Guide: Self-Audit Tool for Complaints Management Introduction This self-audit provides a tool for health service providers (HSPs) to assess their current complaints management system and processes. The tool allows HSPs to identify areas for improvement and develop plans for action to address them. Background The WA Health Complaints Management Policy (Complaints Policy) outlines the processes for the management of feedback/complaints relating to WA Health services. The Complaints Policy falls under the mandatory requirements of the Clinical Governance, Safety and Quality Policy Framework. The Complaints Policy advocates an efficient, proactive approach to complaint management that results in the best possible outcomes for the patient experience and achieving a more responsive health service. The self-audit tool has been informed by principles outlined in the Complaints Policy, which correlate with the Australian Standard for the handling of complaints as well as the guidelines from a range of agencies including the Ombudsman WA and the Australian Council for Safety and Quality in Health Care. The self-audit tool has been adapted from the Victorian Ombudsman’s (2007) and the Victorian Disability Services Commissioner’s (2013). Guiding Principles The following seven principles from the Complaints Policy underpin the management of complaints with the WA health system and the relationship with consumers throughout that process. HSPs demonstrate their commitment to the appropriate management of complaints by providing sufficient leadership and embedding a culture that values feedback for improvement opportunities. Adequate resources, training and support to officers should assist in creating and maintaining such a culture. People who are involved in the complaints process are treated with respect and dignity. The process ensures that their concerns are treated as genuine, investigated and they are involved in the decisions/outcomes. Complainants also respect the role of the staff responding to their complaint. People who receive health care should be encouraged by HSPs to provide feedback. The process for lodging compliments, concerns or complaints should be clear and easily accessible. An open, receptive and transparent approach should be in place when addressing the feedback. Complaints should be acknowledged and addressed in a timely manner in accordance with the timeframes and risk profile as outlined in the Complaints Policy. Staff should be empowered to address complaints early and fairly. HSPs to establish procedures to ensure complaints are recorded, investigated and resolved in a fair and confidential manner. Each complaint should be addressed in an equitable, objective and unbiased manner, be
Example of response to Self-Audit Tool of WA Health Service Providers’ Complaint Management Systems Principle Indicator Rating 1,2,3,4 What supports your assessment? Recommended actions for improvement Action plan (Who, what & when) A - Commitment A.1 Policy and procedures You have a written policy and procedures to support your complaints management system. Sample response 2 Sample response Complaints Handling Policy 2015 Sample response Need to revise policy by 2018 Sample response Tom Smith to coordinate a review of the policy to be completed by 1 July 2018 Your agency communicates its commitment to complaint handling to the general public. 3 Policy only available on the intranet Policy to be placed on internet as part of a wider communication campaign Jane Wright to liaise with Tom Smith to obtain the policy and work with communications team to develop communication strategies for complaints by July 2018.
G - Continuous service improvement Self-Audit Checklist of WA Health Service Providers’ Complaint Handling Systems Principle Indicator Rating 1,2,3,4 What supports your assessment? Recommended actions for improvement. Action plan (Who, what & when.) 7 - Continuous service improvement i. Guiding Principles: pg11, Appendix 2: pg44-45 Reporting of complaints: pg31 ii. Continuous Improvement Principle iii. 5.4.2, 9.1, 9.2, 9.3, 9.5, 9.6, 9.7 iv. s.75 v. Schedule 2 vi. s.309 Consumer feedback is used to initiate the implementation of local and service-wide practice improvements, including practices relating to the management of complaints. G.1 Collecting complaints data Your service utilises the Datix CFM to collect service wide complaints data including divisional and regional complaints data.
biases? where the event occurred? when and if this has happened before? why did it happen? how can the complaint be resolved for the complainant? recommendations for actions to avoid reoccurrence and timeframes for implementation Step 4 – Response Self-Audit Checklist of WA Health Service Providers’ Complaint Handling Systems Principle Indicator Rating 1,2,3,4 What supports your assessment? Recommended actions for improvement. Action plan (Who, what & when.) 4 - Response Response: pg21-24 Appendix 4: pg54 Remedy Principle Review Principle 5.2.5, 8.7.3, 8.7.4, 8.9 The outcome of the investigation is clearly communicated to the complainant, service staff and management. 4.1 Range of remedies/outcomes Your service has guidelines that outline the range of remedies available, depending on the
4.3.1 Service improvement notification to complainant Your service notifies complainants of any specific changes or improvements made as a result of their complaint. 4.3.2 Further options of review Your service informs the complainant of further avenues of review if they are not satisfied with the outcome of the complaint process conducted by the service. 4.4 Record of response Your service records the following complaint information in Datix CFM: action, completion milestone dates and outcome/s recommendations for improvement 4.5 Closing the loop Where appropriate service staff and senior management are informed of the outcome of the investigation, response and suggested improvements. Step 5 – Service Improvement Self-Audit Checklist of WA Health Service Providers’ Complaint Handling Systems Principle Indicator Rating 1,2,3,4 What supports your assessment? Recommended actions for improvement. Action plan (Who, what & when.) 5 – Service Improvement Service Improvement: pg25-27 8.9 Services are required to to provide a safe and quality health care service, which is consistently evaluated through continuous quality improvement processes to make sure that it meets consumer requirements.