommendation, the methodology for complaints analysis has been adopted in areas beyond healthcare. The UK’s Ministry of Justice has adapted it (in commissioned work by LSE) to analyse public complaints to Her Majesty’s Courts and Tribunal Service, which is responsible for criminal, civil, and family courts and tribunals in England and Wales. Their version – the Courts and Tribunals Complaints Analysis Tool – analyses every complaint submitted according to its codification taxonomy to identify problems and areas for improvement, such as delays in probate cases or procedural errors in criminal enforcement.
Finally, HCAT has delivered commercial impacts via a long-term collaboration between LSE and Resolver – Europe’s largest handler of commercial complaints – by helping them to recognise and develop the potential business opportunity of aggregated analyses of complaints.