We developed the gripes tool with input from junior doctors and piloted it at a large UK teaching hospital trust. We evaluated the tool through an analysis of concerns reported over a 3-month pilot period, and through interviews with five stakeholders and two focus groups with medical students and junior doctors about their views of the tool.
Junior doctors reported 111 concerns during piloting, including a number of problems previously unknown to the trust. Junior doctors felt the tool was easy to use and encouraged them to report. Barriers to engagement included lack of motivation of junior doctors to report concerns, and fear of repercussions. Ensuring transparency about who would see reported concerns, and providing feedback across whole cohorts of junior doctors about concerns raised and how these had been addressed to improve patient safety at the trust, were seen having the potential to mitigate against these barriers. Sustainability of the tool was seen as requiring a revised model of staffing to share the load for responding to concerns and ongoing efforts to integrate the tool and data with other local systems for gathering intelligence about risks and incidents. Following piloting the trust committed to continuing to operate the gripes tool on an ongoing basis.
The gripes tool has the potential to enable trusts to proactively monitor and address risks to patient safety, but sustainability is likely to be dependent on organisational commitment to staffing the system and perceptions of added value over the longer term.
A three-person team managed the gripes system and took daily responsibility for monitoring and responding to the concerns reported. The team comprised a registrar seconded on a clinical education fellowship with dedicated time away from clinical duties; the director of safety and risk at the trust (an executive role that involves taking responsibility and providing clinical leadership for safety across the trust); and an information analyst. Prompt feedback about actions taken in response to concerns was provided to individual junior doctors who reported concerns, if contact details were provided. Concerns were resolved by the gripes team where possible or escalated by team through various routes (e.g. through IT services, the trust executive quality board, the trust chief executive).
Concerns were analysed descriptively, to summarise the number reported, and patterns of reporting. We interviewed five stakeholders (members of the gripes team and trust senior executives) about their experiences of operating the system and managing concerns. We conducted two focus groups with nine participants overall (one specialty trainee, one core trainee, two foundation year 2 doctors, one foundation year 1 doctor, and four final year medical students) to examine user views of the tool and how it could be improved. Participants were recruited by email using local lists and snowball sampling. Informed consent was gained from participants. Focus groups were facilitated by TM and CT, with a topic guide used flexibly to promote discussion. Interviews and focus groups were digitally recorded and transcribed verbatim.
The gripes website attracted over 1500 page views during the pilot period. Overall, 111 concerns were reported. Figure 1 shows the number of concerns reported by date across this time period alongside a variety of activities promoting the tool.
The gripes team was able to quickly rectify a number of urgent or straightforward problems, such as missing or broken equipment, and some personal issues such as difficulties with annual leave. More complex or serious problems were escalated within the trust. Examples of serious problems that the team was alerted to, and was able to address, included the following:
Focus group participants highlighted a number of ways to optimise the gripes tool and system to help promote junior doctor engagement, including further simplification of the form, promotion of the tool and feedback of actions taken in response to concerns, transparency about who would see reported concerns, and consideration of making the tool available off trust premises.
The gripes team registrar reviewed concerns daily, provided prompt feedback to all who provided their contact details, and where possible worked with the junior doctor who reported the concern to try to resolve the problem. The trust director of safety and risk also reviewed concerns regularly and, in consultation with the registrar, took responsibility for escalating more serious or complex problems: working with other senior staff in the trust to coordinate solutions and develop action plans and reporting back to higher levels of the organisation.
Concerns about negative consequences of reporting were expected to be relieved to some extent if the gripes tool became embedded in the organisation, as long as there was good evidence that concerns were being handled sensitively by the gripes team, and evidence that reporting actually did make a difference.
Designing a sustainable system was challenging. The day to day running of the system was dependent on a registrar in a clinical education fellow post; the gripes register left the trust after the pilot was completed, but the trusts were able to reallocate this role to a new incoming fellow to ensure the work continued. IT and analytic support were also important but hard to resource. The level of commitment of the trust director of safety and risk was seen as unsustainable beyond the pilot, partly because it was not financially resourced. The proposed solution was to gain the commitment of other trust directors to share the responsibility for managing reported concerns, rather than this responsibility resting solely with a single director.
This pilot indicates that the gripes tool offers an approach for organisations to gather knowledge about risks to patient safety from junior doctors, who are well-placed to see these risks in the course of their day to day practice. Given that there are multiple tools and systems for reporting concerns in operation across hospitals, this is only one part of a bigger picture. Gripes data is likely to be of most value when triangulated or used alongside data on problems and incidents from a range of other sources including incident reporting systems and soft intelligence from staff and patients about problems in care .
This pilot study was limited in that it was run in a single large trust; the replicability of the gripes system in other contexts is likely to be in part dependent on the availability of resources to support its operation. Stakeholders suggested that the tool worked well because it was part of a wider shift within the trust towards developing a positive organisational climate of listening to staff concerns. The extent to which such a system will embed in other contexts is likely to be dependent on the local organisational climate in relation to listening to staff concerns.