What can high risk organisations learn from complaints?

Sai Kalvapalle is a PhD candidate in the Department of Business-Society Management at RSM. She is interested in investigating the sensemaking processes underlying the use of dating apps such as Tinder, and what this might mean for the institutions of love and relationships. In this blog post for CESAM, she discusses research she began during her MSc at the London School of Economics (LSE): Can online data from employee reviews provide crucial insights that organisations can learn from?

Irony and tragedy are not merely facets of Shakespearean literature: they are also persistent factors in high-risk organisations such as healthcare and aviation. The irony is that such organisations need feedback to learn from errors, and yet their internal culture prohibits that voice, particularly the voice of employees. The tragedy is in the consequences: the effect on patient safety and quality of care. A recent, poignant reminder of this tragic irony can be found in the Staffordshire Hospital scandal in the UK over a period of four years (2005-2008): between 400 and 1,200 more patients died than would be expected. What was particularly tragic about this is its entirely avoidable nature. An investigative inquiry in 2013 revealed hospital management completely disregarded warnings raised by patients and staff, leading to a major crisis in the UK’s National Health Service (NHS). 


Why don’t organisations listen?

What perpetuates this culture of silence that is so detrimental to safety? Taking a human factors approach, we can either blame the person, or blame the system. Blaming the person attributes the error to their carelessness, negligence, forgetfulness, or inattention. To counter such behaviours, the organisation resorts to ’naming, shaming and blaming’. The systems approach, on the other hand, acknowledges human fallibility, and aims to improve the systems in place to safeguard against such human error.

Guess which approach the medical industry most often takes? The person approach. So employees do not speak up, because they fear facing negative consequences if they do, and the culture of the organisation persists in silence, and thereby fails to use the value of complaints as opportunities for preventing future harm.


Resolving the paradox: Glassdoor

So if employees cannot speak up in the organisation, and the organisation cannot learn from errors, can it ever escape this paradoxical state? Maybe. Primarily, we can speculate if perhaps employees are speaking up anywhere outside the organisation. And if we can then access this voice, we can facilitate organisational learning.

In research I conducted with Dr Tom Reader at the London School of Economics (LSE), we did just this. We found that employees were speaking up about their organisation on a publicly accessible platform, the employee review website Glassdoor.co.uk. Glassdoor is a website where current and former employees can appraise their organisation, both on predefined scales (e.g. work-life balance), or by writing reviews of the organisation, its pros and cons, and even giving advice to management. What was of specific interest to us in the context of organisational learning were the ‘cons’ and ‘advice to management’ sections, because we wanted to provide the organisation (in this case, the NHS) with insights into quality and safety failures. 

I extracted and analysed 514 employee reviews from Glassdoor, revealing approximately 1,700 issues. I analysed these reviews several times, but conducted two distinct content analyses. In the first study, I used a pre-existing patient complaints framework (the Healthcare Complaints Analysis Tool; HCAT) to code the data. In the second study, I inductively built a framework specifically for employee complaints, called the Employee Complaints Analysis Tool (ECAT).


What we learned  

We learned that NHS employees were indeed raising issues on Glassdoor. More than half of the issues pertained to management problems, others were about relationship problems, staff quality of life problems, and patient care problems. The top four problem categories reported were institutional processes, followed by environment, physical and psychological problems and respect and rights.

In addition to these important insights into NHS failures in safety and quality of care (such as poor staffing, lack of resources, waste of resources, poor managerial competence, bullying, and disrespect), there was another crucial finding.


Back end issues

We found that the issues that employees complain about are significantly different to the issues that patients complain about. Patients are more concerned with point-of-care issues such as neglect, but employees report on back-end issues that lead to the point-of-care failures, such as understaffing.

Triangulating problems using complaints from patients and complaints from staff provides a holistic overview of failures; it is a way to proactively prevent avoidable errors. Perhaps this holistic understanding will facilitate a cultural shift toward a system approach to error in healthcare.



Establishing ECAT as a comprehensive, reliable framework for coding employee complaints data has several implications for research, methodology, and practice. The NHS could use the aggregated complaints data to reflect on organisational failures and assess blind spots in service delivery – and it is a step in the right direction to foster a culture of safety. Using Glassdoor as an unobtrusive data source is a case in point that methodological novelty can yield insights into organisational phenomena that would not otherwise be accessible using traditional research methods.

While high risk organisations must make consistent efforts to encourage speaking up behaviours, we must also be creative in finding methods that enable us to peer through the glass door.

Picture: Stethoscope by Rosmarie Voegtli, Flickr


If you enjoyed reading this, try another one in our series of blog posts about aspects of safety from the Centre of Excellence in Public Safety Management (CESAM) at Rotterdam School of Management, Erasmus University (RSM). It is intended to act as an introduction to the Centre’s work; to promote and foster the professional development and management of public safety organisations, and to give CESAM members a platform to share their observations and experiences as academics and citizens. Please see our webpage to find out more.


CESAM blog