Policy: Consumer Related Complaints and feedback
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Policy: Management of Consumer Related Complaints and Feedback
Purpose
This policy outlines expectations in relation to the management of all consumer (see definition) related
complaints and feedback received by Te Whatu Ora – Health New Zealand Te Whatu Ora Counties
Manukau District.
The purpose of this policy is to:
Ensure that consumer (see definition) complaints and feedback are addressed in an empathetic,
professional, timely and in a consumer centric manner.
The complaints service is accessible, well publicised, open and transparent
Ensure staff are empowered to deal with complaints as they arise in an open and non-defensive
way
The learnings from complaints are identified and used for improvement
The complaints procedure is supportive for those who find it difficult to complain
Note: This policy must be read in conjunction with the Complaints Resolution and
Management of Consumer Feedback procedure
Scope of Use
Applies to all staff employed by Te Whatu Ora Counties Manukau, including any trainee/student
undergoing instruction, or any person contracted to provide a service on any Te Whatu Ora Counties
Manukau worksite.
Roles and Responsibilities
Executive Leads
Chief Medical Officer – The owner of the complaints process (including the HDC and complaints
received through the Te Whatu Ora Interim District Directors office)
Chief Nurse and Director of Patient & Whaanau Experience – Visibility of major complaints.
Executive Professional Leads - Visibility of all moderate and major complaints relating to
professional groups.
Feedback Central
Feedback Central has overall responsibility for ensuring the effective governance of all feedback,
including complaints and compliments process across Te Whatu Ora Counties Manukau services
using the SafetyFirst feedback and incident reporting system. This includes coordination, expert
advice and support for investigations, timely resolution, communication and highlighting the
improvements to be made.
Monitor and report on the completion of the corrective action plans and facilitate organisational
learnings from complaints and compliments.
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Policy: Insert proposed name of
Page 2 of 6
Ensure all relevant professional leads (Associate Directors Allied Health/Clinical Directors/Clinical
Nurse Directors/Director of Midwifery) are informed of the serious complaints.
Provide themes, learnings, examples and advice to relevant services and committees (e.g. Clinical
Governance Group (CGG)) to promote improvement
Inform the Patient Experience Lead and the Patient Safety Quality Assurance Lead of feedback
relating to themes specifically relevant to areas of improvement.
Clinical Director/ General Manager/ Divisional Lead
The Clinical Director/General Manager of the Division has overall responsibility for ensuring the
effective management of complaints and compliments.
This includes designating a staff member within the division who will help keep oversight of
complaints for their division (usually a Clinical Quality Risk Manager (CQRM) or Clinical Quality Co-
ordinator (CQC)) and ensure timely investigation, coordination of response, communication, and
service improvement.
When causative/contributory factors are identified, they must be documented and the General
Manager (or delegate) must allocate responsibility for developing and implementing a corrective
action plan and checking that the action taken has been effective.
Organisational complaint management timeframes must be adhered to.
Complaint, enquiries and compliment data will be analysed for learning.
There must be a feedback process for the staff so that learning can take place from complaints,
enquiries and compliments.
Staff
All staff have a professional and ethical responsibility to respond positively and with empathy to
complaints and feedback. Relevant line managers are to be advised of complaints and compliments
as soon as they are received.
Feedback Definition
Information provided to the organisation by the consumer regarding their experience with us. This could be
provided via complaints, compliments, enquiries or suggestions.
Complaint: A complaint is any expression of dissatisfaction that needs a response from the
organisation. If the consumer believe they have a complaint, then it is a complaint.
Compliment: A compliment is an expression of praise, commendation or admiration about staff
and/ or a service.
Enquiry: A question or request for clarification of information or process
Suggestion: A remark provides information on how to change or improve care or services
Policy Statements
Te Whatu Ora Counties Manukau operates a centralised complaints and compliments process
through the Feedback Central team to provide a central point of contact and coordination to
ensure consumers experience a seamless resolution process.
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Policy: Insert proposed name of
Page 3 of 6
Te Whatu Ora Counties Manukau is committed to the timely resolution of concerns that consumers
raise. Complaints and compliments are welcomed and viewed as an opportunity to improve and
monitor the quality and experience of our services.
Consumers do not have to put their complaints in writing to have their concerns acted on or
logged.
Effective and timely communication with consumers is essential throughout the complaint
management process.
Te Whatu Ora Counties Manukau encourages the resolution of minor concerns when they are
raised at the point of care. However, if it is not possible to resolve the concern immediately, then
the complaint process must be followed.
All complaints and compliments received must be logged into the Safety First (Feedback reporting
system) as soon as practicable.
Any communication with the media in relation to complaints will be undertaken by the Interim
Director, Chief Medical Officer (CMO) and Communications General Manager or delegate.
At all times consumer privacy and confidentiality must be maintained, and Te Whatu Ora Counties
Manukau’s Privacy Policy requirements met. No patient information should be provided to third
parties (including whaanau) without the authorisation of the patient.
Complaints and responses to complaints should not form part or be recorded in the clinical records
of a patient and should be documented only in the SafetyFirst Feedback reporting system.
Complaint Grading
On receipt, all complaints (with the exception of HDC complaints) are graded by the Feedback Central team
based on the information contained in the complaint, the source and the impact on the consumer
(Appendix 1). These are graded as Major, Moderate and Minor complaints. The grading can be changed
(escalated/de-escalated) after further investigation, if required. The Feedback Central Team should be
notified if the grading of a complaint needs to be changed
Source of Feedback
Feedback can be received through multiple channels such as feedback forms, letters, Te Whatu Ora
Counties Manukau website, emails, telephone, after communication with any staff member or via patient
experience surveys.
All complaints received from external agencies (e.g. Health and Disability Commissioner (HDC),
MP’s, Privacy Commissioner) should be classified as high priority (Major) and timelines mentioned
in the communication are to be strictly adhered to. An extension can be requested if needed.
All requests for information from Coroners and the HDC office should be logged into SafetyFirst as
an enquiry and they should be classified as high priority (Major) and timelines mentioned in the
communication are to be strictly adhered to. An extension can be requested if needed.
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Policy: Insert proposed name of
Page 4 of 6
Open Communication
Te Whatu Ora Counties Manukau has a policy of open communication and this approach is to be reflected
in the complaint investigations and responses, including the provision of empathetic and sincere apologies
where indicated.
Resolution Timeframes
All complaint responses must be managed within the timeframes set out in the Te Whatu Ora Counties
Manukau Complaints Resolution and Management and Consumer Feedback Procedure.
Staff Support
In line with the organisations
Just Culture policy staff are to be supported by the division during the
complaint investigation process and have the option for their legal representative body, such as the
Medical Protection Society (MPS) or New Zealand Nurses Organization (NZNO), to review their response to
a complaint on their behalf.
The staff can also seek support from the Employee Assist Programme (EAP) as required through the course
of a complaint investigation. Assistance can also be sought from the Feedback Central team.
Storage and Confidentiality of Complaint Information
Complaints and any associated documentation are to be stored securely under conditions that comply with
Te Whatu Ora Counties Manukau Information policies, the Privacy Act 2020, the Health Information Privacy
Code and the Public Records Act 2005. The complaint correspondence is generally not to be filed in the
consumer’s clinical record unless requested by the consumer.
Reporting
The Feedback Central Manager will disseminate quarterly feedback report reports to all the ELT members
and the relevant divisions. The reports will indicate the themes of feedback, the complaints statistics and
the resolution timeframes. It is expected that these reports along with the recommendations arising from
complaints will help the organisation to learn from complaints and use them for improvement.
The data from Feedback can also be used as a rationale for projects across the organisation which focus on
improvement and learning.
The Feedback Central team will also disseminate fortnightly compliments reports to the designated staff
member within the divisions. A monthly report is also sent to the Communications team to include the Te
Whatu Ora Counties Manukau Daily Dose newsletter.
Definitions
Terms and abbreviations used in this document are described below:
Term/Abbreviation
Description
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Policy: Insert proposed name of
Page 5 of 6
Consumer
A person receiving care/treatment from CM Health. This
could also be a whaanau related to the person receiving
the care or a Kaitiaki (visitor) or a member of public who
came into the hospital.
Third party complaints
Complaints made by people other than the patient about
the care provided to the patient e.g. whaanau, Kaitiaki,
GPs/community providers or members of the public
Corrective Action Plan
Refers to recommendations developed following an
investigation into a complaint that improves care delivery
and prevents reoccurrence of problems.
SafetyFirst
Feedback Reporting System for all complaints, enquires,
comments, or compliments. Used for the tracking of
information including automatic electronic alerts to assist
in achieving target timeframes, reporting and to monitor
compliance.
Associated Documents
Other documents relevant to this policy are listed below:
NZ Legislation /Standards
The Health and Disability Commissioner’s Code of Health
& Disability Services Consumers’ Rights Regulations 1996
(Code of Rights)
Privacy Act 2020
Health Information Privacy Code 2020
Public Records Act 2005
Official Information Act 1982
Health and Safety at Work Act 2015
Health Practitioners Competency Assurance Act 2003
Coroners Act 2006
The Mental Health (Compulsory Assessment and
Treatment) Act 1992
Nga Paerewa Health and Disability Services Standard NZS
8134:2021
CM Health Documents
Procedure: Consumer Related Feedback and Complaints
Policy Open Disclosure with Patient’s Policy
Policy: Incidents Reporting and investigation
Procedure: Incidents Reporting and management
Policy: Media
Policy: A Just Culture
Procedure: Checking for Accuracy and Authorising Entries
into the Clinical Record
Procedure: Correcting and Altering Personal Health
Information at the Patient’s Request
Procedure: Correcting Inaccuracies in the Clinical Record
Policy: Disclosure of Health Information
Procedure: Disclosure Of Health Information -How A Third
Party Requests Personal Health Information About A
Patient
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Policy: Insert proposed name of
Page 6 of 6
Appendix 1
Complaints Grading
Minor: Resolution is straightforward consisting of a follow up with the service, an explanation,
clarification of policy or procedure or an apology to the consumer / whaanau (e.g. no system issue
is identified).
Moderate: Resolution requires investigation, and may require meetings with consumer, whaanau
and other providers, and corrective actions.
Major: Resolution requires extensive investigation, meetings with consumers / whaanau and other
providers, extensive corrective actions or reporting of event to regulatory body or authority.
Document ID:
A5164
CMH Revision No:
3.0
Service:
CMO Directorate
Last Review Date:
06/10/2022
Document Owner:
CMO
Next Review Date:
06/10/2025
Approved by:
Clinical Governance Group
Date First Issued:
01/02/1998
If you are not reading this document directly from the Document Directory this may not be the most current version.
Document Outline
