Complaints Management Handbook for Health Care Services

Loading...

Please note that the following document was created by the former Australian Council for Safety and Quality in Health Care. The former Council ceased its activities on 31 December 2005 and the Australian Commission for Safety and Quality in Health Care assumed responsibility for many of the former Council’s documents and initiatives. Therefore contact details for the former Council listed within the attached document are no longer valid. The Australian Commission on Safety and Quality in Health Care can be contacted through its website at http://www.safetyandquality.gov.au/ or by email [email protected] Note that the following document is copyright, details of which are provided on the next page.

The Australian Commission for Safety and Quality in Health Care was established in January 2006. It does not print, nor make available printed copies of, former Council publications. It does, however, encourage not for profit reproduction of former Council documents available on its website. Apart from not for profit reproduction, and any other use as permitted under the Copyright Act 1968, no part of former Council documents may be reproduced by any process without prior written permission from the Commonwealth available from the Department of Communications, Information Technology and the Arts. Requests and enquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Intellectual Copyright Branch, Department of Communications, Information Technology and the Arts, GPO Box 2154, Canberra ACT 2601 or posted at http://www.dcita.gov.au/cca

Complaints Management Handbook for r Health Care are Services

AUSTRALIAN COUNCIL FOR SAFETY AND QUALITY IN HEALTH CARE - JULY 2005

AUSTRALIAN COUNCIL FOR SAFETY AND QUALITY IN HEALTH CARE

Complaints Management Handbook for Health Care Services

July 2005

ISBN: 0642 82641 2 © Commonwealth of Australia 2005 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth available from the Department of Communications, Information Technology and the Arts. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Intellectual Property Branch, Department of Communication, Information Technology and the Arts, GPO Box 2154, Canberra ACT 2601 or posted at http://www.dcita.gov.au/cca. The Australian Council for Safety and Quality in Health Care is a joint Australian, State and Territory government initiative to lead national efforts to improve the safety and quality of health care, with a particular focus on minimising the likelihood and effects of error.

Acknowledgements The Australian Council for Safety and Quality in Health Care (Council) acknowledge all stakeholders involved in the Council’s program of work and activities. The Council particularly thank the State Quality Officials’ Forum and Council Working Groups and Taskforces for their significant contribution to the Council’s work and the patient safety agenda in Australia. Council would also like to acknowledge the contributions to this project made by: Amanda Cornwall, project manager, Turning Wrongs Into Rights project at that NSW Health Care Complaints Commission; Tania Sourdin, Professor of Law and Dispute Resolution, La Trobe University; Michaela Lauren, project officer, Health Care Complaints Commission; and the contributions made by the people in accreditation and standards bodies, medical defence organisations, government agencies and expert consultants who provided helpful advice and comment on drafts of the handbook. Finally, Council is grateful to the people who agreed to have their stories presented in the case studies in Part 4, which are published with their permission.

Publication approval number: 3628 (JN 8952)

Preface The Australian Council for Safety and Quality in Health Care (Council) aims to reduce harm to patients and improve the safety and quality of health care. The Council’s vision for a safer system is one that places consumers at the centre of the system and harnesses the experiences of patients and their carers to drive improvements. The Council is also committed to improving responsiveness of the health system to the needs and concerns of consumers. Consumers (including patients and carers) have a unique expertise in relation to their own health and their perspective on how care is actually provided. Consumer complaints are, therefore, a unique source of information for health care services on how and why adverse events occur and how to prevent them. As well as reducing future harm to patients, better management of complaints should restore trust and reduce the risk of litigation, through open communication and a commitment to learn from the problem and prevent its recurrence. In 2003, Council funded the Turning Wrongs into Rights: learning from consumer reported incidents project as part of a practical way to promote better practice in complaints management by Australian health care services, with a focus on using complaints to improve safety and quality. The Council engaged the NSW Health Care Complaints Commission to undertake the project on behalf of the Australasian Council of Health Care Complaints Commissioners, working with the Royal Australasian College of Physicians and the Health Issues Centre. The project reviewed research on good complaints management, surveyed 53 health care organizations, conducted consultations and drew upon existing policies, standards and laws to develop the Better Practice Guidelines on Complaints Management for Health Care Services. This accompanying Complaints Management Handbook was also developed, as part of the project, to assist organisations in implementing the Guidelines. The Complaints Management Handbook is intended to provide practical assistance to organisations wanting to implement the Guidelines and to promote positive attitudes to complaints as part of a wider consumer feedback strategy.

Contents How to use the Handbook ......................................................................................................1 Part 1: A new approach ...........................................................................................................5 Part 2: Implementing better practice ....................................................................................15 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

Commitment to consumers and improvement ........................................................15 Accessible processes and information ....................................................................18 A responsive approach ............................................................................................20 Effective assessment of complaints ........................................................................22 Appropriate resolution processes ............................................................................25 Privacy and open disclosure ...................................................................................29 Gathering and using information ............................................................................31 Making improvements ............................................................................................33

Part 3: Sample documents ....................................................................................................39 Sample Complaints policy and procedure ......................................................................39 Sample Consumer Feedback brochure ...........................................................................48 Suggestion for improvement form ...................................................................................49 Complaint follow up record ............................................................................................50 Letter acknowledging a complaint ..................................................................................53 Letter confirming a complaint has been resolved ...........................................................54 Self Assessment Guide: how does your health service rate? ..........................................55 Part 4: Case studies ...............................................................................................................61 1: 2: 3: 4: 5: 6: 7: 8: 9: 10:

A general practice ...................................................................................................61 A large, metropolitan teaching hospital ..................................................................64 A small, private nursing home ................................................................................66 A community health service and residential aged care ..........................................68 A semi-rural community pharmacy ........................................................................69 A statewide children’s hospital ...............................................................................71 Collaborating with consumers ................................................................................73 A private, rural hospital ..........................................................................................74 Consumer focus ......................................................................................................76 A corporate group of hospitals and nursing homes ................................................77

Supplement for general practices and other specialists ........................................................85 Health complaints contacts ...................................................................................................93 Figures Figure 1– The learning cycle ..................................................................................................7 Figure 2– The Consumer Feedback Loop ..............................................................................9 Figure 3– Severity Assessment Matrix .................................................................................24 Figure 4– Complaints Management Flowchart ....................................................................47

How to use the Handbook This Handbook offers practical information and assistance to people who manage complaints in health care services. It also provides guidance for the implementation of the national Better Practice Guidelines on Complaints Management for Health Care Services. The Handbook is presented in four parts. Part 1: A new approach

Discusses the research and policy basis for the quality improvement approach to complaints management, based on fairness, risk management and partnerships with consumers.

Part 2: Implementing better practice

Discusses each guideline and the indicators, which describe practices consistent with each guideline. Topics include, learning from errors, recording complaints, fairness, privacy and confidentiality, risk assessment and evaluation.

Part 3: Sample documents

Provides tools, including a sample Complaints Policy and Procedure; a sample Suggestion for improvement form; a sample Complaint follow up record; sample letters; a sample Consumer feedback brochure; and a Self assessment guide.

Part 4: Case studies

Provides 10 case studies to illustrate how health care services in different settings manage complaints and describe the experiences of consumers who have lodged complaints.

Supplement:

A Supplement for general practices and specialists is provided at the end of the Handbook with summary tips and a short sample complaints policy.

Contacts:

Contact details for health complaint organisations.

There are many different ways of managing complaints well, and the approach will vary according to the type and size of a health care service. This Handbook recognises the differences between the acute care, primary and office-based care, mental health and the aged care sectors. A distinction is also made between ‘large’ services (those employing 25 or more staff) and ‘small’ services (those employing less than 25 staff). Turning wrongs into rights This Handbook and the Better Practice Guidelines on Complaints Management for Health Care Services are initiatives of the Australian Council for Safety and Quality in Health Care (the Council) and the Australasian Council of Health Care Complaints Commissioners. The Guidelines and Handbook are the result of the Turning wrongs into rights: learning from consumer reported incidents project, undertaken in 2003 and 2004. The Council engaged the Health Care Complaints Commission NSW to conduct the project on behalf of the Australasian Council of Health Care Complaints Commissioners, with the Health Issues Centre and the Royal Australasian College of Physicians.

1

The project conducted research on better practice complaints management in Australia and internationally and consulted widely with interest groups. Information about the project is available at www.hccc.nsw.gov.au and a literature review from the project is available on Council’s website www.safetyandquality.org. About the Guidelines The Guidelines are designed to assist health care services when developing or improving their complaints management system. The Guidelines take into account relevant policies of Australian governments; the standards of leading accreditation programs in the health sector; the national Open Disclosure Standard 2003; and relevant Australian and International Standards. The ‘better practice’ approach used in the Guidelines supports health care services to continue improving their performance over time.

2

PART ONE A NEW APPROACH This part of the Handbook discusses the research and policy basis of the Guidelines and Handbook.

Part 1: A new approach Listening and learning Comments and complaints from consumers provide unique information about their needs and the quality of care they receive. Open discussion of consumers’ concerns helps health care professionals to understand potential problems and how to improve their service to the public. Only a small proportion of people who are dissatisfied will lodge a complaint (less than 4 per cent), but they will tell their family and friends about their bad experience and go elsewhere if they can. A proactive approach to capturing consumer feedback is needed if consumers are to make a useful contribution to quality improvement, whether it’s through complaints, suggestions or comments. Benefits While poor complaints management can damage your service, good complaints management systems help: •

improve the safety and quality of the service, by providing information about the experiences of consumers and carers;



restore the trust and confidence of a consumer or carer;



save management time by the quick and simple resolution of complaints, avoiding escalation;



promote a culture of reporting and accountability;



prevent wasteful practices and reduce the costs, such as insurance;



create a more satisfactory working environment for clinicians and staff; and



enhance the reputation of the service and prevent negative comments or publicity.

Fairness Good complaints management procedures are based on the principles of fairness and natural justice. Fairness means that decisions are fair and seen to be fair, and based on what is regarded as good practice in the health care sector. Natural justice requires that consumers, health care professionals and other staff know the claims that have been made in a complaint and their views are considered without bias or prejudice. ‘The days are gone when you can ignore complaints. Often people only want to be heard.’ Dr Ferguson, Principal Partner, Brooke Street Medical Centre.

Fairness requires that information provided for the purpose of complaints is kept confidential, unless the law requires disclosure. Fairness also means people can go to an independent health care complaints commission at any time if they wish.

5

Good complaints handling The traditional approach to dealing with complaints in the health care sector was to avoid them and deal with them separately from other risk management and compliance issues. Under this approach the investigation of complaints examined only what happened, not why, with a focus on the individuals directly involved rather than the systems of care. The quality improvement approach to handling complaints has a number of elements: •

actively encouraging feedback from consumers about the service;



negotiating with consumers about outcomes and not just ‘telling them’;



managing complaints as part of risk management, enabling appropriate reporting, assessment and follow up action; and



learning from complaints and consumer feedback, enabling improvements to the systems of care.

Good complaints management means being open with consumers, investigating the causes of what happened and developing strategies to prevent re-occurrence. Complaints and quality International and Australian research over the past decade has provided a new understanding about the extent of harm occurring to people while receiving health care and how the harm can be prevented. There have also been a number of high profile public inquiries in England, Australia and Canada revealing instances of mismanaged care that have either gone unnoticed or been ignored. Quality improvement in the health care sector emphasises the need for reporting and analysis of all types of incidents that have, or may have, caused harm so they might be prevented in future. Quality improvement promotes: •

a new culture of trust so adverse events are reported and discussed, instead of a culture of blaming and isolating individuals;



a greater partnership between consumers and health care professionals;



clear lines of accountability for individuals and the organisation; and



services that are designed from the consumer’s perspective, rather than the ‘silos’ of professional specialty or types of care.

Information on poor quality services is available from a range of sources: mortality and morbidity rates; confidential surveys of doctors; clinical and medical audit; post operative infection rates and rates of re-admission. Consumers’ views about the quality of care are equally relevant to the quality improvement jigsaw. ‘… patient complaints can provide vital red flags.’ Professor Linda Mulcahy, 2003

Consumers may be the only ones who know they are in pain longer than anticipated, that medication is not having the desired effect, or that the time they are expected to wait for the next appointment is unreasonable. The views of family and friends can be just as important.

6

Learning from mistakes Recognising the factors that enable learning from mistakes is an essential element of effective quality improvement. Lessons can be learned from error regardless of the consequences that flow from the mistake. Monitoring all types of incidents that have the potential to result in harm is, therefore, important. This preventive approach is reflected in the Australian Council for Safety and Quality in Health Care’s definition of ‘incident’. ‘Incident: an event or circumstance which could have, or did lead to unintended and/or unnecessary harm to a person, and/ or a complaint, loss or damage.’ Organisational culture is central at every stage of the quality improvement cycle, from identifying and reporting incidents, through to making sure the necessary changes occur. A ‘safety culture’ promotes reporting and balanced analysis, in principle and practice. Conversely, a ‘blame culture’ encourages cover up for fear of retribution, with a heavy focus on individual actions and largely ignoring the role of underlying systems of work and systems of care. Reporting systems are vital for providing useful and reliable information for analysis and recommendations. Experience in other industry sectors demonstrates the value of systemic recording and reporting of a wide range of performance-based information. Figure 1 – The learning cycle

Embed and sustain changes

Monitor Service Delivery

Awareness of systems

Identify potential and actual risks

Implement changes

Prioritise, disseminate, train

Analysis

Make changes to policy and validate

Lessons learned

Distill and validate

Source: An organisation with a memory, NHS (UK)

Attitudes to complaining The first and most important step in good complaints management is to be open to complaints and see them as an opportunity for improvement. In the health care sector, this poses a significant challenge as neither doctors nor consumers are comfortable with complaints. International research has found that doctors view complaints as unwarranted attacks on their commitment and competence. A significant proportion of doctors is unlikely to discuss

7

complaints with family or colleagues because they worry about being poorly regarded. The fear of being investigated, where the investigation process lacks credibility, is another factor. As a result, health professionals have been found to respond to complaints defensively. They tend to blame others for what happened, or diminish the validity of the complaint by characterising the person complaining as difficult or unworthy. Consumers and their carers are reluctant to complain about health care services because they generally place a high level of trust in health care professionals and rely on them for their expertise. The fact that people are unwell makes them reluctant to express dissatisfaction or even to ask for explanations. Fear of repercussions and simply not knowing how to go about lodging a complaint have also been found to be significant deterrents. One approach to overcoming these feelings is to treat complaints as part of a wider consumer feedback strategy. This encourages consumers to talk about whether their needs are being met, and invites compliments as well as criticism. Changing the way health care professionals feel about complaints and error requires training, and structured time for clinicians to reflect on their performance among trusted colleagues. Trusted and credible systems for reporting and analysing error are also essential. Consumer participation The quality improvement approach supports consumers being active participants in their health care. Consumers, and nominated family members, need to be included in discussions about their care, and treated as a member of the care team. This helps to enable consumers to take responsibility for decisions about their care. When something goes wrong consumers need to be informed, be involved in discussions about any remedial treatment required, be told the findings of an investigation and action that will be taken to improve the service in the future. In the context of complaints, health care services need to find out what the complainant wants, be open about what happened and be prepared to come to a mutual agreement about the outcomes. The complainant needs to be involved at each stage of the resolution of the complaint, not just at the beginning, when they lodge the complaint, and at the end, when they are informed what has been decided. Family members and others who are responsible for the care of consumers make up about 40 per cent of complainants in the health care sector. Their experience of the health care system and views about quality of care are important and need to be accommodated. Figure 2 illustrates the quality improvement approach to dealing with consumer complaints and other feedback.

8

Figure 2 – The Consumer feedback loop Complaint/ Incident

Acknowledge

Clarify

Investigate

Change

Monitor

Clarify issues raised by consumer

Advise consumer of outcome of the investigation

Advise consumer of changes in administrative practice

Monitor through quality committees

Consumer’s experience of the health system

Acknowledge receipt of feedback Consumer feedback

Analysis of performance

Change in practice

Improved health care service for all

Source: Health Care Consumers Association (ACT)

Relationship with other standards The Better Practice Guidelines on Complaints Management for Health Care Services are voluntary Guidelines. However, they have been developed with the active involvement of accreditation bodies, health care complaints commissioners, governments, medical defence organisations, consumer groups and professional bodies and are likely to become what is expected of health care services. The standards set for accreditation programs in the health care sector include requirements for complaints management. If a health care service implements the Guidelines they would have a high level of achievement against the areas of those standards that relate to consumer rights and consumer participation. In the aged care sector all ‘approved providers’ are required to maintain an internal complaints management framework under the Aged Care Act 1997 and the Aged Care Principles 1997. The Standards for Aged Care Facilities, which are used to determine suitability for accreditation, have the most detailed requirements for complaints management. Health care complaints commissioners Since the early 1990s every state and territory government has established an independent, statutory body to deal with complaints about health care services. The commissioners conciliate complaints where appropriate and refer serious complaints about health professionals to the relevant professional registration authorities. Some commissioners also investigate complaints and provider reports about standards of care. In New South Wales the commission has the authority to prosecute complaints.

9

In the aged care sector, a Commissioner for Complaints was established under the Aged Care Act 1997 (Commonwealth) to provide an alternative dispute resolution scheme for complaints about services. Aged care service providers are required under the Act to advise residents about the availability of the scheme. The Private Health Insurance Ombudsman is also a statutory body, established to deal with complaints about private health insurance. The New Zealand Health and Disability Commissioner is established by statute to provide advocacy, conciliation, investigation and prosecution of complaints. The commissioners are referred to in this Handbook as ‘health care complaints commissioners’. Contact details for the health care complaints commissioners are provided on page 93. Indicators of good complaints management Good complaints management in a health care service is evident when: •

principals and executive managers demonstrate support for consumer feedback about the quality of the service, including complaints;



all clinicians and staff are trained in complaints resolution and understand their responsibilities for dealing with complaints;



consumers and their families are aware of the complaints policy and feel comfortable using it;



the service promotes awareness of health care complaints commissioners;



prompt and appropriate resolution of complaints takes place, using a joint problem solving approach;



complaints are recorded to support effective management of individual complaints and analysis of trends in all types of complaints;



all complaints are assessed for risk and appropriate steps are taken;



complaints are investigated to determine the events that occurred, the causes and to identify preventive strategies;



complaints resolution procedures reflect the principles of fairness and natural justice;



clinicians and staff routinely discuss complaints and other incidents;



complaints are reported to the community as part of quality improvement reporting;



the performance of the complaints management system is monitored and regularly evaluated with advice from consumers, clinicians and staff;



complainants, clinicians and staff are satisfied with the complaints process and outcomes; and



changes are made to improve the service in response to issues raised in complaints.

References: ‘Turning wrongs into rights’, keynote address by Professor Linda Mulcahy, Birbeck College, University of London, 2003, available at www.hccc.nsw.gov.au. Survey of examples of better practice complaints management by Australian health care services, Health Care Complaints Commission, 2003, available at www.hccc.nsw.au.

10

Annotated Literature Review, for Turning wrongs into rights project, Health Issues Centre and Health Care Complaints Commission, 2003, available at www.hccc.nsw.au. An organisation with a memory, report of an expert group on learning from adverse events in the National Health Service chaired by the Chief Medical Officer (UK), Department of Health, 2000, available at www.doh.gov.uk/orgmemreport. Literature Review, Open Disclosure, Associate Professor Merrilyn Walton, 2002, available at http://www.nsh.nsw.gov.au/teachresearch/cpiu/open_disclosure.shtml. Australian Council for Safety and Quality in Health Care, Shared Meanings Project, available at www.safetyandquality.org.

Further information: Guidance Document to the Queensland Health Complaints Management Policy, Making Feedback Work for You!, Queensland Health, 2003, and Complaints Co-ordinators Handbook, Queensland Health 2003. Listening and Learning: A Consumer Feedback Tool, ACT Health, 2003. Better Practice Guidelines on Frontline Complaints Handling, NSW Health, 1998. Complaints Management Policy: driving quality improvement by effective complaints management, Government of Western Australia, Department of Health, 4th edition, 2003. Australian Standard, Complaints handling, AS4269:1995. Complaints handling—Guidelines for organisations, draft International Standard, ISO/DIS 10018, 2003. Dispute management, draft Australian Standard, DR 03522, 2003. Aged Care Act, 1997 (Clth) and Aged Care Principles, Commonwealth Department of Health and Ageing, 1997. Complaints Handling Kit: Residential Aged Care Homes, Commonwealth Department of Health and Ageing, 2002.

11

PART TWO IMPLEMENTING BETTER PRACTICE This part of the Handbook provides information and tips about how to implement the Better Practice Guidelines on Complaints Management for Health Care Services. The Guidelines set out the key principles for good complaints management and indicators that describe practices consistent with each principle. The eight Guidelines are: 1 Commitment to consumers and improvement 2 Accessibility 3 Responsiveness 4 Effective assessment 5 Appropriate resolution 6 Privacy and open disclosure 7 Gathering and using information 8 Making improvements

Part 2: Implementing better practice 2.1 Commitment to consumers and improvement Leaders in the health care service promote a consumerfocused approach to complaints as part of a continuous quality improvement program. (Guideline 1) Leadership Every organisation has a unique culture, reflected in the beliefs and philosophies about how things are done and the reasons why. The most influential factor in changing attitudes and culture in an organisation is leadership from those in authority—practice partners, senior clinicians, chief executive officers and board members. Leaders need to be visible in their support of quality improvement processes and promotion of consumer-centred care. If good complaints handling is a genuine priority, the CEO or practice partner will be actively involved because of their belief that they regard this as a good use of their time. Leadership within a team of clinicians is equally important in promoting a view that consumer feedback is important. Anyone with a management or supervisory position in a health care service needs to have complaints handling and risk management as part of their job description or contract. Clinicians and managers need to understand the tasks that are required and take responsibility for ensuring proper procedures are followed. The Patient Safety Education Framework Project is developing core competencies for all health care workers. For more information go to www.patientsafety.org.au. Your complaints policy A formal complaints policy and procedure enables your clinicians and staff to understand what is expected of them. It promotes the view that complaints are an integral part of modern health care practice, not just an annoyance or distraction. A policy is also important to inform consumers and their families about your approach to dealing with complaints. ‘Having a protocol in place makes complaints handling easier. The doctors and nurses support it.’ Principal partner, Brooke Street Medical Centre.

Your complaints management policy needs to be clear, and indicate how: •

your service encourages feedback and complaints;



risk assessment and follow up occur;



complaints are investigated;



complaints are recorded and reported;



serious complaints are dealt with; and



complaints can lead to improvement in the quality of service.

15

Your policy needs to be relevant to the services you provide, your client base and your clinicians and staff. Obtaining input from clinicians, staff and consumers when your service is developing or revising the policy can be helpful. A Sample Complaints Management Policy is provided in Part 3, and a Sample Policy is included in the Supplement for general practices and other specialists. Staff training and awareness All clinicians and staff need to know and understand how your service’s complaints and risk management processes work. Training about the complaints policy should be provided as part of the initial induction program and in follow up training on the service’s procedures. Clinicians and staff who are dealing with informal complaints at the point of service will need specific training and support in customer service, communication and dispute management techniques. The level and quality of training will reflect the commitment of principal partners and executive management. Promoting the discussion of complaints among clinicians and staff helps to promote awareness and understanding of complaints management. Some effective ways to do this are discussed in Section 2.7. The case studies in Part 4 provide examples of how some health care services promote clinician and staff awareness of complaints and dispute management. Tip: conduct spot quizzes to test clinician and staff knowledge of the complaints policy. Communication and informed consent Effective communication with consumers is fundamental to good health care services. Poor or inadequate communication with consumers is the reason behind many complaints and legal claims, so good communication is an essential part of risk management. A written policy and procedure on informed consent and communication with consumers helps to support good practices. Medical defence organisations and quality improvement accreditation programs support this practice. An informed consent policy needs to address: •

effective approaches to communication;



the subjective nature of comprehension, particularly in stressful circumstances;



techniques to check the level of understanding of information;



use of written information sheets; and



recording the details of what has been communicated.

Checking the effectiveness of informed consent practices is also essential. Further information: Australian Council on Health Care Standards, various guidance documents at www.achs.org.au. Australian General Practice Accreditation Limited, various guidance documents at www.agpal.com.au. Informed Consent Policy, Government of Western Australia, Department of Health, available at www.wa.health.gov.au. Informed Consent Policy, Queensland Health, available at www.qld.health.gov.au.

16

The complaints manager Good complaints management requires a senior clinician or staff member to have the specific responsibility for making it work properly—the complaints manager. The case studies in Part 4 reflect the variety of personnel who may fill the position of complaints manager. To be effective, the complaints manager needs to: •

have sufficient authority to address the issues that are raised in complaints;



be of a level and position that will attract the respect and cooperation of all clinicians and staff;



report to the chief executive officer or principal who has the authority to follow up an issue; and



be accessible to consumers and their families.

The position needs to be linked to the systems and personnel who are responsible for risk management, quality improvement and compliance. The complaints manager’s job is to: •

attempt to achieve a satisfactory resolution of complaints;



assist complainants to describe their concerns and to understand complaints procedures and responses that the service may provide;



assist clinicians and staff to gather information about individual complaints, and any strategies for improvement in service as a result;



ensure clinicians and staff understand the complaints policy and know how complaints are handled;



ensure that risks are assessed and immediately notify senior management of any high risk complaints; and



ensure that the lessons learned from complaints are used to improve the service.

These tasks require special skills. Therefore, a complaints manager needs to: •

have skills in assessing a complaint, gathering information, managing timelines and negotiating with people;



be impartial;



be ethical when promoting the service or eliciting information from any person involved in a complaint;



ensure equal and fair participation of all parties involved in a complaint;



maintain confidentiality;



be able to identify and acknowledge concerns;



show understanding through listening and questioning skills;



use appropriate language and terminology;



be able to use conflict resolution strategies; and



be accessible, well organised and consistent.

17

The complaints manager needs sufficient resources to be efficient and effective in their job. A good system for recording and reporting complaints is essential if the service wishes to save time and generate useful information. See Section 2.7. Complaints managers and others frequently dealing with complaints need: •

complaints handling procedures and reference materials that are easy to access;



a good complaints handling environment (for example, interview facilities and a private space);



adequate work tools (for example, telephone, computer, printer and copier);



secure facilities to record and store information about complaints;



access to clinical assistance, medical records and other information to help interpret the events that have occurred and the reasons behind them, and to help resolve any misunderstandings;



access to senior management for reporting of any high risk complaints; and



authority to disclose information to consumers, where required.

The job of the complaints manager is to coordinate complaints as part of the quality improvement framework. All clinicians and staff are responsible for communicating with consumers and attempting to resolve complaints and concerns as they arise. Further information: National Association for Alternative Dispute Resolution, A Framework for ADR Standards, Report to the Commonwealth Attorney–General, April 2001, Section 5.3 ‘Knowledge, skills and ethics required for Alternative Dispute Resolution practitioners’, available at www.nadrac.gov.au. Australian Association for Quality in Health Care, website: www.aaqhc.org.au. Compliance Institute, Discussion Paper, Accreditation of compliance management officers, 2003, available at www.compliance.org.au. The Society of Consumers Affairs Professionals website, www.socap.org.au. Health Services Liaison Association, Every Complaint is an Opportunity: Guidelines for Hospitals in the Management of Complaints, 1994, chapter 3. Health Services Liaison Association, Health Complaints Toolkit: Guidelines for Health Services in the Management of Complaints, 2000, chapter 2.

2.2 Accessible processes and information Encourage consumers to provide feedback, including concerns and complaints, and make it easy to do so. (Guideline 2) Promote your policy In general, people are reluctant to complain about health care services. Your service needs to actively promote the message that your service welcomes discussion and comments about the quality of service and care that you provide. The most effective way to obtain consumer feedback is for clinicians and staff to invite them to comment in the course of conversation and discussion. Clinicians and staff need 18

training and guidance for this task, and assurances that their efforts will be supported. Other ways to promote awareness of your consumer feedback and complaints program are: •

a Consumer feedback brochure (see Part 3);



placing posters or signs in public areas;



publishing a summary of the Complaints Policy in a prominent position on your service’s website; and



mentioning the program in general publicity.

Make sure any printed information is simple and easy to understand. Remember to provide details about how, when, and where complaints and concerns can be raised and the name and contact details of the person responsible for managing complaints. Tip: Use a catch phrase to promote your policy. For example: ‘Consumer feedback is important because it helps us learn how to improve.’ ‘If you have a concern or are not satisfied, discuss it with your doctor or one of our staff, or send us a note so we can put things right.’ Target your message not just to consumers but also to their family members and friends who care for them, visitors and members of your community. Family members who care for consumers are responsible for about 40 per cent of all complaints about health care services. A variety of ways to give feedback Encouraging people to provide feedback is best achieved if a variety of methods are offered. The most effective methods are: •

clinicians and staff recording comments from consumers or making observations (see Suggestions for improvement form, Part 3);



a consumer feedback brochure (see sample Consumer feedback brochure, Part 3);



a suggestion box (when combined with signage and feedback forms); and



consumer satisfaction surveys.

The variety of approaches used in different health care settings, and their results, are discussed in the case studies in Part 4. Anonymous complaints One of the common reasons people are reluctant to complain about health care services is a fear that it will adversely affect their future treatment or access to the service. While providing assurances that complaints will not result in any kind of retribution, allowing people the option of providing feedback anonymously is also important. Complaints and other feedback received anonymously can be valuable in providing information about trends and specific issues. The information is valuable, even if issues cannot be thoroughly pursued due to a lack of information.

19

Special needs Special measures may be needed to ensure everyone in your client base is aware of our consumer feedback policy and is comfortable with raising their concerns. For example, should you provide brochures in a language other than English? Some people are less likely to complain for cultural reasons. For example, some Aboriginal people may be culturally less inclined to complain, particularly to non-Aboriginal people. People with certain conditions such as hepatitis C or with a mental illness, may have concerns about discrimination that will make them less likely to speak up if they are not satisfied or if something is wrong. Tip: When collecting information or evaluating your complaints, consider whether some groups within your client base are not providing feedback. If this is the case, what might be the reasons? Some people need assistance if they wish to make a complaint. For example, young people or a person with a disability may need a support person, or a person who cannot speak English fluently may need an interpreter.

2.3 A responsive approach Acknowledge all complaints and concerns and respond promptly and sensitively. (Guideline 3) Everyone has responsibility Managing complaints should be the responsibility of everyone in a health care service because it is part of effective communication with consumers and providing quality health care. A tiered approach indicates the delineated roles in complaint handling at different levels for clinicians, administrative staff, managers and executive management. People with a complaint about health care services want to be treated with dignity and be assured that their complaint will be treated seriously. A positive attitude to complaints by clinicians and staff is crucial in successful complaints management. Three levels of complaints handling: 1. Informal

straightforward matters that clinicians and staff can resolve at the point of service;

2. Formal

more complex matters that may need to be referred to a supervisor or complaints manager; and

3. Serious and unresolved complaints that may require notification to external bodies such as insurers or regulatory bodies will be referred to principals or senior management (see Section 2.4). Many complaints can be resolved immediately at the point of service—on the ward, clinic, office or home. Clinicians and staff need to be encouraged to resolve complaints at the point of service, before frustration and delays worsen the situation. Clinicians and staff require training and support to deal with complaints, including a designated colleague or manager to turn to if a situation becomes too difficult.

20

Clinicians and staff should be expected to: •

listen to the complainant and show understanding and empathy;



attempt to identify the problem and the outcomes sought by the complainant;



provide an explanation and apology or expression of regret, if appropriate;



offer solutions and find out if the solutions are acceptable;



take action to implement the solution offered, or refer the complaint to a more senior clinician or manager if required;



confirm with the complainant that they are satisfied, or if not, that the matter will be taken further; and



make a quick record of the complaint or concern.

The service’s complaints management policy should provide guidance for when complaints can be resolved at the point of service and when to refer them to a more senior person or to the designated complaints manager. See the sample complaints policies in Part 3, and the Supplement for General Practices and other specialists. Encourage staff and clinicians to record informal complaints and concerns that they resolve on the spot by making it quick, easy and rewarding. A sample Suggestion for improvement form is provided in Part 3, or an exercise book kept at reception to record suggestions might be just as effective in a smaller service. The results should be compiled regularly and provided for discussion. See Section 2.7 for more discussion about recording and reporting. Tip: Essential steps in managing complaints are listen, resolve, record, analyse and improve. Formal complaints If a complaint is not resolved at the point of service, and the complainant wishes to pursue the matter, they need to be told the complaint is being handled formally. A follow up letter acknowledging the complaint is useful. If a complaint has been received by mail or email, a written acknowledgement needs to follow. A formal letter acknowledging the complaint is an opportunity to provide information about the procedures that will follow, how long the process is likely to take and details of the person who they can contact with questions and inquiries. This is a good time to inform complainants about how personal information may be shared with others during the investigation of the complaint. See the sample acknowledgement letter in Part 3. Telephone calls and face-to-face meetings can be important to clarify information and to rebuild trust. Keep in touch with the consumer and their family and consider their views. Written communication needs to be clear and informative, using every day language. More challenging consumers and family members may require more time and flexibility. Minimising conflict To help minimise conflict and move towards resolving the problem, clinicians and staff need to: •

provide their name;



listen to the complaint without interrupting;

21



be empathetic and recognise the person’s feelings;



be attentive and courteous;



use clear language and avoid inflammatory language;



be open and respectful; and



provide and accept feedback.

After the complainant has spoken, the information they have given needs to be summarised to confirm the basis of the complaint. Clarification or questions about desired outcomes can then be pursued. Timeframes The most common causes of dissatisfaction in complaints management are the long delays in resolution and the failure to inform complainants of the progress in their case. The complaints policy of your service needs to set target timeframes for: •

how soon your service will acknowledge complaints (within two days is good practice);



how soon your service will refer serious issues to external agencies (no more than three days);



how quickly complaints will be discussed, investigated and resolved; and



how often your service will provide information to complainants.

Determining a reasonable set timeframe for resolving complaints depends on the size and nature of the service. In practice each complaint is different, depending on the complexity of the complaint, and the quality of the resolution process is paramount. For smaller services, most complaints policies can provide for resolution within 10 to 15 days. For large hospitals or health care groups, where investigation can be more complicated because of the number of people involved, a longer timeframe is usually provided. See the Sample Complaints Policy in Part 3. Tip: Keep complainants informed about the progress of their complaint. It shows that you are taking them seriously. Tracking complaints Using a tracking system will support essential tasks being completed within the timeframes stated in your service’s complaints policy. This could consist of a tracking sheet to provide a summary record of the progress of each complaint, including the dates of letters, interviews, phone calls and meetings. Tracking sheets also support continuity when staff changes occur or where numerous people in large organisations may be involved in handling a complaint. Tracking can be performed effectively by paper-based file or a computer record. An example of a tracking sheet is provided in the sample Complaints follow up form in Part 3.

2.4 Effective assessment of complaints Assess complaints to determine appropriate responses by considering risk factors, the wishes of the complainant and accountability. (Guideline 4)

22

Understanding the problem Complaints need to be assessed to decide the most appropriate course of action and to ensure serious incidents receive immediate attention. The first level of assessment occurs at the point of service, where clinicians and staff assess whether they can deal with the complaint or not. This section of the Handbook explores the assessments and actions required when dealing with formal complaints and incidents. The designated complaints manager performs risk assessments at this level. The first step is to take some time to understand the problem. In some cases, what is said or written down by a complainant may not reflect their real concerns. It can require time and patience to gain an understanding of their underlying issues. Research by Professor Linda Mulcahy in the United Kingdom found that up to 40 per cent of people who had made complaints to the National Health Service were not clear about what they wanted, or minimised the seriousness of their complaint because they did not feel confident to question the standard of clinical care. Resolution options Most complaints will be resolved directly through a simple process of negotiation and discussion with the complainant, which will usually follow an investigation of the events and why they occurred. However, in some circumstances, it may be more appropriate to have a complaint dealt with by a health care complaints commissioner, or an independent mediator. The complaints manager should understand the processes used by health complaints commissioners and how long they take. A complaint might need to be referred for external resolution if: •

there are complex technical issues or a large number of people involved and the health care service does not have the expertise to manage it;



the issues raised are so serious that managing the complaint internally would be inappropriate; and



the person who is the subject of the complaint is the person who manages complaints, which may be perceived as compromising impartially.

Another task at this stage is to find out whether the complainant will need assistance or support during the resolution process. Assessing risk Risk management strategies help your service to identify, assess and manage risk. Risk management is not necessarily designed to reduce or eliminate risk, but to understand and consciously manage it. All formal complaints should be assessed immediately after they have been received to identify the level of risk and the appropriate course of action that needs to be taken. The purpose of risk assessment at this stage is to identify high risk complaints that raise significant safety, legal or regulatory issues, that need to be notified to senior management immediately. The severity assessment code or seriousness assessment matrix is a useful tool to assist with consistent and reliable risk assessment. A fixed rank rating can be obtained by combining the consequences (or impact) of an incident with the probability (or likelihood) of the same type of incident recurring. A sample severity assessment matrix is set out in Figure 3 below.

23

Figure 3 – Severity assessment matrix Consequences

Serious

Major

Moderate

Minor

Minimum

Frequent

4

4

3

2

2

Likely

4

4

3

2

2

Possible

4

3

3

2

2

Unlikely

4

3

2

1

1

Rare

2

2

2

1

1

Likelihood

The fixed rank rating correlates with actions that need to be taken, providing the complaints manager with a clear course of action that is linked to the risk assessment system. For example, a rating of ‘4’ prompts notification to senior management and detailed investigation of the causes of an incident. A rating of ‘2’ or ‘1’ is managed in the routine way, which means the complaint is still reviewed to find out what happened and possible improvement strategies. The ‘consequences’ of an incident can be defined as ‘serious’, ‘major’, ‘moderate’ or ‘minor’ by reference to factors such as: •

level of physical injury to a consumer;



failure of administrative systems for patient care (for example, loss of test results)



level of injury to staff (for occupation health and safety incidents);



level of financial or corporate losses (including litigation and adverse publicity); and



level of harm to the customer service relationship.

For example, a consumer suffering harm as a result of treatment, which results in increased length of stay in hospital, or hospital admission if not an inpatient, may be defined as ’major’, so a one off incident is rated ‘2’ or ‘3’. A single complaint about poor communication may be classified as ‘moderate’ and rated ‘2’, but more frequent complaints about rudeness become ‘3’. Tip: The ‘customer service relationship’ is about a consumer’s loss of trust or confidence in a service. It may be caused by problems such as delays in obtaining appointments, waiting times, rudeness, poor communication or even difficulties with parking. A sample risk assessment matrix, and definitions of ‘consequence’ are set out in the Sample Complaints Policy, in Part 3. See Part 4 for examples of risk assessment tools used by a general practice (case study 1) and by NSW Health services (case study 6). Performance of individuals Risk assessment also requires assessment of individual clinicians to identify behaviour that may be unsatisfactory professional conduct, requiring consultation with health care complaints commissioners or professional registration boards. Unsatisfactory conduct by a health professional includes:

24



a lack of knowledge, skill, care or judgement;



inappropriate behaviour, including criminal acts (for example, assault or fraud);



inappropriate sexual relationships with consumers; or



inappropriate prescribing.

External referral Your service needs to have a clear policy setting out when you are legally obliged to notify regulatory bodies, such as coroners, and circumstances where you will consult with professional registration boards and health care complaints commissioners about the behaviour of individual. The CEO or principal should consult with the relevant professional registration board or health care complaints commissioner where there is behaviour that raises a significant risk to the health and safety of consumers or raises a significant concern as to the appropriate care or treatment of a consumer. All clinicians and staff need to have a basic awareness of this policy and the person responsible for making notifications. The circumstances in which notifications should be made to insurers will also be included. The Sample Complaints Policy in Part 3 gives an example. Further reading: Turning wrongs into rights, keynote address by Professor Linda Mulcahy, Birbeck College, University of London, 2003, available at www.hccc.nsw.gov.au. Guidance Document to the Queensland Health Complaints Management Policy, Making feedback work for you!, Queensland Health, 2002. Severity Assessment Code, NSW Health Safety Improvement Program, 2003. Department of Health Western Australia, Complaints Management Policy, 2003. Australian Standard, Risk Management AS/NZ 4360:1999. Open Disclosure Standard, Australian Council for Safety and Quality in Health Care, 2003. Open Disclosure: Health Care Professional’s Handbook and Open Disclosure: Manager’s Handbook, Australian Council for Safety and Quality in Health Care, 2004, available at www.qualityandsafety.org.

2.5 Appropriate resolution processes Deal with complaints in a manner that is complete, fair to all parties and provides just outcomes. (Guideline 5) Fairness Natural justice, or procedural fairness, is a legal principle that requires investigations into complaints to be conducted in a fair and even-handed way. It requires attention to be given to any power imbalance that may exist between the complainant and your service, or a staff member. Natural justice also requires decisions to be based on relevant material, and the decision maker to be free of prejudice or bias.

25

The process for investigating and resolving complaints needs to be clear so complainants, clinicians and staff who are directly affected can follow what is happening. Uncertainty and delays should be avoided by setting timeframes for completing the key stages of the process. If investigating and resolving a complaint is likely to be a complicated process, the investigation can be broken up into stages. Tip: Give adequate information to everyone who is directly affected by the complaint and provide sufficient time for them to provide an adequate response. Natural justice also requires: •

the complainant and any clinicians and staff directly affected by a complaint to be informed of the nature of the claims that have been made and have an opportunity to provide information relating to the complaint;



policies and procedures to be followed, so the process is well known and predictable;



decisions to be based on relevant information, including the views of the complainant, clinicians and staff directly involved; and



all interested parties to be informed of final decisions and the reasons for the decisions.

Natural justice also requires confidentiality, discussed in Section 2.6. Joint problem solving Negotiation is the process of people attempting to work through their differences and reach an agreed solution. This is a two-way process that requires people to explore options, listen to each other and identify common ground. In most cases, negotiation can only be effective after there has been an investigation into a complaint. ’The resolution of complaints is facilitated as much as possible. Open disclosure is encouraged … The process is designed to be fair to staff and consumers and to ensure both have the opportunity to give their account of events.’ Clinical Risk Manager, The Children’s Hospital at Westmead

Providing an opportunity for people to discuss their concerns can result in information that is more useful and more detailed. Telephone contact and face-to-face meetings are essential for an exchange of information and to rebuild trust. A joint problem solving approach to negotiation is particularly important where there is a continuing relationship between a health care service and a consumer. Joint problem solving negotiation requires the person conducting the negotiation to: •

have knowledge about the subject matter;



be able to think clearly;



listen actively and ask questions, not just provide a lecture;



identify the issues and interests (underlying motivations), not just the respective positions (demands);



separate the person from the content of the complaint;



discuss what would happen if there was no agreement between the parties;

26



develop a range of options; and



ensure that any agreement is workable for all parties.

The case studies in Part 4 illustrate how a general practice (case study 1) and a community pharmacy (case study 4) routinely use telephone contact as part of complaint resolution. Case studies 6, 7 and 9 illustrate how dialogue with consumers and a collaborative approach to problem solving can achieve improvements in a hospital setting. Investigating complaints The nature of an investigation into a complaint will vary according to the nature of the complaint. Investigating a complaint consists of: •

collecting relevant facts—interviewing all people involved in the complaint, collecting relevant records, accessing policy and procedure documents and examining equipment;



analysing the information collected;



making findings about the events and the underlying causes of the complaint; and



considering strategies and making recommendations for improvements.

In serious matters, it is important that investigations begin as soon as possible while memories are fresh and before material relevant to the case is lost or destroyed. The person conducting the investigation, who is usually a departmental or section manager, needs to remain impartial. Their responsibilities include maintaining confidentiality and ensuring that no judgement is made against individuals while initial assessments are being made. Assistance should be provided to complainants where necessary, so they can present their views and contribute to an investigation. ‘Staff members directly involved in a complaint provide a factual report of the incident and are asked to identify system issues that may have contributed … Our approach … removes fear of personal blame.’ Quality Coordinator, Princess Alexandra Hospital

The investigation process needs to analyse the underlying causes of complaints from an organisational and systems perspective. For example, information such as occupied bed days at the relevant time or the level of experience of clinicians should be examined. When reviewing the causes of an incident it is important to not rely on assumptions. Once the cause of the problem has been correctly identified, strategies to prevent it occurring in the future can be developed. Once again, the person making the decision needs to keep an open mind, and avoid the assumption that the solutions lie entirely with increased funding or resources. The case studies in Part 4 provide examples of creative approaches to solving problems.

27

Informing complainants and others After an investigation has been completed, the results should be provided to the complainant and any clinicians and staff directly involved. The Open Disclosure Standard advises that at the conclusion of an investigation health care services should provide consumers with: •

an expression of regret for the harm suffered;



clinical and other relevant facts;



details of the concerns raised by the consumer;



a summary of the factors contributing to the adverse event; and



information on what has been done and will be done to avoid repetition of the adverse event, and how this will be monitored.

The information may be provided in a letter or a face-to-face meeting, or both. Care needs to be taken to ensure it is presented in a sensitive and clear manner. If sensitive information is discussed during or after an investigation, the people who discuss the information with the complainant should be: •

already known to the complainant;



familiar with the facts;



senior and credible; and



able to communicate well and offer reassurance and feedback.

Just outcomes The action a health service is prepared to take to resolve a complaint should be just—that is, it should be appropriate and respond to the needs of participants as far as possible. A policy of aiming to achieve the best outcome for everyone is fair. The most commonly sought-after outcomes from a complaint to health care services are: •

an explanation;



an apology;



a request for the health care professional to show they care;



rectifying the problem: for example, an earlier appointment or a bill adjustment;



reassurance and sympathy; and



to prevent the same incident occurring to other people.

Compensation may need to be considered in some cases. Contact your service’s insurer or indemnity provider for advice on the options that are available. The service should confirm that the complainant is satisfied with the outcome of the complaint by telephone call or letter. A sample letter is provided in Part 3. If a complaint is not resolved everyone should have a clear understanding about what the next steps might be. Consumers should be reminded that they can take their complaint to an external complaints body such as a health care complaints commission. A letter should be sent to the complainant confirming that you understand the matter remains unresolved and informing them of the options that are available to them.

28

Further reading: Open Disclosure Standard, Australian Council for Safety and Quality in Health Care, 2003. Australian Standard, Complaints Handling, AS4269:1995. Draft Australian Standard, Dispute management, DR 03522, 2003.

2.6 Privacy and open disclosure Manage information in a fair manner so relevant facts and decisions are openly communicated while confidentiality and personal privacy is protected. (Guideline 6) Confidentiality and fairness are important principles for any complaints management system. The principles create a tension between keeping some information confidential, while being open with consumers, clinicians and staff about information and decisions that directly affect them. The service’s complaints policy and procedures need to provide clear guidance on these issues. Confidentiality Information gathered during the course of an investigation will generally be kept confidential because it: •

helps people to feel safe about coming forward with a complaint, as their name will not be disclosed (unless they want this to happen);



prevents incomplete or inaccurate information being released until all the facts are established; and



protects individual reputations from being harmed by unsubstantiated allegations.

A request for additional confidentiality should be respected and acted on, where possible. For example, codifying names in records and reports to reduce the risk of inadvertent disclosure. However, at the end of an investigation process, the principles of natural justice and fairness require that people who are directly affected be provided with information about the conclusions that have been reached and the reasons for those decisions. There are various Australian state and territory laws imposing obligations of confidentiality on people employed in the public health sector. The Commonwealth, all states and the ACT have laws protecting from disclosure certain information generated as part of particular quality assurance activities by health care services. On the other hand, in some circumstances, the law may compel organisations or individuals to disclose information. Open disclosure The Open Disclosure Standard provides for consumers and their nominated family member to be given information, including the following, when they have suffered harm as a result of an adverse event: •

an acknowledgement that an adverse event has occurred;



the known facts about what has happened;

29



information about further treatment required;



an explanation of how the adverse event will change anticipated care and short-terms effects; and



advice that an investigation will occur and how feedback from the investigation will be provided.

The Standard advises that while disclosure is required where harm has occurred, it may also be appropriate to disclose to a consumer where an incident has occurred, but no harm is immediately apparent. This is a matter of judgement by the health care treating team. Once the investigation has been completed, the Standard states that consumers and nominated support persons should be given information on the established facts about the incident, a summary of the contributing factors or causes of the incident and recommended measures to prevent similar incidents occurring again. Privacy Privacy obligations apply to personal information, including personal information collected and used for the purpose of resolving a complaint. Personal information is information that identifies or could identify an individual, not just a name, address and Medicare number. It could be a combination of information, for example, about a person’s condition, dates of treatment, place of treatment, age, gender, and postcode. The key elements of privacy, relevant to managing complaints records, are: •

keeping complete, accurate and up-to-date records of complaints;



collecting only the information that is relevant to the complaint;



keeping records secure and confidential; and



informing the complainant at the outset of investigation about how their personal information is likely to be shared with others, such as insurers and other clinicians.

Take care not to include any information that identifies individuals in reports about complaints, whether for internal or public use. ‘De-identify’ the information by removing details that enable the identification of a consumer, staff member, clinician or other person. Tip: keep complaints records separate from medical records and provide a private space for concerns to be discussed. Privacy laws also generally require that personal records be destroyed once they are no longer required for the purpose for which they were collected. Laws applying to the public sector, such as archives and state privacy laws specify retention periods. Access to medical records Providing people with access to their medical records and an explanation of what they mean is often important in addressing misunderstandings that have lead to a complaint. The privacy policy of your service will set out how to deal with requests by consumers for access to their records, and requests from family members. The complaints manager needs to be familiar with the privacy policy and have access to medical records to help facilitate a resolution.

30

‘Adverse event’: ‘an incident in which unintended harm resulted to a person receiving health care.’ Open Disclosure Standard, 2003

Further reading: Office of the Federal Privacy Commissioner, Guidelines on Privacy in the Private Health Sector, 2001, available at www.privacy.gov.au. Royal Australian College of General Practitioners, Handbook for the Management of Health Information in Private Medical Practice, 1st edition, October 2002 available at www.racgp.org.au. Australian Council for Safety and Quality in Health Care, Open Disclosure Standard, 2003. Open Disclosure: Health Care Professional Handbook and Open Disclosure: Managers Handbook, 2004, available at www.safetyandquality.org. Australian Council for Safety and Quality in Health Care, The Public Interest in Health Care Qualified Privilege, Issues Paper, August 2001, available at www.safetyandquality.org.

2.7 Gathering and using information Record all complaints to enable review of individual cases, to identify trends and risks, and report on how complaints have led to improvements. (Guideline 7) Recording informal concerns Information about informal complaints and concerns that have been resolved at the point of service is enormously valuable for quality improvement purposes. By analysing the types of issues raised in these complaints and the outcomes agreed, the service can recognise recurring problems and devise strategies to prevent them recurring. Staff and clinicians will need to be encouraged to record informal complaints and concerns. A quick and easy method for recording complaints is essential. The sample Suggestion for improvement form provided in Part 3 is designed to be completed in less than a minute. An exercise book kept at reception to make a hand written note of the date and the issue could be just as effective. Provide regular feedback on the issues and trends so clinicians and staff can see how the information is being used. Examples of effective approaches to recording frontline complaints are discussed in the case studies in Part 4. Formal complaint records Records of formal complaints need to be complete, but do not need to be elaborate—a simple paper file is sufficient for smaller health care services. The record needs to: •

identify the person responsible for managing the complaint;



track the progress of the investigation and resolution of the complaint;



record the views of the complainant about the events that have occurred and the outcome they are seeking;



keep a log of conversations, correspondence and other documents;

31



outline how and when risk was assessed and follow up action taken, including any notifications to managers, to insurers and to others;



record decisions about the facts and the cause(s) of the complaint;



record the outcomes for the complainant; and



record any recommendations for change and how they will be implemented.

A sample Complaints follow up form is provided in Part 3. Recording complaints as part of the incident monitoring system can help to reinforce the view that complaints are part of the quality improvement system. Examples of effective approaches to recording complaints along with other incidents are provided in the case studies in Part 4. Complaints managers who administer the complaints records should distinguish established facts from speculation or claims. Reports on complaints The way your service reports on complaints will vary according to the size of the organisation. In large organisations statistical reports on the number and types of complaints are likely to be provided on a monthly or three-monthly basis, whereas in smaller services with small numbers of complaints, statistical information may only be useful on an annual basis. Tip: In smaller services, the system of recording complaints can be simple, but someone needs to be responsible for analysing and reporting the information! Codifying the types of issues raised in complaints allows you to identify problems in particular areas so strategies can be developed to address them. The categories devised for your service should produce information that is useful and relevant to your service. Smaller services may simply distinguish clinical and administrative issues. The Sample complaints policy in Part 3 provides other suggestions. Narrative reporting of complaints, or case studies, assists clinicians, staff and managers to understand the consumer’s experience of the health service and the failings that lead to a complaint. Case studies can also demonstrate the resolution process and quality improvement measures that were adopted to address the underlying causes of a complaint. Reporting to staff and management Structured time for clinicians and staff to discuss consumer complaints and other incidents is one of the most important strategies for supporting a quality improvement culture in a health care service. Statistics on trends and narrative reporting of individual complaints provide a useful contribution to discussion of the issues and help to reinforce their role in resolution and improvement. The Brooke Street Medical Centre has complaints and incidents as a standing item on the agenda at staff meetings and clinical review meetings (see case study 1, Part 4). In larger organisations complaints reports, complainants letters, and case studies can be incorporated into staff newsletters or placed on notice boards (see case studies 6 and 8, Part 4). In addition to the immediate referral of serious matters to senior management, there should

32

also be regular reports on complaints to senior clinicians and management. These reports need to address clinical governance and organisational performance issues. The reports should cover: •

the number and type of complaints (formal and informal) in a specified period (in larger organisations provide this for each service unit or department);



trends in the number and types of complaints over time and factors influencing the trends;



significant individual complaints that highlight systemic problems;



information about the risk ratings of complaints;



the time taken to resolve formal complaints compared with timelines in the complaints policy;



the types of outcomes achieved for complainants;



recommended improvements;



whether previous recommendations have been implemented; and



monitoring of the impacts of changes that have been implemented.

Reporting to the public Publicising how complaints resulted in improvements to your service educates consumers about the benefits of speaking up if they have a concern and improves your reputation. Complaints information can be in the annual report or in stand-alone quality improvement reports. Smaller services can report on complaints and other consumer feedback in general publicity. Reports to the public should offer useful information about complaints, such as: •

the number and type of complaints in the current year, compared with previous years;



the common types of outcomes from complaints;



initiatives taken to address consumer complaints or feedback;



the impact of improvements made as a result of the complaints process; and



the performance of the complaints process when compared with the complaints policy.

If your service conducts surveys of consumer satisfaction or consumer experiences, include a summary of the results in the reports.

2.8 Making improvements Use complaints to improve the service, and regularly evaluate the complaints management policy and practices. (Guideline 8) Using complaints to improve the service Executive management, including hospital boards or principal partners, need to regularly receive reports on complaints so they can analyse trends in complaints and identify where and how complaints are addressed within the organisation. The focus should be on the organisational systems, such as work flow and systems of care that create those trends, rather than on individuals.

33

Complaints and consumer feedback information should be used when making strategic and operational decisions about planning, professional development and quality improvement. Consumer feedback and complaints should appear in strategic and business plans, annual reports, and mission statements. Complaints and other incidents rated as high risk should always be notified promptly to designated senior clinicians or executive managers. Their responsibility to respond appropriately to these notifications should be included in their job descriptions and assessed regularly in performance appraisals. The responsibilities are to instigate investigation, reporting, analysis, review and implementation of follow up action. Tip: An exit survey can be a useful way to check if people are satisfied with the complaints process and the outcomes. Contact people by telephone or use a written survey form to ask if the process was timely, fair or effective and whether they were satisfied with the outcomes. The cases studies in Part 4 illustrate different approaches to using consumer feedback and complaints as part of the improvement cycle. Routine monitoring and review Routine monitoring and review of your service’s complaints system is necessary to check that the system works in the way the complaints policy intended. Performance reports should be compiled regularly against preset performance criteria, which will typically cover: •

how long it takes to resolve formal complaints compared to the timeline in the complaints policy;



levels of clinician, staff and consumer awareness of the complaints process, measured through the results of spot quizzes;



how high risk complaints were managed by senior clinicians or managers;



recommendations from board meetings or principal partners’ meetings arising from complaints reports;



recommendations that have been implemented and the impacts monitored;



trends in the number and types of complaints, formal and informal, and factors that may have influenced trends, such as specific quality improvement initiatives; and



levels of complainant, clinician and staff satisfaction with the processes and outcomes of complaints.

When devising your service’s performance criteria or measures of success, be careful with numbers and statistics. If you are seeking to improve consumer awareness of complaints or consumer feedback, a relevant measure of success may be an increase in the number of complaints, not a decrease. The performance of your complaints management system should also be checked against external criteria. The Better Practice Guidelines on Complaints Management for Health Care Services and standards used by accreditation schemes are likely to be the most relevant. A self-assessment guide for the Guidelines is provided in Part 3. Comparing your service’s performance with others of similar size may also be an option.

34

Evaluation A more detailed evaluation of your complaints system should be conducted every few years to assess where it is working well and where improvements may need to be made. This involves examining your complaints and consumer satisfaction files, statistics, trends and policies and asking staff, former complainants and other consumers what they think about the system. Evaluating your complaints system involves: •

asking people who have used the complaints system what they thought of the process and the outcomes;



asking all consumers what they know about the complaints process and what they expect;



using statistical information to check timelines, the number and types of complaints that have been made and how this has changed over time, and the outcomes of individual complaints;



using complaints records and reports to determine the changes that have been implemented and how they have been monitored; and



comparing your complaints system against external standards, and where possible, with services of similar size and nature.

Your service needs to consider revising the complaints policy and procedure if there have been significant changes in organisational structure, or client base. Clinician, staff and consumer involvement To determine what clinicians, staff and consumers think of the complaints system, your service needs to ask them. Clinicians and staff can be asked about issues such as the adequacy of training and support and whether they are comfortable dealing with complaints. Written and telephone surveys are the most common method of obtaining consumer views, but a special purpose discussion group, or focus group, can also be helpful. These groups offer interactive discussion, which can provide more information than surveys. Consider the type of people you are trying to attract and what is likely to make the discussion interesting for the participants. Support groups for people with specific health conditions can be a good place to find people who would be interested. Tip: Use questions about people’s specific experiences and knowledge to measure the performance of the complaints system. Use open-ended questions to find out where people believe improvements could be made. For example: ‘Do you have any suggestions on how we can improve our health care service?’ Obtain the views of existing staff advisory committees and consumer or community advisory committees as part of the evaluation. A special purpose evaluation advisory group could be established to provide advice and comment from interested consumers, community members, staff and clinicians.

35

Further information: National Resource Centre for Consumer Participation in Health, available at www.participateinhealth.org.au Australian Standard, Complaints Handling, AS4269:1995.

36

PART THREE SAMPLE DOCUMENTS This part of the Handbook provides sample documents to assist health care services to adopt good practice in complaints management. It provides: • a Sample Complaints Policy and Procedure, for inclusion in your procedures manual; • a sample Consumer feedback brochure; • a sample Suggestion for improvement form, for recording comments and informal complaints that can be dealt with at the point of service or on the spot; • a Complaint follow up form, for keeping a complete record of actions relating to a complaint, including a tracking sheet; • sample letters for acknowledging a complaint, and for concluding resolution of a complaint; and • a Self-assessment guide to assess the performance of your complaints management system against the national Better Practice Guidelines on Complaints Management for Health Care Services. A Sample complaints policy for general practices and other specialists is provided in the Supplement at the end of the Handbook.

Part 3: Sample documents Sample complaints policy and procedure A sample policy for health care services to incorporate into their policies and procedures manual. Policy •

We aim to provide a service that meets the needs of our consumers and we strive for a high standard of care;



We welcome suggestions from consumers, their family members who care for them, and from our clinicians and staff about the safety and quality of care we provide;



We are committed to an effective and fair complaints system; and



We support a culture of openness and willingness to learn from incidents, including complaints.

Procedures 1. Our policy Consumers and their families are encouraged to provide suggestions, compliments, concerns and complaints and we offer a range of ways to do it. Consumers and their carers are encouraged to discuss any concerns about clinical care with their treating doctor [or alternate], or they can complete the Suggestion for improvement form or Consumer feedback form. Clinicians and staff can also use the Suggestion for improvement form to record concerns and complaints about the quality of service or care to consumers. All complainants are treated with respect, sensitivity and confidentiality. All complaints are handled without prejudice or assumptions about how minor or serious they are. The emphasis is on resolving the problem. Consumers, their families, clinicians and staff can make complaints on a confidential basis or anonymously if they wish, and be assured that their identity will be protected. Consumers, clinicians and staff will not to be discriminated against or suffer any unjust adverse consequences as a result of making a complaint about standards of care and service. Our clinicians and staff are expected to provide assistance to consumers who have special needs, such as those who do not speak English well or have a disability, so that they can provide feedback or follow up a complaint. 2. Everyone’s responsibility All clinicians and staff are expected to encourage consumers and their families to provide feedback about the service, including complaints, concerns, suggestions and compliments. Clinicians and staff are expected to attempt resolution of complaints and concerns at the point of service, wherever possible and within the scope of their role and responsibility. 39

Sample Complaints Policy

Page 2

The process of resolving the problem will include: •

an expression of regret to the consumer or carer for any harm suffered;



an explanation or information about what is known, without speculating or blaming others;



considering the problem and the outcome the consumer is seeking and proposing a solution; and



confirming that the consumer is satisfied with the proposed solution.

If the problem is resolved, clinicians and staff are expected to complete the Suggestion for improvement form to record feedback from consumers and their families. Our clinicians and staff will consult with their manager if addressing the problem is beyond their responsibilities. For example, fee waivers or reductions can be considered in certain circumstances. 3. If the complaint is not resolved Complaints that are not resolved at the point of service, or that are received in writing and require follow up, are regarded as formal complaints. Our clinicians and staff refer complaints to [complaints manager/clinical director] if: •

after attempting to resolve the complaint, they do not feel confident in dealing with the complainant; or



the outcome the complainant is seeking is beyond the scope of their responsibilities (for example, an earlier appointment can only be made by someone more senior); or



they or the complainant believe the matter should be brought to the attention of someone with more authority.

If the complaint is not resolved at the point of service, clinicians and staff are expected to acknowledge to the complainant that a formal complaint has been received and will be acted on. Clinicians and staff then complete the first two sections of the Complaint Follow up form and forward it to the complaints manager. The complaints manager coordinates resolution of formal complaints in close liaison with the treating clinician and other staff who are directly involved. 4. Administration and oversight The complaints manager is responsible for coordinating investigation and resolution of formal complaints, conducting risk assessments (in consultation with clinicians), liaising with complainants, maintaining a register of complaints and other feedback, providing regular reports on informal and formal complaints, and monitoring the performance of the complaints policy and procedure. [Clinical directors/managers] are responsible for a proactive approach to receiving feedback from consumers and staff, risk management in consultation with the complaints manager investigation and review of complaints and follow up action for serious complaints, or where complaints result in recommendations for change in policy of procedures.

40

Sample Complaints Policy

Page 3

The [CEO/hospital board] is responsible for: •

ensuring appropriate action is taken to resolve individual complaints;



acting on recommendations for improvement arising from complaints;



ensuring there is meaningful reporting on trends in complaints;



ensuring compliance and review of the complaints management policy;



notifications to insurers; and



consultation with professional registration boards, and others where necessary.

5. Clinician and staff training All clinicians and staff need to have skills in handling complaints competently. The service provides training in dispute management, customer service and our complaints management procedures as part of induction and through regular updates. Regular reviews are conducted by the [complaints manager] to check understanding of the complaints process among clinicians and staff. 6. Promoting feedback Information is provided about the complaints policy and external complaints bodies that consumers can go to with a complaint, such as the [health care complaints commissioner], in a variety of ways: •

on our website;



through our consumer feedback brochure;



publicity about the service;



posters in reception;



discretely located suggestion boxes; and



by clinicians and staff inviting feedback and comments.

[insert other as appropriate] 7. Risk assessment After receiving a formal complaint, the [complaints manager/clinical director] reviews the issues in consultation with relevant clinicians to decide what action should be taken, consistent with the risk management procedure. Step 1: The Severity Assessment Code (SAC) is used to consider the likelihood and consequence of an incident to obtain a fixed rate ranking, which correlates with actions to be taken to address the incident.

41

Sample Complaints Policy

Page 4

Consequences

Serious

Major

Moderate

Minor

Frequent

4

4

3

2

Likely

4

4

3

2

Possible

4

3

3

2

Unlikely

4

3

2

1

Rare

2

2

2

1

Likelihood

‘Serious’ incidents

A patient has died as a result of receiving health care in a manner that is unrelated to the natural course of the illness and differing from the expected outcome of patient management. Death of a staff member or visitor. Complete loss of service capability. Huge financial loss. Serious threat to customer service relationships, permanent harm to reputation of the service.

‘Major’ incidents

A patient has suffered harm as a result of receiving health care in a manner that is unrelated to the natural course of the illness and differing from the expected outcome of patient management, resulting in hospitalisation (or increased length of stay). Permanent injury to staff members or visitors. Loss of service capability including cancelled appointments. Major financial loss. Serious breakdown of customer service relationships.

‘Moderate’ incidents

A patient has suffered harm in the course of treatment, no further treatment is required. A staff member has been injured and requires medical treatment resulting in lost time or restricted duties. Reduced efficiency or some disruption to services. Significant financial loss. Significant loss of customer service relationship.

‘Minor’ incidents

No harm to patients as a result of receiving health care. No harm to staff or visitors that requires medical treatment. No loss of service. Low financial loss. Minor damage to customer service relationship.

A SAC 4 rating requires notification to the [CEO/departmental manager] for immediate action and a detailed assessment of the causes and the corrective action that should be taken. A SAC 3 rating requires notification to the [CEO/manager of relevant department] and a detailed investigation at their discretion, and the [practice manager/complaints manager] conducts a review of policies as part of managing the complaint, which may result in recommendations for change.

42

Sample Complaints Policy

Page 5

A SAC 2 rating results in the [complaints manager] drawing attention to the nature and impact of problem to [departmental manager] as part of managing the complaint, and may be the subject of recommendations for change. A SAC 1 rating results in the issues being considered by the [complaints manager] as part of managing the complaint, and may be the subject of recommendations for change. Step 2: Consider if the complaint raises issues about the ability or appropriateness of a health care professional continuing to practice. Factors to be considered are risks to the adequacy and safety of care being provided, a lack of knowledge, skill, judgement or care, inappropriate behaviour, especially criminal acts. The CEO is notified of any complaint that involves a serious question about the adequacy of care provided by an individual health care professional, or of unprofessional behavior. 8. Assessing resolution options Formal complaints are normally resolved by direct negotiation with the complainant, but some complaints are better resolved with the assistance of an independent mediator or conciliator. The [complaints manager] will consider appointing an independent mediator, or encourage the complainant to take the matter up with [health care complaints commission] if: •

there is a serious question about the adequacy and safety of a health practitioner;



the complaint is against a senior clinician or manager who will be responsible for investigating the complaint, resulting in a perception that there is a lack of independence; and



the complaint raises complex issues that require external expertise.

9. External notification The [CEO/manager of relevant department] will inform or consult with external agencies in the following circumstances: Issue

External agency

Complaint has not been resolved directly with complainant

Health care complaints commissioner

Offence under privacy laws, privacy breach amounting to breach of professional standards

Office of the Federal Privacy Commissioner [state privacy commissioner or health care complaints commissioner if applicable] Health professional registration body

Unsafe care or inappropriate behaviour by a health practitioner Reportable deaths under the Coroners Act [insert as appropriate]

Health professional registration body [in NSW, the Health Care Complaints Commissioner]

[public sector only—all serious incidents]

[Department of Health/District or Area]

State Coroner

An incident that could possibly result in a complaint or claim is notified to the [medical defence organisation or insurer].

43

Sample Complaints Policy

Page 6

10. Timeframes Formal complaints are acknowledged in writing or in person within 48 hours. The acknowledgment provides contact details for the person who is handling the complaint, how the complaint will be dealt with and how long it is expected to take. If a complaint raises issues that require notification or consultation with an external body, the notification or consultation will occur within three days of those issues being identified. Formal complaints are investigated and resolved within [10–35 days, insert as appropriate]. If the complaint is not resolved within 20 days, the complainant, clinicians and staff who are directly involved in the complaint will be provided with an update. 11. Records and privacy The complaints manager maintains a complaints and consumer feedback register, with records of informal feedback (Suggestions for improvement and Consumer feedback forms) and formal complaints. Personal information in individual complaints is kept confidential and is only made available to those who need it to deal with the complaint. Complainants are given notice about how their personal information is likely to be used during the investigation of a complaint using our standard letter for acknowledging complaints. Individual complaints files are kept in a secure filing cabinet in the [complaints manager]’s office and in a restricted access section of the computer system’s file server. Consumers are provided with access to their medical records [in accordance with the privacy policy]. Family members and others requesting access to a consumer’s medical records as part of resolving a complaint are provided with access only if the consumer has provided authorisation [in accordance with the privacy policy]. 12. Open disclosure and fairness Complainants are initially provided with an explanation of what happened, based on the known facts. At the conclusion of an inquiry or investigation, the complainant and relevant clinicians and staff are provided with all established facts, the causal factors contributing to the incident and any recommendations to improve the service, and the reasons for these decisions. 13. Investigation and resolution The [complaints manager/clinical director/other] carries out investigations of complaints to identify what happened, the underlying causes of the complaint and preventative strategies. Information is gathered from: •

talking to clinicians and staff directly involved;



listening to the complainant’s views;



reviewing medical records and other records; and



reviewing relevant policies, standards or Guidelines.

44

Sample Complaints Policy

Page 7

14. Complaints about individuals Where an individual clinician or staff member has been nominated by a complainant, the matter will be investigated by the relevant manager or supervisor, who will: •

inform the clinician or staff member of the complaint made against them;



ensure no judgement is made against a clinician or staff member while an investigation is being carried out;



ensure fairness and confidentiality is maintained during the investigation; and



encourage the clinician or staff member to seek advice from their professional association, if desired.

The clinicians and staff members will be asked to provide a factual report of the incident, identify systems issues that may have contributed to the incident and suggest possible preventive measures. Where the investigation of a complaint results in findings and recommendations about individual clinicians and staff members, the issues are addressed through the service’s staff performance and review process. 15. Reporting complaints The [complaints manager/quality unit] prepares [monthly] reports on the number and type of complaints, the outcomes of complaints, recommendations for change and any subsequent action that has been taken. The reports are provided to staff, clinicians, senior management and the consumer advisory committee [or alternate, if relevant]. The [complaints manager/quality unit] periodically prepares case studies using de-identified individual complaints to demonstrate how complaints are resolved and followed up, for the information of staff, the consumer advisory committee and for use in annual reports to inform the public about complaints. Information about trends in complaints and how individual complaints are resolved is routinely discussed at staff meetings and clinical review meetings as part of reflecting on the performance of the service and opportunities for improvement. Complaints reports are considered and discussed at monthly clinical review meetings and directors’ meetings. An annual quality improvement report is published that includes information on: •

the number and main types of complaints received, common outcomes and how complaints have resulted in changes;



how complaints were managed—how the complaints system was promoted, how long it took to resolve complaints (and whether this is consistent with the policy) and whether complainants and staff were satisfied with the process and outcomes; and



the results of the annual consumer satisfaction survey.

The service promotes changes it has made as a result of consumer complaints and suggestions in its general publicity.

45

Sample Complaints Policy

Page 8

16. Monitoring and evaluation The [complaints manager/practice manager] continuously monitors the amount of time taken to resolve complaints, whether recommended changes have been acted on and whether satisfactory outcomes have been achieved. The [complaints manager/practice manager] annually reviews the complaints management system to evaluate if the complaints policy is being complied with and how it measures up against the indicators in the Better Practice Guidelines on Complaints Management for Health Care Services [insert any other applicable standards]. As part of the evaluation, consumers, clinicians and staff are asked to comment on their awareness of the policy and how well it works in practice.

46

Sample Complaints Policy

Page 9

Figure 4 – Complaint Management Flowchart for health care services

Resolved?

Complaint or concern received

Complete Suggestions for improvement form

YES

END

NO

Start Complaint follow up record

Seek more information

assess risk

High risk?

External agency consulted or notified

Principal notified

YES

NO

Consumer/carer

Gather information, analyse, conclude

YES

Appropriate to proceed?

NO

A

Quality Improvement cycle – record, analyse, improve

Report on facts, causes and recommendations

Negotiation and discussion

Resolution achieved ?

Advise of external resolution options

NO

A

YES

Letter confirming outcomes

END A = The service co-operates with investigation and resolution processes of external bodies

47

Sample consumer feedback brochure Your feedback

What would you like us to do?

What do you like most and what do you like least about our service?

Improving our service Are we meeting your needs? If you have concerns about a particular event please tell us what happened, when and where and the staff members involved. Ideal Health Services is committed to providing a high standard of care and meeting the needs of patients. We would appreciate you taking some time to let us know what you think we do well and where we can make improvements.

Date: ………………………………

IDEAL HEALTH SERVICES 234 High Street Our Town 5412 Tel: (08) 9219 7444

We want to hear from you

What we will do

Ways to give feedback

If you have a concern, chances are that you are not alone. Your feedback could make us aware of problems that we don’t know about. So, we want to hear from you.

We will work with you to assess the most appropriate way to resolve the problem and the best outcome. We ask you to consider the outcome you would like and we will strive to provide it.

Please place the completed feedback form in the suggestion boxes provided, or mail it to:

Let’s talk

We will provide you with all the facts about what happened and any strategies we have devised to improve our service as a result.

Please discuss any concerns or questions you have about your treatment with your treating doctor or practice nurse. In health care, it is especially important that people understand what is happening and feel comfortable about it. You are welcome to speak to other staff if you have any issues you wish to raise. Alternatively, use the feedback form overleaf.

What to expect If you have a complaint, we will respond to it promptly and sensitively. Feedback information is treated as confidential and managed according to privacy obligations. You can play an important role in resolving the problem by providing as much relevant information as possible, such as documents and the names of staff you have dealt with. The practice manager deals with all complaints and ensures that all serious complaints are brought to the attention of the practice partners. We investigate complaints thoroughly to know what happened and why, and ways to prevent it happening again. We will keep you informed at all times so you know what is happening.

48

Improving our service Compliments and complaints are discussed at staff meetings and monthly meetings of our doctors and nurses. We work together to find ways to improve and keep staff informed of what has happened.

IDEAL HEALTH SERVICES 234 High Street Our Town 5412 Or, you can send us an e-mail message setting out your concerns: [email protected]

If you would like us to follow up your comments please provide your name and contact details.

Taking it further The [relevant health care complaints authority] provides independent mediation and conciliation for complaints about health care services. If the matter is serious they will refer it to the relevant licencing authority.

Name ................................................................................ .......................................................................................... ..........................................................................................

Tel (XX) XXXX XXXX

Address ............................................................................ Postcode ...........................................................................

Day time tel no .......................................................................................... Other telephone .......................................................................................... .......................................................................................... Special needs – do you have any special needs? e.g. do you require an interpreter? Are you hearing impaired?

Suggestion for improvement form For use by clinicians and staff to record suggestions, complaints and compliments 1: Name and details of person making the suggestion, complaint or compliment Name: (Ms/Mrs/Miss/Dr)

(If anonymous, write ‘ANON’)

Address:

Postcode: Day time telephone no.:

Interpreter required?

Other telephone no.:

Preferred language?

Is the person a:

Date of Birth:

Relative or friend of a client

Consumer

Clinician or staff member

Other

Gender:

MALE

YES

NO

FEMALE

2: Area/unit of the service that is the subject of comment: ................................................. 3 : Complaints issue type:

Compliment issue type:

Attitude or rudeness

Staff kindness and helpfulness

Waiting time, access to doctor of choice

High level of care and treatment

Inadequate information

Excellent information about treatment

Inadequate or incorrect diagnosis or treatment

Prompt treatment and care

Medication error

Other (specify)

Billing and charges Other

4: What happened? If the complaint or suggestion has been resolved at the point of service, briefly describe what happened: ................................................................................................................................................................................................. .................................................................................................................................................................................................

5: How can we improve?

.............................................................................................................................................

.................................................................................................................................................................................................

6: Is immediate action required?

YES

NO

Action taken [practice manager/complaints officer] notified Notified [CEO/principal partner]

7: Name of clinician or staff member:

Other

Date ......./......./............

49

Complaint follow up record This sample form provides the person responsible for managing complaints in a health care service with the information required to manage a formal complaint. The information in the form may be adapted to incorporate complaints records as part of broader incident monitoring.

1. Initial receipt of complaint Date of receipt ....... /....... /....... REF NO. Name of clinician or staff member receiving complaint ............................................................................................. Initial action taken ....................................................................................................................................................... How was it received?

by mail

by phone call

by email

in person

2. Details of complaint: Name of complainant:.................................................................................................................................................. Address: ....................................................................................................................................................................... ...................................................................................................................................................................................... Tel:................................................................. email: ...................................................................... Is the person a:

Consumer of the service? Relative or friend of a consumer? Other? ......................................................................................................................................

Complainant’s age: ....... years

MALE

Gender:

FEMALE

Interpreter required?: NO YES ›Language.................................................................................................... Describe the events and the problem (what happened, when and who was involved):.............................................. ...................................................................................................................................................................................... ......................................................................................................................................................................................

Issue type: Attitude or rudeness Waiting time, access to doctor of choice Inadequate information about health care Inadequate or incorrect diagnosis or treatment Medication error Billing and charges Other (describe) ...................................................................................................................................................................................... Outcomes sought by complainant: .............................................................................................................................. ...................................................................................................................................................................................... ......................................................................................................................................................................................

3. Risk assessment rating If rating of 4 notification to:

1 CEO

2

3

4

Department of Health

Consultation with registration board, Department of Health, other

Insurers

Date: ....... /....... /....... Date: ....... /....... /.......

Action taken as a result: ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... If rating of 4, director/manager notified to conduct review Date: ....... /....... /.......

50

4. Investigation Person responsible for investigation or review: ......................................................................................................... ..................................................................................................................................................................................... List relevant documents: ............................................................................................................................................. ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... Interviews with clinicians and other staff directly involved (record names, dates, reason for interview): ............... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... Discussion with complainant (record dates and names): ........................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... Policies or procedures affected: .................................................................................................................................. ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... .....................................................................................................................................................................................

5. Complaint resolution Describe outcome agreed:........................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... Action to be taken: Explanation Apology Fee reduction or waiver Review of policy or procedure Other

51

Recommendations for change to policy or procedure:................................................................................................ ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... Complainant informed:

By letter

By phone call

Date: ....... /....... /.......

Copies of resolution process details to: CEO/department head

Date: ....... /....... /.......

6. Corrective action Corrective action adopted: ........................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... Corrective action monitored: ....................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... Monitoring of changes considered by principal partners/CEO/department head: ...................................................... ...................................................................................................................................................................................... ...................................................................................................................................................................................... Date: ....... /....... /....... Complaint closed

Complaint tracking Task

Who

Complaint acknowledged Complaint assessed Investigation of events Resolution with complainant Confirmation to complainant Corrective actions adopted (if applicable) Monitoring of corrective action complete Complaint closed

52

When

Letter acknowledging a complaint

[Your organisation’s letterhead]

To:

[Name]

Address:

[Line One] [Line Two]

Insert date:

Dear [Insert name] I have received a copy of your complaint about [insert summary description of complaint] [Insert apology or expression of regret. For example, ‘We are sorry that you experienced a delay in the oncology unit the other day’]. We are committed to a high standard of care and we will be looking into your complaint over the next few weeks. I understand your complaint is about [insert details of the complaint]. We plan to review what has happened to you, why it happened and what we can do to prevent it happening again. As part of our inquiries, we will consider what you have told us and provide a copy of your complaint to the [doctors/nurses] who were caring for you. We will also interview the doctors and nurses who were caring for you, and examine your medical records and other internal documents and policies. [As the incident has been rated as serious, we will also be notifying insurers/the Department of Health/other]. Our inquiries should be completed within [xx] days/weeks. If you are not satisfied with the way we handle your complaint, you can contact the [insert where appropriate—health care complaints commissioner and telephone number] at any stage. If you have any concerns or would like to discuss any of these matters, please contact me on [insert details]. Yours sincerely,

[Name and contact details]

53

Letter confirming a complaint has been resolved

[Your organisation’s letterhead]

To:

[Name]

Address:

[Line One] [Line Two]

Insert date:

Dear [Insert name] Thank you for discussing your concerns about [insert details about the complaint] on [insert date of telephone discussion or face-to-face meeting]. I wish to confirm that we have agreed to [insert details about agreed facts, any actions taken or promised to be taken]. I understand that you do not want us to take any further action on this matter. Please let me know if there is anything else you would like to discuss with me. Thank you for taking the time to assist us. Yours sincerely,

[Name and contact details]

54

Self Assessment Guide: How does your health service rate? To assess the performance of your complaints management system against the Better Practice Guidelines on Complaints Management for Health Care Services, allocate a rating between 1–5 against each of the practices described below. Assess your service each year to gauge the impact of changes that are made over time. Asking people who are working at different levels in the service to complete the assessment will enable you to gain a variety of perspectives from managers, clinicians, administrators, where possible, consumers or residents. 1 = your service is a leader in this area. 2 = your service is exceeding the Guidelines. 3 = your service meets the Guidelines in this area. 4 = your service has processes in place but has not yet reached the indicator. 5 = your service does not meet the indicator. 1. Commitment to consumers and improvement Leaders in the service promote consumer-focused care as part of quality improvement. All managers of the service are responsible for and understand effective complaints management. There is a complaints management policy and procedures that address:



the policy basis and rationale for the complaints policy, especially the link between complaints and overall management and strategic planning;



how and when complaints can be resolved by frontline clinicians and staff;

• •

how complaints are assessed for risk;

• • • •

how and when complaints must be referred to management and notified to external bodies;

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

timeframes for acknowledgment and resolution of complaints; what information is collected about complaints and how it is managed; how complaints are reported, as part of quality improvement; and

evaluation of the complaints system. Clinicians and staff understand and routinely use the complaints management policy within the scope of their responsibilities. There are adequate resources to maintain the complaints management system, especially: adequate staff with appropriate skills; training for clinicians and staff about customer service and conflict resolution; and effective records and reporting systems. There is a policy on informed consent, which is understood by clinicians and other relevant staff. There is an appropriately skilled, senior member of staff with responsibility for the complaints management system, reporting to senior management.

55

2. Accessibility Information is made available in a range of ways to ensure that consumers are informed of the complaints management policy and what they can expect if they lodge a complaint. Consumer feedback is actively sought by offering a variety of ways to raise concerns and suggestions, such as a widely distributed ‘opportunities for improvement’ brochure, signage in appropriate locations and asking for feedback when talking to consumers and their families. Clinicians and other staff, actively seek feedback from consumers and their carers when talking to them. There is provision for complaints to be made anonymously. Assistance can be provided to people to help them raise concerns or make a complaint, understand the complaint process and follow it up. Population groups who may be less likely to complain for reasons of culture or health status have been identified and steps have been taken to encourage feedback from them. Written information is provided in simple and easy-to-understand formats. The people who make complaints and provide other feedback are representative of the service’s consumer base.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

3. Responsiveness Clinicians and other staff can deal with consumer concerns and complaints in a manner that minimises disputes. Clinicians and other staff understand that the handling of complaints is the responsibility of everyone, appropriate to their role and responsibilities. Clinicians and other staff can describe the types of complaints that can be resolved at the point of service and those that require referral for further action. Complaints that are not resolved at the point of service are acknowledged within 48 hours and complainants are informed about the complaints process, what they can expect and options for further action if they are not satisfied. Complaints are resolved within timeframes in 80 per cent of cases and according to the complaints policy. The progress of resolution and investigation of complaints is tracked by the complaints manager. Complainants are informed about the progress of their complaint if resolution takes longer than 20 days.

4. Assessment and accountability Complaints are assessed to decide the most appropriate dispute resolution process, taking into account the seriousness, complexity and the wishes of the complainant. The risk management program provides strategies for managing complaints as a category of incidents, so that complaints are routinely assessed to identify and classify risk using a Severity Assessment Code or Seriousness Assessment Matrix. The service has a system for rapid and effective notification of serious complaints to senior management so that the appropriate action can be taken. The complaints policy sets out the circumstances in which complaints will be referred to external bodies, such as professional registration boards, health complaints commissions, coroners, police and other regulators.

56

5. Effective resolution The complaints resolution and investigation processes are simple and clear, and complainants, clinicians and other staff understand them. The approach to complaints resolution emphasises joint problem solving. Complaints not resolved at the point of service are reviewed to enable the service to determine the sequence of events and the underlying causes of the complaint and to implement corrective strategies. Investigations of complaints are complete and based on facts, taking into account information provided by complainants, clinicians and other staff directly involved in the complaint, relevant records and applicable policies and standards. The approach to investigation of complaints seeks to establish the facts and sequence of events, to identify the underlying causes or contributing factors, and to recommend preventative strategies. The complaints resolution process is fair to all parties, equitable and objective. Complainants, clinicians and staff who are directly involved are informed of the outcomes of investigations and given reasons for decisions. The service provides just outcomes for people who make complaints appropriate to the circumstances.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

6. Privacy and open disclosure The investigation and resolution of complaints are managed in a confidential manner. Complainants are informed when their formal complaint is first acknowledged and how their personal information is likely to be used during the investigation of their complaint. Complaints records are kept separately from other records, the records are accurate, kept securely, are only used for resolution and destroyed once the complaint process has been completed. Consumer requests for access to their personal records, or to amend errors in the records, are responded to promptly, and in a manner that is consistent with privacy obligations. The service has a documented policy and procedures protocol on open disclosure that is understood by clinicians and relevant staff. At the conclusion of an investigation of a complaint, complainants, clinicians and other staff directly involved are provided with the established facts, a summary of factors contributing to the incident, information about procedural changes that have been made (or will be made) and how those changes will be monitored.

7. Privacy and open disclosure Complaints are recorded in a manner that allows review of individual complaints, and analysis to identify trends and patterns for the purpose of clinical governance and quality improvement. There is a risk management system that identifies, analyses, evaluates, treats, monitors and communicates risks effectively and minimises losses and maximises opportunities. Sufficient information is collected to facilitate monitoring and review of the complaint management system and to demonstrate compliance with relevant policies and standards (internal and external).

57

Information about complaints is regularly provided to clinicians and other staff and a forum is provided for clinicians and staff to discuss complaints, lessons learned and how performance has been improved. The service periodically reports information to the public about consumer feedback, including complaints, as part of reporting on quality improvement.

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

8. Monitoring and improvement Executive management or principals of the service routinely use complaints information as part of clinical governance, quality improvement, planning and to inform professional development and staff training. Senior clinicians and managers respond to complaints after the risk assessment has been completed, so that investigation, reporting, analysis, review and follow up action can occur, where appropriate. The service monitors whether complainants, clinicians and staff are satisfied with the complaint resolution process and the outcomes of complaints resolution. The service continuously monitors and regularly reviews the performance of the complaints management system against the complaints management policy and external standards. Management regularly evaluates the policies and practices on complaints management, informed consent and open disclosure, to determine their effectiveness, and makes improvements if required. Consumers, clinicians and other staff are involved in the design of the complaints management system.

List areas where a rating of ‘1’ was achieved:

List areas where a rating of ‘4’ or ‘5’ was achieved:

Priorities for improvement for the next 12 months:

58

PART FOUR CASE STUDIES This part of the Handbook provides 10 case studies of complaints and consumer feedback programs in a range of health care services. The health care services and consumers selected for the case studies were drawn from the Survey of examples of better practice complaints management in health care services, 2003, conducted by the Turning wrongs into rights project. Case study 1:

A general practice

Case study 2:

A large, metropolitan teaching hospital

Case study 3:

A small, private nursing home

Case study 4:

A community health service and residential aged care

Case study 5:

A semi-rural community pharmacy

Case study 6:

A statewide children’s hospital

Case study 7:

Collaborating with consumers

Case study 8:

A private, rural hospital

Case study 9:

Consumer focus

Case study 10:

A corporate group of hospitals and nursing homes

Part 4: Case studies CASE STUDY 1: A General Practice ‘The days are gone when you can ignore complaints. Often people only want to be heard.’ Brooke Street Medical Centre is a general practice in Woodend, 70 kilometres north of Melbourne on the city fringe. The practice has 12 general practitioners and four practice nurses serving a varied client base. The Centre’s complaints policy actively seeks comments from consumers. The Practice Manager, Deborah Stidwell, is responsible for managing complaints. ‘Our philosophy is to encourage clients to contact the practice directly with their concerns, rather than talking badly about the business in town’, she says. ‘It is important for staff that wrong things are not being said about them.’ The Principal Partner, Dr Peter Ferguson, believes ‘the days are gone when you can ignore complaints. Often, people only want to be heard.’ The Centre receives about 60 complaints a year. One-third of these are about clinical issues such as communication and treatment, and the rest are administrative issues, such as billing practices, occupational health and safety issues or issues concerning the premises. A team approach All staff, both clinical and administrative, have received training in customer service and are tuned into identifying complaints and resolving disputes. Staff are aware of the consumer feedback policy and inform consumers about it. The complaints process is explained to the client at the time a complaint becomes formal, when it is put in writing. If the Practice Manager needs to speak with a general practitioner about the complaint, she will ring the client back. Her next step is to speak with the relevant staff and the complainant to establish some facts about what happened. The complainant is contacted by phone, or in writing if they cannot be phoned, on the day the complaint is lodged. Complaints about clinical issues are dealt with by the senior doctors at the Centre, but the Practice Manager is always involved. She handles the paperwork and does the risk assessment, often with the doctor. ‘Usually, we sit down and discuss the matter with staff. Some things are just blatant mistakes. The discussions could lead to retraining of staff. If the problem is one of staff attitude, we discuss it thoroughly’, says Ms Stidwell. Meeting client needs ‘We try to get the best outcome for everyone involved. From a public relations viewpoint, it is important to get a positive outcome for the client’, says Ms Stidwell.

61

The typical outcomes of complaints are an explanation or an apology about the situation. If the matter is about inappropriate billing, the bill may be adjusted. Prompt resolution The Practice Manager places a high priority on complaints and is able to resolve most of them within a week. The time taken to reach a resolution depends on the seriousness of the matter—a complaint raising more serious issues is referred to a managers’ meeting and, in this case, resolution may take up to a month. Risk management The Centre has developed risk assessment tables based on the Australian Standard, Risk Management AS/NZ 4360:1999. The Practice Manager uses the risk assessment tables to evaluate the consequences and likelihood of recurrence of every incident, including complaints. Ms Stidwell finds the tables help her to evaluate risks quickly. ‘The tables indicate clearly what steps need to be taken to rectify the situation and you get a feel for action required. Another benefit is that it provides a permanent record of the assessment of the complaints’, says Ms Stidwell. Dr Ferguson also believes the risk assessment tables have a lasting benefit. ‘Being aware of the risk assessment tables tunes the clinicians into thinking about the overall consequences of a complaint. Using the tables prevents negative outcomes in the future.’ Learning from complaints The Practice Manager reports on individual complaints (de-identified) at the monthly clinical meetings for doctors and nurses, meetings of reception staff and quarterly meetings of all staff. ‘Complaints’ is a standing agenda item at every meeting, enabling staff to receive feedback and hear the outcome of a particular complaint. ‘We use it as a learning tool and for discussion’, says Ms Stidwell. Dr Ferguson finds the supportive environment good for learning. ‘Sharing information with colleagues enables you to utilise their expertise.’ Benefits ‘In the past, we didn’t really know what was happening … managing complaints was haphazard’, says Ms Stidwell. ‘Now we are able to work on complaints. We are happy to have a system that draws it all together in one place.’ According to Dr Ferguson, the doctors and nurses in the practice support the complaints management system. ‘Having a protocol in place makes complaints handling easier.’

62

Risk assessment tables Brooke Street Medical Centre, Woodend, Victoria CONSEQUENCES

LIKELIHOOD

almost certain

A

likely

B

moderate

C

unlikely

D

rare

E

insignificant

minor

moderate

major

catastrophic

1

2

3

4

5

Consequences Insignificant Minor Moderate Major

1 2 3 4

Catastrophic

5

No injury, little or no physical damage, low financial loss. First aid treatment, on-site release immediately contained, medium financial loss. Medical treatment required, on-site release contained with outside assistance, high financial loss. Extensive injuries, loss of capabilities, off-site release with no detrimental effects, major financial loss. Death, toxic release off-site with detrimental effect, huge financial loss.

A B C D E

The event is expected to occur in most circumstances. The event will probably occur in most circumstances. The event should occur at some time. The event could occur at some time. The event may only occur in exceptional circumstances.

Likelihood Almost Certain Likely Moderate Unlikely Rare

SEVERE RISK

Detailed research and management planning required at senior levels ● Director’s meeting ● Director’s meeting ● An outline for investigation prepared ● Issue investigated

SIGNIFICANT RISK

Senior Management attention needed ● Practice Manager reviews policies ● Practice Manager discusses policies with senior clinicians ● Possible policy changes

MODERATE RISK

Management responsibility must be specified ● Practice Manager review procedure

LOW RISK

Manage by routine procedure ● Issue reviewed ● Practice Manager contacts complainant

63

CASE STUDY 2: A large, metropolitan teaching hospital ‘We don’t have a blame culture. Our approach increases staff participation and removes fear of personal blame.’ Princess Alexandra Hospital is an acute care tertiary referral hospital in central Brisbane. The hospital has 712 in-patient beds offering all specialties except maternity and paediatrics. The hospital has a comprehensive complaints management system based on the principle that complaints are opportunities to improve service delivery, and increase staff and consumer satisfaction. The Hospital’s Complaints Procedure states that the hospital aims to ‘provide an easily accessible, responsive and fair complaints procedure for consumers, carers and staff; to develop a culture of openness and a willingness to learn from mistakes…’. A Patient Liaison Officer is responsible for managing complaints, reporting to the Quality Coordinator, Karin Perisic, in the hospital’s Quality Improvement Unit. The Unit is responsible for complaints and other incidents, bringing together all sources of information about the quality of care and service. Each year, the hospital receives about 1,000 complaints, mostly about access to services, such as long waiting lists or cancelled surgery, poor staff attitude, and a lack of privacy and respect. The most common outcomes of a complaint are an apology and changes to hospital procedures. Assessing complaints The hospital recognises informal complaints, dealt with at the point of service, and formal complaints—those that have not been resolved at the point of service or raise serious concerns. If a consumer is not happy with the management of a complaint, staff will usually encourage them to formalise their complaint. For example, a patient expressed concerns about delay in access to surgery and no date for surgery could be agreed. The complaint was formalised, which meant more senior staff would become aware of delays and investigate the causes. Formal complaints are assessed by the Patient Liaison Officer and classified according to seriousness and risk, consistent with the Queensland Health Complaints Management Policy 2003. ‘Risk assessment enables complaints to be managed in a timely and appropriate way, and more serious complaints receive the attention they require’, says Ms Perisic. Under the Queensland Health Complaints Management Policy all complaints assessed as moderate, major and extreme must be referred to the complaints coordinator, and all major and extreme complaints must also be notified to the District Manager. The Policy also provides guidance on when a complaint should be referred to external agencies, such as professional registration bodies, police and the Health Rights Commission. Investigating causes The head of the relevant department or division is responsible for investigating complaints and informing staff members who are directly involved. Heads of departments are responsible for ensuring that no judgement is made against any staff member and maintaining confidentiality while initial assessments are being carried out.

64

The investigation seeks to identify the cause of the complaint, any contributing factors and opportunities to prevent recurrence. Staff members directly involved in a complaint provide a factual report of the incident and are asked to identify organisational issues that may have contributed to the event. The results of the investigation and a proposed response to the complainant are forwarded to the Quality Improvement Unit. The Patient Liaison Officer is responsible for dealing with the complainant, including hearing their account of what happened, documenting their concerns, and considering their expectations. The Patient Liaison Officer considers the report of the hospital’s investigation and informs the complainant of the outcome. ‘We don’t have a blame culture. Our approach increases staff participation and removes fear of personal blame’, says Ms Perisic. Recording and reporting complaints The Patient Liaison Officer records complaints in a database that supports efficient management of complaints. It produces reminders according to the complaints policy timelines, manages documents and produces customised reports on complaints. The database uses Respond 3, a commercially available document management and case management system. The Quality Improvement Unit provides monthly reports to each division in the hospital on the number and types of complaints in their area. The Unit also reports on whether complaints have been resolved within the timelines in the complaints policy, and provides analysis of implementation of recommendations for improvement. Reports on complaints are regularly tabled at the Safety and Quality Committee of the regional Health Service District. Complaints lead to improvement According to Ms Perisic, complaints have lead to changes in a number of aspects of the hospital’s service. For example, the hospital was receiving a large number of complaints about fees for private patients. After an investigation, the hospital found that consumers were provided with limited and inconsistent information about fees and prior to admission. The hospital now provides clear information about fees to all private patients prior to admission. Another issue is staff communication skills. As a result of the hospital having a high level of complaints about poor communication, the District Safety and Quality Committee recommended that the hospital provide training in this area. ‘A number of staff have received the training so far and it has become an on-going quality improvement initiative’, says Ms Perisic. The impact of the training is currently being evaluated but early indications suggest that it has contributed to a decline in the number of complaints about communication. Benefits The hospital’s approach to complaints management links numerous data sources and enables the hospital to view the performance of its services from many perspectives. ‘The organisation becomes aware of major complaint themes and these issues can be prioritised. This also leads to better management of resources. Funds can be allocated or sought and directed to areas identified as needing improvement’, says Ms Perisic. 65

CASE STUDY 3: A small, private nursing home ‘We actively involve carers and family members in the residents’ daily life, which helps communication and allows us to resolve issues with an informal approach.’ Woodfield Nursing Home in the Sydney suburb of Haberfield, provides 44 high care beds for people with special needs, such as dementia, visual impairment, multiple sclerosis, depression, personality disorders and developmental disabilities, and people of non-English speaking backgrounds. There is a 58-bed hostel co-located with the nursing home. Woodfield Nursing Home has systems to actively promote continuous improvement, with preventive and reactive elements. It has well-established practices for residents, families and staff to raise concerns and compliments as part of the improvement program. ‘Our approach to complaints reflects our philosophy of care, which is stated in our mission, values and strategic plan’, says Paul McMahon, the Regional Director of the home. ‘We promote all stakeholders being recognised as part of the service.’ ‘We actively involve carers and family members in the residents’ daily life, which helps communication and allows us to resolve issues with an informal approach.’ Improvement logs Staff and residents are encouraged to provide comments, suggestions, complaints and compliments by completing ‘improvement logs’. ‘It’s a system to capture feedback from everyone’, says Helen Emmerson, Director of Nursing at Woodfield. The logs are standard forms that are contained in folders located around the facility. There are also posters giving people instructions on how to use the improvement logs. The forms provide an area for suggestions and an area for management to respond to the suggestion on the same page. The system allows everyone to see what type of issues have been raised and how they have been answered. If desired, logs can be completed anonymously or they can be sent to management confidentially. Envelopes addressed to management are provided at the back of the folder for confidential lodgement. The nursing home maintains a register of quality activities arising from improvement logs. Complaints are recorded in a separate complaints register. ‘The registers are useful to track issues raised previously and to show how the improvement cycle has been completed’, says Ms Emmerson. Issues raised in improvement logs that require additional resources or further investigation are transferred to a continuous improvement report, which captures action plans and evaluations. Staff and residents’ meetings ‘Continuous improvement’ is on the agenda for all resident meetings, which occur at regular times. Residents can discuss new suggestions and are provided with updates on areas for improvement from previous meetings.

66

Suggestions and complaints made at the meetings are immediately reported to management so they can be followed up. Feedback occurs directly to the individuals who have raised the issue, through memos and letters and at the next residents’ meeting. Minutes of the meetings are displayed in the nursing home so everyone can view them. Promoting partnership The service has an innovative Exercise Program for residents of the hostel and nursing home and their families. The Exercise Program offers hostel residents a chance to improve fitness, develop socialisation and enhance well-being. Evaluation of the Exercise Program suggests the health and strength of the residents has improved and a closer relationship has developed between staff and carers. As a result, staff and family feel that problems can be raised informally. ‘Our staff encourage families to get involved with the life of the nursing home’, says Mr McMahon. ‘This ensures a home-like environment and good relationships are promoted, making it easier for everyone to raise issues of concern.’ Reporting and action If a complaint is raised through an improvement log or through other means, the director of nursing or the relevant manager arranges a meeting to develop a resolution plan and discuss it with the complainant. Suggestions from improvement logs and complaints are discussed at weekly management meetings, so they can be followed up effectively and promptly. Complaints and suggestions are reported to the nursing home’s board as part of the regional director’s report on continuous improvement. ‘Our approach ensures that complaints and suggestions are monitored, dealt with quickly, everyone concerned is involved, and feedback is given to all stakeholders’, says Mr McMahon. Consumers suggestions for improvement Suggestions made through the improvement logs by carers and visitors cover a wide range of topics. For example, a man visiting the nursing home offered to volunteer his time to read poetry to the residents. The offer was accepted and the man provided a very successful weekly session for a period of six months. He provided great entertainment for dementia residents by reading poetry and stories. Another example concerned a long-term resident who had very bad breath, despite a good regime of oral care. Different products were investigated and a new product was tried, at the suggestion of a family member. The product proved to be effective in clearing the problem. The nursing home introduced it as part of the general oral care regime for all residents. Changes on the way The Woodfield Nursing Home and Hostel are part of the Uniting Church network, which amalgamated with Lucan Care and Edina facilities to become the UnitingCare Sydney region in early 2004. Following the amalgamation, all policies and procedures, including complaints mechanisms, are being reviewed to provide greater consistency and effective systems across the region.

67

CASE STUDY 4: A community health service and residential aged care ‘Every issue raised becomes an opportunity to improve our services.’ Macedon Ranges Health Services provides residential aged care, community health services and a range of allied health services in Gisborne, 55 kilometres from Melbourne. Services for older people include a 30-bed nursing home and a 45-bed hostel. The service actively seeks consumer views as part of an Opportunities for Improvement program (OFI). Helen Cashin, Project and Development Officer at the service, says calling consumer feedback ‘opportunities for improvement’ encourages feedback in a positive way. ‘Every issue raised becomes an opportunity to improve our services’, says Ms Cashin. Encouraging feedback The service has an ‘Opportunities for Improvement’ form for clients and staff to note issues, suggest improvements and participate in planning within the service. The OFI form includes a space for consumers, staff and visitors to raise issues and a section to record follow up action for the person managing suggestions and complaints—the priority of the issue, planned action, progress notes and the outcome of the action taken. The OFI form is included in an information package sent to every client prior to receiving the service. Staff encourage clients to use the form. ‘It usually starts with a staff member asking a client to make a suggestion. Staff will offer an OFI form to clients, or staff can write an OFI even if the patient does not want to write one’, says Ms Cashin. The OFI form is also sent out with accounts once a year, and this attracts many responses. Forms and information regarding the OFI system are available in the foyer of the nursing home and hostel, and the community health centre. The OFI forms can be returned by mail, given to staff or dropped anonymously in an OFI (suggestion) box in the foyer. If contact details are provided, the service sends an acknowledgment of the OFI form with details of planned further action. In 2003 the service received 514 forms, mostly dealing with compliments and suggestions, and a small proportion of complaints. Keeping track of feedback Information from the OFI forms is entered into the ‘Continuous Improvement Action Plan’, a database created using Microsoft Excel software. It records the nature of the issue raised and the action required, the person deemed responsible for the action, the action taken, the outcome and the month of further review (if applicable). Before a matter is signed off, the provider of the feedback, if known, is contacted to see if they are satisfied with the outcome. Comments and complaints are separately identified, with sub-categories for: quick fix; occupational health and safety; quality project; quality; comments and complaints; and other.

68

A ‘quick fix’ is a concern that is resolved at the point of service or within 24 hours. If a matter requires more than 24 hours, it becomes a ‘quality project’. A designated staff member and the Project and Development Officer closely monitor the progress of quality projects. If the matter has not been closed within a week, the Project and Development Officer will follow the matter up with the unit manager. If a matter is serious, a copy of the OFI form is given to the CEO immediately. Consultative resolution ‘The Opportunities for Improvement system provides a framework for managing feedback and assists us to give a timely and appropriate response’, says Ms Cashin. ‘A major advantage is that it provides a consultative approach to resolution with open and transparent documentation. One OFI form often leads to another as the suggestions and ideas are developed.’ Overcoming challenges ‘It took a while to implement the Opportunities for Improvement system’, says Ms Cashin. ‘Now that it is in place, it saves time because the system tracks the OFI and indicates what has been done and what needs to be done.’ ‘One of the biggest challenges has been to get unit managers and staff to understand the importance of seeing this as a tool to support continuous quality improvement. Now that the system is a part of the culture of the organisation, consumer feedback is welcomed and addressed in a meaningful and constructive way.’

CASE STUDY 5: A semi-rural community pharmacy ‘Retaining customers is a strong motivator for good complaints management.’ Murray Fry Amcal Pharmacy is a community pharmacy in Camperdown, a rural township on the Western District plains of Victoria. The pharmacy provides both prescription and non-prescription medicines and general chemist-related retail goods. It services the general population of Camperdown and two nursing homes in the area. It is the only pharmacy in town, and the next one is 13 kilometres away. Murray Fry is the owner and pharmacist. He believes complaints management is part of consciously fostering customer relations in a small business. ‘My business is customer focused [and] if high standards are set and followed, the number of complaints will be reduced. It is essential in a small community.’ The pharmacy receives about 50 complaints a year, generally about the retail side of the business. Issues include staff rudeness and goods not meeting acceptable standards. Complaints about prescriptions are usually about the time taken to fill scripts.

69

‘No frills’ record keeping Pharmacy staff record all comments and complaints in a book kept at the cash register. As the pharmacy is a small business and there are not many complaints, it is easy to keep track of each complaint. Mr Fry reviews the book regularly and provides comments at weekly staff meetings for fulltime staff and monthly meetings for part-time staff. ‘Complaints are regularly discussed at staff meetings’, says Mr Fry. ‘The Office Manager and I review complaints and provide feedback to staff.’ Everyone’s responsibility The pharmacy has a philosophy of not being complacent about any aspect of customer service. ‘All complaints are handled immediately or as soon as possible’, says Mr Fry. A detailed procedures manual and Guidelines for staff enable the pharmacy to resolve common complaints as quickly as possible. If a customer wants to return or exchange an item and the item is still saleable (in original packing), staff are authorised to refund or exchange the product. If the product is not saleable, the customer must be referred to the Office Manager or Mr Fry. Staff can refer the customer to Mr Fry if they feel unable to resolve the complaint or deal with upset customers. Meeting customer needs ‘The general approach to complaints is to meet the customer’s needs within reason, regardless of whether the pharmacy is at fault. If the pharmacy is at fault, we do whatever is necessary to compensate the customer and send them away satisfied’, says Mr Fry. The most common outcomes from complaints are refunds, exchange of goods or the offer of an apology. If necessary, a staff member will receive additional training. Customers are told of the outcome of their complaint either by a phone call from a staff member, or Mr Fry waits for the customer to come into the pharmacy again and talks to them personally about the matter. Improving the service Mr Fry uses customer feedback to alter and develop new procedures. For example, a major issue in small towns is privacy. Customers and the staff serving them often know each other socially or through family networks, and some customers feel embarrassed when asking for a particular medical prescription that reveals their medical condition. Mr Fry has responded by implementing a system for customers to request service from the pharmacist or a different staff member. Information cards have been handed out at local schools and in the doctor’s surgery telling customers about the procedure. Staff are trained to be sensitive to privacy issues and are required to sign confidentiality agreements. Staff training All staff receive training about customer service and complaints during business hours, including part-time and casual staff. The training covers all aspects of the business including resolving customer complaints.

70

‘The focus is on encouraging all staff to provide an “A” level service’, says Mr Fry. The Amcal customer service training modules are used for staff development. Benefits Mr Fry knows a complaint has been successfully resolved when a customer returns to the pharmacy. ‘Retaining customers is a strong motivator for good complaints management.’

CASE STUDY 6: A statewide children’s hospital ‘... we are exposed to the full spectrum of issues and can more efficiently use complaints to provide opportunities for improvement.’ The Children's Hospital at Westmead is a statewide service providing acute and long-term care for children. The main hospital is based in Sydney and there are outreach services and clinics throughout the state. The Children’s Hospital has 340 beds and manages all cases, simple and complex. The hospital has a Service Improvement Unit, which deals with complaints and consumer input, medico–legal matters, clinical review and clinical risk management. ‘By combining all these functions in one unit we are exposed to the full spectrum of issues and can more efficiently use complaints to provide opportunities for improvement’, says Dr Stuart Dorney, Clinical Risk Manager and head of the Unit. ‘The hospital’s approach to complaints management is motivated by a recognition that complaints signal potential issues that need improving or rectifying.’ The service receives about 300–350 complaints a year, mostly about staff attitude, cancelled surgery, missed diagnosis, poor communication, wrong and misleading information, availability of resources, waiting lists and billing. Patients’ friend The hospital employs a patients’ friend, Ms Betty Radcliffe, who is an advocate for all patients and their families. Her office is located near the entrance to the hospital and she has an ‘open door’ policy. Ms Radcliffe works closely with Dr Dorney, who are both members of the Service Improvement Unit. Staff are aware of the patients’ friend and refer parents to her when they feel this could be helpful. Ms Radcliffe says parents appreciate the service and are often happy that there is someone to help out who is not involved in the child’s treating team. Parents have also found her to be a good information source when they don’t know who to contact or ask questions of. Fair and open When a complaint is received, Dr Dorney or Ms Radcliffe approach staff who are directly involved with the incident to discuss the complaint and give their account of events. Dr Dorney considers the personal approach to be less confronting for staff than receiving the complaint in internal mail.

71

Complainants also meet with Dr Dorney or Ms Radcliffe to discuss complaints and help to explain what has happened. If appropriate, they provide parents with medical records and Dr Dorney or Ms Radcliffe help them to make sense of them. Complaints resolution is facilitated as much as possible. Open disclosure is encouraged, especially when clinicians meet with the complainant to discuss the complaint. The process is designed to be fair to staff and consumers, and to ensure both have the opportunity to give their account of events. Collaboration for improvement Complaints are used to identify areas where improvements are needed and the hospital works closely with parents to find solutions. An example is the improvements made to pathology collection times at the liver transplant clinic. Complaints were received by the liver transplant clinic that children were waiting too long for their blood to be collected for pathology. The parents compared the liver unit’s services to the oncology clinic, which had a specific paid collector. Staff at the clinic felt they were under pressure from the parents as a result of the different approaches to blood collection. The liver transplant parent group discussed the problem and decided the parents would raise funds to pay for a dedicated pathology collector for four hours during the weekly liver clinic. Parents and staff are happy with the outcome. Integrated risk management During 2004 the hospital will implement a new statewide NSW Health incident management system, bringing together monitoring and reports on complaints and other incidents. Under the new system all complaints will be subject to risk assessment, using the NSW Health Severity Assessment Code (see Figures 1–4 at the end of Part 4). Recording complaints The hospital’s complaints records identify any clinical risks, areas where improvements are needed, and the performance of the complaints process. The information is used for internal reports, staff newsletters and reports to NSW Health. Information about complaints is entered on a complaints database, which supports efficient monitoring and analysis of complaints. The database uses Respond 3 to provide case management support, document management and customised reporting. The Service Improvement Unit provides a report on the number and type of complaints to NSW Health every three months, using complaint type codes provided by NSW Health. The Unit produces a newsletter, The Clinical Improvement Herald, every two to three months to inform staff of improvement activities. Occasionally, letters of complaint from consumers are published to alert staff of problems. For example, the Herald published a letter from the mother of a child with a disability. Her letter complained that staff were using inappropriate language to refer to children with disabilities and clearly outlined the need for staff to be sensitive to others and use respectful language. Monitoring performance The performance of the complaint management system is reviewed regularly against benchmarks in the NSW Health Guideline for Frontline Complaint Handling 1998 as part of

72

reports for NSW Health and the Public Accountability Committee. The benchmarks cover issues such as timelines for acknowledging and resolving complaints. Executive support Dr Dorney believes the hospital’s executive group is committed to improvement and provides a high level of support for the Unit. The Hospital’s Public Accountability Committee, which meets every three months, receives and discusses reports on issues raised in complaints and compliments at each meeting. Recommendations for improvement are made at these meetings, and previously recommended changes are monitored. Information from the Public Accountability Committee is forwarded to the Hospital’s Quality Council, which reports to the Hospital Board.

CASE STUDY 7: Collaborating with consumers ‘Asking for access to my medical records was one of my ways of trying to regain control and understanding of what had happened. When that was blocked, my distress turned to anger and fear.’ Ms C, a long time member of the Health Care Consumers’ Association of the Australian Capital Territory, spent eight days in hospital following complications from a procedure that should have taken only two days. ‘Once I was out of hospital, I wanted to pursue what went wrong so it won’t happen to someone else’, says Ms C. ‘At the time I was in hospital I felt powerless, frightened and very sick.’ Understanding the issues ‘My main concern was that there were several days between my first reporting concerns about new symptoms and receiving any diagnostic and remedial medical attention. It took about a month after I came home to fully recover from the physical harm that resulted from the delayed acknowledgment of my new symptoms.’ ‘Asking for access to my medical records was one of my ways of trying to regain control and understanding of what had happened. When that was blocked, my distress turned to anger and fear.’ After recovering fully, Ms C wrote a letter to the hospital’s Chief Executive Officer (CEO). She identified five main areas of concern about her treatment and the difficulties accessing her medical records, and asked for an appointment to discuss the issues with the CEO. Direct Negotiation The hospital’s Customer Liaison Officer called the next day and offered an appointment for a meeting with the CEO. A letter of confirmation of the appointment arrived the following day. Between then and the meeting, Ms C had two phone discussions with the Customer Liaison Manager to clarify the details of Ms C’s concerns. Ms C had a meeting at the hospital with the CEO, the Director of Nursing, the Quality Control Manager and the Customer Liaison Manager. A member of Health Care Consumers

73

Association accompanied her at the meeting. The Liaison Manager had prepared a full briefing of issues and the results of the hospital investigations. These issues were discussed at the meeting and Ms C was provided with a copy of the briefing. ‘There seemed to be a focus on reassuring me that the initial treatment was appropriate for my condition’, says Ms C. ‘I had never been in doubt about that. I felt it was difficult to convey my prime concern, which was the lack of appropriate follow up once I reported new symptoms and evidence that the treatment was damaging me or there was a new condition.’ After the meeting Ms C received a letter from the CEO outlining the results of the meeting and agreements made for follow up about quality improvement issues. The CEO acknowledged that the meeting was ‘extremely beneficial to all, and has raised some very important issues that do require attention’. Collaborative Solutions During the meeting, it was agreed that the hospital would work with consumer representatives on the issues arising from Ms C’s complaint, including: •

development of new pain management protocols for Accident and Emergency and other service areas in the hospital;



a review of procedures on patient-reported symptoms relating to fluid;



development of Guidelines for administration of time-specific medicines;



improvement of patient access to medical records; and



improved information in the wards to patients about access to complaints procedures.

The letter reassured Ms C that her concerns about not being heard were well understood. ‘Generally, I felt satisfied with the way the hospital handled my concerns’, says Ms C.

CASE STUDY 8: A private, rural hospital ‘Building rapport with patients is important in a small community.’ Customer relations is the key to continuing business viability. Patients have to keep coming through the door. One disgruntled patient who talks to friends and family can lose the hospital a lot of business.’ Illawarra Private Hospital is a 101-bed hospital in Fig Tree, a town near Wollongong, New South Wales. The hospital provides medical, surgical, obstetrics, pathology and radiology services, and a day surgery unit, which provides urological services to the nearby Illawarra Public Hospital. Helen Webb, the Chief Executive Officer of the hospital, takes complaints management seriously. The CEO and the Director of Clinical Services are directly responsible for complaints. According to Ms Webb, a philosophy of good customer service drives the hospital’s complaints policy. ‘It results in timely responses to complaints and involvement at the highest level of management.’ The Ramsay Health Care Group owns the hospital and the group’s complaints management policy provides the framework for the hospital’s complaints policy.

74

‘Building rapport with patients is important in a small community’, says Ms Webb. ‘Customer relations is the key to continuing business viability. Patients have to keep coming through the door. One disgruntled patient who talks to friends and family can lose the hospital a lot of business.’ There are about 30 complaints a year, mainly about fees and the ‘gap’ payment, food and clinical issues such as infections, and situations where the patient feels their needs have not been met. Recording all complaints All complaints are recorded on a complaint resolution form, whether informal (resolved at the point of service) or formal (not resolved at the point of service). The form records the type of complaint, resolution process, resolution timelines, action taken and outcomes. All complaints are recorded in a complaints register developed using Microsoft Excel software, and adverse events are recorded in a ‘Riskman’ database. The CEO collates information from the two sources to identify areas that may need improvement. Risk assessment The hospital uses a risk assessment matrix to determine the consequences and likelihood of the recurrence of each complaint. Complaints assessed as ‘high risk’ are subject to a root cause analysis, or RCA. A team, consisting of the staff members involved in the complaint and a mediator, usually the CEO, conducts the RCA. The team identifies what happened, causes and makes recommendations for action, including changes to procedures or the updating of equipment. The objectives, outcomes and the person responsible for implementing changes are recorded. The CEO audits RCA records regularly. Speedy resolution The hospital’s complaints procedure is summarised in a complaint resolution process chart, providing a step-by-step guide and the timeframe for each step. Formal complaints are acknowledged within 24 hours. The manager for the relevant unit reviews the information within the next two days and must communicate with the complainant within another three days. The CEO sends a letter to the complainant within 10 working days advising them about what happened and the outcome of the complaint. The CEO then contacts the complainant by phone to see if the complainant is happy with the outcome. According to Ms Webb, the timelines are achieved in 90 per cent of cases. Generally, the hospital will do what the complainant requests, as long as it is reasonable. For example, if the complaint is about fees, a reduction or waiver will be considered. Staff awareness Ms Webb says all staff know and understand that complaints are an opportunity to improve services and are aware of the complaints policy and procedures. The hospital uses storyboards to educate staff about policies and protocols, including the complaint and risk management policies. The storyboard is displayed on a portable room divider, and uses photographs, computer-generated ‘clip art’ and text to portray information. The storyboard is designed by the staff member responsible for promoting a particular policy or procedure. For example, the hospital’s privacy officer designed material for a display about new privacy laws, and the infection control manager regularly uses the storyboard for infectious disease updates. 75

The storyboards are placed in strategic areas in the hospital. ‘All staff have easy access to the storyboard as it tours each unit and ward’, says Ms Webb. Staff members have to sign a register to indicate that they have read a storyboard. ‘Spot quizzes’ are conducted by the producer of the storyboard to test the reader’s knowledge of the main issues. Ms Webb believes that using storyboards for staff education has proved to be very effective. Talking about complaints De-identified individual complaints are discussed at staff meetings to provide learning opportunities for staff and enable the identification of training needs. Complaints, compliments and adverse events are discussed at the monthly meetings of the hospital’s leadership and management group. The focus is on systems and performance improvement.

CASE STUDY 9: Consumer focus ‘Good communication is the key to successful service delivery and complaints management. Good intent and genuine interest in addressing the concerns expressed by the consumer need to be explicit.’ The Health Consumers’ Council is an independent organisation representing health consumers in Western Australia. The Council’s services include assisting consumers to resolve grievances about health care services. Where appropriate, it also assists health service providers to respond to complaints from consumers. During 2002/03, the Council assisted over 280 people with complex complaints about health care services. Consumer centred approach ‘Problems often arise simply because health care services lack a consumer-centred approach’, says Maxine Drake, an advocate with the Health Consumer’s Council. ‘The structures focus on diagnosis and treatment, not the people who are receiving it.’ She believes quite simple measures can make a big difference. An example of this is Mr M, a man who had a lump removed and sent to a laboratory for testing. His doctor told him the next available appointment was a week away, and despite Mr M’s distress, the appointment could not be brought forward. Mr M and his family contacted the Medical Administrator of the health service. He agreed that the wait was unreasonable and unnecessary and gave Mr M an earlier appointment. The Administrator undertook to raise the issue with the treating doctor. The family found the response to be respectful and authoritative. ‘I suppose my request was quite minor’, says Mr M, ‘but I felt so much better when they took the time to explain everything and were prepared to bring the appointment forward.’

76

Demonstrate good intentions ‘Good communication is the key to successful service delivery and complaints management’, says Ms Drake. ‘Good intent and genuine interest in addressing the concerns expressed by the consumer need to be explicit.’ The point is illustrated by the case of Mr H, whose mother, Ms H, died in hospital after being admitted for a severe nosebleed. His daughter was present when Ms H was admitted and she raised concerns with the hospital about the time taken for the resuscitation alarm to be called. The cause of death was recorded as a heart attack, which Mr H disputed. The Chief Executive Officer of the hospital, the Director of Nursing and a senior nurse met with Mr H and another family member. The account of events was examined in detail and all queries about the death were answered—the hospital staff were clearly familiar with the medical notes and the facts of the death of Ms H. The discussion during the meeting included: the limitations of death certificates in describing the range of causes resulting in a death; the hospital procedures on calling a resuscitation team; and the likelihood of Ms H’s survival if resuscitation had been performed. No time limit was placed on the meeting and all questions were explored and discussed fully. The hospital CEO expressed his regret that Ms H had died despite the best efforts of hospital staff. He invited further contact if the family felt that the issues had not been resolved. ‘Hospital staff took time to listen to Mr H’s concerns and recreated events so the reason for each step could be explained’, says Ms Drake. ‘This helped to reassure Mr H, that all that could be done, had been done.’ ‘The level of preparation showed the family that the complaint had been taken seriously and the care and treatment of Ms H had been closely examined. The apology had a greater impact because of the effort put into the meeting.’

CASE STUDY 10: A corporate group of hospitals and nursing homes ‘We wanted to create a culture where people felt they could report incidents and concerns, and be confident that action would be taken.’ Catholic Health Care Services is a private health care group that owns and manages 20 facilities throughout New South Wales, mostly residential aged care facilities, and some hospitals. The service has an integrated approach to managing complaints and other incidents at all its facilities. A feature of the system is an incidents database and information management system that keeps reliable records of all incidents, tracks the progress of each complaint and provides detailed analysis and reports for management. ‘We wanted to create a culture where people felt they could report incidents and concerns, and be confident that action would be taken’, says Ann Young, the Corporate Director of Quality and Clinical Risk Management.

77

The complaints management system is based on the system devised by one of the service’s hospitals, the Hawkesbury District Health Service in Windsor, a small town west of Sydney. The hospital has 127 beds providing medical and surgical services, including an emergency department and community health care services. Comprehensive complaints records The service encourages staff to record all complaints, including those resolved at the point of service, through the completion of a standard complaints form. ‘Recording even minor complaints is important because it allows us to pick up problems that are occurring frequently and to fix them’, says Ms Young. The complaints form requires a risk assessment of the incident, using a severity assessment code. Staff members are encouraged to complete the risk assessment, but the assessments are checked by the facility’s quality manager. Incidents database Each facility uses a common incidents database to record complaints, adverse events and other incidents, such as occupational health and safety or security incidents. Each facility only has access to their own information. ‘We tried to have a single form for all types of incidents—complaints, adverse events and “near miss” clinical incidents, but the medical staff were reluctant’, says Ms Young. ‘So instead, we have a complaints form and a separate “case review request” form, for near misses and adverse events.’ The incidents database gives a reliable record of all types of incidents, the outcomes of investigations, any recommendations for change arising from investigation, and whether polices or procedures need to be altered. Complaints are categorised in the same way as other incidents. Tracking complaints Complaints entered into the incidents database go onto a Records Management Information system, which tracks the progress of complaints, and generates e-mail reminders if no action has occurred within set timeframes. It also provides reports to alert facility management and Catholic Health Care Services if action has not occurred within a specified timeframe. ‘Catholic Health Care invested in information technology to make incident reporting, investigation and follow up reliable and very efficient in terms of the quality of information it generates for us’, says Ms Young. The database is simple to use and staff are trained to use it, especially quality managers. Reporting and discussion Standard monthly reports are generated at facility level on the number and types of complaints, any recommendations for corrective action, impacts on policy and procedure, and dates that recommended actions were implemented. At the Hawkesbury District Health Service, for example, the reports are discussed by its Quality Committee each month. The database allows detailed analysis so that causes and solutions can be identified. ‘The database allows categorisation of issues and trending so we have meaningful information about where the system has failed’, says Ms Young. ‘The quality committees are, therefore, more proactively focussed on taking action.’ 78

The Hawkesbury District Health Service offers an example of how the analysis of complaints can result in improved service quality. As a result of a large number of complaints about the hospital’s emergency department, the hospital worked with the local Area Health Service to introduce a new triage system. The new system improved communication between the service and the Area Health Service when transfer of a patient is required. It also improved communication between nursing and medical staff as the system provided less subjective interpretation. Quarterly reports are now generated at the corporate level on each facility for the Quality and Risk Management Committee of the Catholic Health Care Service Board. Reporting to the community Reporting of complaints and other incidents does not end with internal and corporate reporting—the Hawkesbury District Health Service provides detailed monthly reports on incidents to its Community Board of Advice. The Community Board of Advice monitors the categories and location of complaints and raises questions about cause and how improvements can be made to the quality of service. One member receives a full de-identified summary of complaints information and is able to provide answers to questions raised by the Board, while maintaining the privacy of the parties. The Board also advises the hospital on how the complaints system works. Bottom line benefits ‘Our main motivation in the beginning was to reduce our insurance risk and improve the reliability of incident reporting’, says Ms Young. ‘A measure of our success is an effective saving on insurance costs. Last year, our indemnity and insurance costs did not increase, while charges for similar services increased by 10–20 per cent.’

79

80

Possible suicide

Retained instruments

Unintended material requiring surgical removal

Intravascular gas embolism resulting in death or neurological damage

Haemolytic blood transfusion

Medication error leading to death

Maternal death or serious morbidity associated with labour or delivery

Infant abduction or discharge to wrong family

Requires notification under existing DoH legislative reporting requirements



















Fi nanci al : loss of assets replacement value due to damage, fire etc > $1M, loss of cash/investments/assets due to fraud, overpayment or theft > $100K or WorkCover claims > $100K Envi r onm ent al : Toxic release off-site with detrimental effect. Fire requiring evacuation

Ser vi ces: Complete loss of service or output

Vi si t or s: Death of visitor or hospitalisation of 3 or more visitors

St af f : Death of staff member related to work incident or suicide, or hospitalisation of 3 or more staff

Procedures involving the wrong patient or body part



Patients with death unrelated to the natural course of the illness and diff ering from the immediate expected outcome of the patient management or any of the following: • Sentinel Events reportable to Australian Council for Safety and Quality in Health Care

Serious

Threatened or actual physical or verbal assault of patient or staff requiring external or police intervention



St af f : Permanent injury to staff member, hospitalisation of 2 staff, or lost time or restricted duty or illness for 2 or more staff or pending or actual WorkCover prosecution Vi si t or s: Hospitalisation of up to 2 visitors related to the incident/injury or pending or actual WorkCover prosecution Ser vi ces: Major loss of agency/service to users, including cancellation of booked surgery more than twice Fi nanci al : loss of assets replacement value due to damage, fire etc $100K–$1M, loss of cash/investments/assets due to fraud, overpaymentor theft $10K–$100K or WorkCover claims $50K–$100K Env ir onm ent al : Off-site release with no detrimental effects or fir e that grows larger than an incipient stage

Patient at risk absent against medical advice



Patients with major permanent loss of function (sensory, motor, physiologic or psychologic)unrelated to the natural course of the illness and diff ering fr om the expected outcome of patient managementor any of the foll owing: • Disfigurement as a result of the incident

Major

Surgical intervention required as a result of the incident

Fi nanci al : loss of assets replacement value due to damage, fire etc $50K to $100K or loss of cash/investments /assets due to fraud, overpayment or theft to $10K Envir onm ent al : Off-site release contained with outside assistance or fire incipient stage or less

Vi si t or s: medical expenses incurred or treatment of up to 2 visitors not requiring hospitalisation Ser vi ces: Disruption to users due to agency problems

St af f : Medical expenses, lost time or restricted duties or injury/illness for 1 or more staff



Patients with permanent reduction in bodily functioning (sensory, motor, physiologic, or psychologic)unrelated to the natural course of the illness and diff ering fr om the expected outcome of patient management or any of the foll owing: • Increased length of stay as a result of the incident

Moderate

Case Study 6 Figure 1: Consequence Table - SEVERITY ASSESSMENT CODE (SAC) Minor

Referral to another clinician



Minimum

Fi nanci al : No financial loss

Envi r onm ent al : Nuisance releases

Envi r onm ent al : Off-site release contained without outside assistance

Ser vi ces: No loss of service

Vi si t or s: No treatment required or refused treatment

St af f : No injury or review required

Patients with no injury or increased level of care or length of stay

Fi nanci al : loss of assets replacement value due to damage, fire etc to $50K

Ser vi ces: Reduced efficiency or disruption to agency working

Vi si t or s: Evaluation and treatment with no expenses

St af f : First aid treatment only with no lost time or restricted duties.

Additional investigations



Patients requiring increased level of care including : • Review and evaluation

Case Study 6 Figure 2: Likelihood Table

Probability Categories

Definition

Frequent

Is expected to occur again either immediately or within a short period of time (likely to occur most weeks or months).

Likely

Will probably occur in most circumstances (several times a year).

Possible

Possibly will recur—might occur at some time (may happen every 1 to 2 years).

Unlikely

Possibly will recur—could occur at some time in 2 to 5 years.

Rare

Unlikely to recur—may occur only in exceptional circumstances (may happen every 5 to 30 years).

Case Study 6 Figure 3: SAC Matrix Consequence

Serious

Major

Moderate

Minor

Minimum

Frequent

1

1

2

3

3

Likely

1

1

2

3

3

Possible

1

2

2

3

3

Unlikely

1

2

3

4

4

Rare

2

3

3

4

4

Likelihood

Case Study 6 Figure 4: Action required Table

Action Required 1 = Extreme risk

immediate action required—A Root Cause Analysis (RCA) investigation must be commenced. Reportable Incident Brief (RIB) must be forwarded to the DoH.

2 = High risk

senior management attention needed—Notification to the DoH and/or RCA investigation is to be undertaken at the discretion of management. If RCA not undertaken, aggregate data then undertake a practice improvement project.

3 = Medium risk

management responsibility must be specified—Aggregate data then undertake a practice improvement project. Exception—all financial losses >0 must be reported to senior management.

4 = Low risk

manage by routine procedures—Aggregate data then undertake a practice improvement project.

NB—An incident that rates a SAC of 3 or 4 should only be reported to the DoH if it is likely to attract external attention or requires notification under existing DoH legislative reporting requirements—do not re score the SAC.

81

Supplement for general practices and other specialists

Supplement for general practices and other specialists Key elements of complaints management General practices and other specialist practices are often small services, run by the doctors who own the business. The system for managing consumer complaints and other feedback needs to be simple and easy to administer, incorporating the following: •

be open to consumer feedback, including complaints;



show your willingness to listen through signage, brochures, general publicity and the attitudes of doctors and staff;



provide information to consumers about how to give feedback and about health care complaints commissioners;



be fair and thorough when investigating a complaint;



keep personal information confidential and secure;



resolve complaints promptly and keep in touch with the complainant if resolution is delayed;



capture information about all kinds of consumer concerns as well as formal complaints;



analyse information about concerns and formal complaints to identify trends and causes;



assess the seriousness of complaints as part of a risk management strategy, and consult with regulatory agencies when serious issues arise;



provide a regular forum for doctors and staff to discuss complaints and other incidents;



implement improvements to the service following analysis of complaints and other feedback; and



regularly review how well the complaints management system is working.

Everyone’s responsibility Resolving complaints and concerns needs to be the responsibility of everyone in the practice, consistent with their role and responsibilities. Everyone needs to understand what is expected of them. Training is important to support doctor’s and staff dealing with complaints and understanding procedures. It is valuable for doctors and staff to discuss complaints regularly. A summary report of complaints and suggestions is a useful starting point for discussions about performance and improvements at clinical review and staff meetings. Capturing comments Information about the informal day-to-day concerns raised by consumers is just as valuable for quality improvement purposes as information from formal complaints. Keep an exercise book in reception where doctors and other staff can make a note of comments

85

and observations, or use a computer-based system if that is more in line with the way the practice works. Consumers should be encouraged to offer comments and suggestions by using a simple photocopied Consumer feedback brochure or Suggestion for improvement form (see Part 3 of the Complaints Management Handbook). Doctors and staff can also use the Suggestion for improvement form. Once a problem is fixed, contact the consumer by telephone to check if they are satisfied and to confirm the agreed outcomes. To ensure complaints receive the attention they need, a senior person needs to have designated responsibility for managing the practice’s Complaints Management Policy, such as the practice manager or principal partner. Sample complaints policy A sample complaints policy is provided on the following pages. Sample complaints policy and procedure for general practices and other specialists Policy •

we aim to provide a service that meets our consumers’ needs and we strive for a high standard of care.



we welcome suggestions from consumers, their family members, and from our doctors and staff about the safety and quality of care, because it helps us identify problems and improve the care we provide.



we are committed to an effective and fair system for resolving complaints.

Procedures 1. Our policy Consumers and their families are encouraged to provide suggestions, compliments, concerns, complaints about their clinical care directly with the treating doctor. We also provide a Suggestion for improvement form and Consumer feedback brochure [or alternative] to encourage consumers to put their views in writing (see samples in Part 3 of the Complaints Manangement Handbook). Our doctors and staff can also use the Suggestion for improvement form to note complaints or concerns about the quality of service to consumers. The forms can be lodged anonymously, and will be acted on to the extent possible based on the information provided. Our practice provides information about the complaints policy through its general publicity, the practice information sheet and on our website [where applicable]. We also provide information about [health care complaints commission], where consumers, their families, clinicians and staff can go to with a complaint about our service at any time.

86

Our practice conducts an annual consumer satisfaction survey to obtain information about levels of satisfaction with standard of care and aspects of the service [or other regular activity]. 2. Respect and sensitivity Consumers, their families, doctors and staff can raise concerns or make complaints on a confidential basis if they wish, and be assured that their identity will be protected. No-one will be discriminated against or suffer any adverse consequences as a result of making a complaint. Our doctors and staff are expected to provide assistance to consumers with special needs, such as those who do not speak English or people with a disability, so that they can provide feedback and follow up a complaint. 3. Everone’s responsibility Our doctors and all staff are expected to encourage consumers and their families to provide feedback on the quality of care and services, including complaints and concerns. Our doctors and staff are expected to resolve complaints directly with consumers, within the scope of their responsibilities. Generally, the process of resolving a complaint will follow the steps outlined below: Step 1:

Express regret for the distress or inconvenience caused, and an explanation or further information, if requested.

Step 2:

Clarify the consumer’s concerns and find out what they want to be done.

Step 3:

Consult with the practice manager or principal partner about the possibilities for agreeing to the consumer’s request. For example, a fee waiver or reduction may be offered if there has been inadequate information about fees or charges.

Step 4:

Confirm with the consumer that they are satisfied with what is proposed, or if not resolved, confirm that it will be referred to the [practice manager/ principal partner].

Step 5:

Make a record of the complaint in the Consumer Feedback book at reception, or by completing the Suggestion for improvement form.

4. If a complaint is not resolved Complaints not resolved at the point of service, or received in writing, that require follow up are treated as formal complaints. Our doctors and staff refer complaints to the practice manager or practice partner if they do not feel confident in dealing with the complainant, or if they believe, or the complainant believes, the matter should be brought to the attention of someone more senior. Complaints raising matters of clinical care are dealt with in close liaison with the treating doctor.

87

5. Training and discussion All doctors and staff need to have skills in handling complaints. The practice provides training in dispute management, complaints management procedures and patient safety as part of induction and through regular updates. Staff meetings and clinical review meetings are used to promote discussion and understanding of how complaints are managed and how they lead to improvements. 6. Risk assessment The practice manager ensures all complaints are assessed for risk to identify high-risk complaints that require urgent notification to the principal partner and a specific action plan, different from the usual process for managing complaints. A designated practice partner assesses complaints concerning clinical care and the practice manager assesses complaints concerning office systems and administrative issues. A complaint is assessed as high risk if: •

a consumer has died or suffered serious harm as a result of receiving health care, unrelated to the natural course of illness or expected outcomes of treatment, but resulting in hospital admission or emergency care;



a health professional appears to lack knowledge, skill, care or judgement, or appears to have behaved in an inappropriate manner for a health care professional, such as committing a criminal act (for example, fraud or assault);



there is a significant failure in practice systems for patient management; and



there is a high likelihood of a consumer leaving the practice.

An important factor in assessing risk is to consider whether the nature of the issues raised by the complaint indicate that the incident is likely to happen again. 7. External notification The principal partner will consult with external agencies where a complaint raises: Issue

External agency

Complaint cannot be resolved directly with consumer

Relevant health care complaints commissioner (see page 93)

Serious breach of consumer privacy

Office of the Federal Privacy Commissioner [and state or territory privacy commissioner or health care complaints commissioner if applicable] Professional registration body, if conduct is breach of professional standards

Unsatisfactory professional conduct of practitioner

Health professional registration [eg. in NSW, Health Care Complaints Commission]

Circumstances giving rise to the possibility of a legal [medical indemnity provider and insurers] claim

88

All reportable deaths under the Coroners Act [insert relevant statutory provision] will be notified to the Coroner as required by law. 8. Timeframes Formal complaints are acknowledged in writing or in person within 48 hours, and will usually be investigated and resolved within 10 days. If the complaint is not resolved within 10 days the complainant and doctors or staff directly affected will be provided with an update. If a complaint raises issues that require notification to an external body, the notification will occur within three days of those issues being identified. The people directly affected will be advised when this occurs. 9. Records and privacy Our practice manager [or alternate person responsible] maintains a complaints register. Our complaints register contains: •

summary records of informal complaints; and



a complete record of formal complaints (see Complaint follow up form in the Complaints Management Handbook, Part 3).

Complaint records are kept in confidential files, separate from patient medical records. Information is only disclosed to those who need the information to manage the complaint. 10. Investigation and resolution Individual formal complaints are investigated to identify the events that took place, the causes of the complaint, remedial action that should be taken and improvements that might be made. Where a complainant names an individual doctor or staff member, the person will be told the nature of the claims made against them. The principal partner or practice manager will conduct the investigation, depending on the position held by the relevant doctor or staff member. The investigation will be conducted in accordance with the principles of natural justice. The views of the complainant and doctors or staff directly involved will be considered along with other relevant information. At the conclusion of an investigation, the complainant and any doctors or staff directly affected are provided with the agreed facts, reasons for decisions, the underlying causes of the complaint and recommended improvements. The conclusions of the investigation are discussed with the complainant and action that will be taken by the practice agreed. The practice strives to achieve the outcomes that are fair and reasonable in the circumstances. If no agreement is reached, the complainant is provided with information about the [health care complaints commissioner.]

89

11. Reporting and discussion The [practice manager/principal partner] provide reports on informal consumer feedback, formal complaints and any recommended changes to policies and procedures for discussion at staff meetings. Information in the reports is de-identified. The [principal partner] provides a report for discussion at monthly clinical review meetings on informal and formal complaints, the causes, outcomes and recommendations for improvement. Doctors and staff are encouraged to discuss complaints and the performance of the practice at staff meetings and clinical review meetings. 12. Policy oversight and evaluation The [practice manager/principal partner] is responsible for coordinating the complaints policy, assessment of risk, investigation and action on formal complaints, regular reporting on complaints, and monitoring the effectiveness of the complaints procedure. The [practice manager] continuously monitors whether complaints management practices are consistent with this complaints policy. The [practice manager/principal partner] annually evaluate the complaints management practices to measure whether we comply with the Royal Australian College of General Practitioners Standards for General Practices, and the Better Practice Guidelines on Complaints Management for Health Care Services.

90

CONTACTS

Health complaints contacts Community and Health Services Complaints Commissioner

Health Complaints Commissioner and Ombudsman

PO Box 977 Civic Square ACT 2608 Tel: (02) 6205 2222 Fax: (02) 6207 1034 Website: www.healthcomplaints.act.gov.au

GPO Box 960 Hobart TAS 7000 Tel: (03) 6233 6217 Fax: (03) 6233 8967 Website: www.justice.tas.gov.au/legpol/ privacy/ombudsman.htm

Health and Community Services Complaints Commission GPO Box 1344 Darwin NT 8001 Tel: (08) 8999 1818 Fax: (08) 8999 1828 Website: www.nt.gov.au/omb_hcscc/hcscc/ Health Rights Commission Level 19, Jetset Centre 288 Edward St Street Brisbane QLD 4000 Tel: (07) 3234 0272 Fax: (07) 3234 0333 Website: www.hrc.qld.gov.au Office of the Health Services Commissioner Level 30 570 Bourke Street Melbourne VIC 3000 Tel: (03) 8601 5222 Fax: (03) 8601 5219 Website: www.health.vic.gov.au/hsc Office of Health Review GPO Box B61 Perth WA 6838 Tel: (08) 9323 0600 Fax: (08) 9323 0600 Website: www.healthreview.wa.gov.au Office of the Health and Community Services Complaints Commissioner

Health and Disability Commissioner, New Zealand PO Box 1791 Auckland New Zealand Tel: +64 9 373 1060 Fax: +64 9 373 1061 Website: www.hdc.org.nz Private Health Insurance Ombudsman Suite 1201, Level 12 31 Market Street Sydney NSW 2000 Tel: (02) 9261 5855 Fax: (02) 9261 5937 Website: www.phio.org.au Office of the Commissioner for Complaints (aged care) GPO Box 1245 Melbourne VIC 3001 Tel: (03) 9665 8033 Fax: (03) 9663 7369 Website: www.cfc.health.gov.au Health Care Complaints Commission Locked Bag 18 Strawberry Hills NSW 2012 Tel: (02) 9219 7447 Fax: (02) 9281 4585 Website: www.hccc.nsw.gov.au

PO Box 199 Rundle Mall SA 5000 Tel: (08) 8226 8652 Fax: (08) 8226 8620 Website: www.hcscc.sa.gov.au

93

Complaints Management Handbook for r Health Care are Services

AUSTRALIAN COUNCIL FOR SAFETY AND QUALITY IN HEALTH CARE - JULY 2005

Loading...

Complaints Management Handbook for Health Care Services

Please note that the following document was created by the former Australian Council for Safety and Quality in Health Care. The former Council ceased ...

588KB Sizes 16 Downloads 23 Views

Recommend Documents

Supplemental Health Care Orientation Handbook for Health Care
2017 v.2. This handbook is designed to acquaint you with Supplemental Health Care and provide you with information about

Revenue Cycle Management - RCM Health Care Services
and timeliness are crucial to. - Patient registration maximize revenue and deliver the. - Insurance eligibility best bot

Risk Management Handbook for Health Care Organizations, Student
Oct 20, 1999 - 7.5 High-Alert Medications by Class or Category. 254. 7.6 Specific High-Alert Medications. 255. 7.7 High-

Health Care services - asean
1. Project on Strengthening Technical Competency for. Consumer Protection in ASEAN. Health Care services. Version 22 Jan

Handbook for Health Care Research - Cleveland Clinic
The following discussion outlines several areas of health care where we may apply the principles of scientific ... respo

Home | THE CENTER FOR HEALTH CARE SERVICES
The 2016 Annual Report offers a look back at key milestones that have shaped our rich history, and a look forward at fut

Physician-Related Services -- Health Care Professional Services
This publication takes effect April 1, 2017, and supersedes earlier guides to this program. HCA is committed to ... call

quality management for health care delivery - GHDonline
continuing resource constraints and rising customer expectations. We hope that Quality Management for Health Care Delive

Complaints about Dental Services Complaints, Consumer Reviews
Mar 22, 2017 - Dentzz Dental Clinic Reviews & Complaints Reported By: Sunaina Contact information: Dentzz Dental Clinic

Care Management Definition and Framework - Center for Health Care
the Center for Health Care Strategies (CHCS) developed the Managed Care for People with Disabilities. Purchasing Institu