Procedure: Complaints Resolution and Management of Consumer Feedback
Page 1 of 21
Procedure: Complaints Resolution and Management of Consumer
Feedback
Purpose
The purpose of this procedure is to outline the process for managing and resolving consumer complaints
received by Te Whatu Ora Counties Manukau. This procedure also covers the management of compliments,
enquiries and suggestions. The topics covered include scope, general responsibilities of all staff,
management of complaints from different sources, logging of the feedback in SafetyFirst reporting system,
legislation related to complaints, investigation process, resolution, target timeframes and related matters.
At all times the goal is to ensure that resolution of complaints is empathetic, professional, timely (Appendix
1) and is consumer centric.
Note: This procedure must be read in conjunction with the Consumer Related
Complaints and Feedback Policy
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
Role/Function
Tasks
Feedback
Receive complaints, compliments, enquiries or suggestions and log the
Central
details into SafetyFirst (the Feedback Reporting System) as soon as
practicable.
Triage, grade, log and acknowledge complaints within 5 working days.
Assign a “file owner” for every complaint based on the type of complaint and
the division(s) involved. They act as a single point of contact in relation to a
complaint and keep an oversight of the complaint.
File owner is usually the Feedback Central Quality Liaison Officer or the
designated staff member within a division (CQRM or a CQC).The file owner is
responsible ensure that investigation is timely, thorough and communication
is maintained with the family if there is a delay.
Sends the details of the complaint to the designated staff member within the
division for investigation and response.
For all complaints involving multiple divisions, Feedback Central will
coordinate and support the investigation and response. They will liaise with
the division during this process.
Advise complainants of any delays in responding to their complaints after
liaising with the designated staff member within the division.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 2 of 21
Send out the final responses for all complaints
Utilise the SafetyFirst database and Qlik sense to produce feedback reports
and data analysis to provide themes and learnings to the Executive
Leadership Team, Clinical Quality and Risk Managers, Professional Leads,
Clinical Directors, General and Operational Managers, Clinical Leaders
Monitor and report on the completion of corrective action plans related to
complaints.
Provide additional reports upon request to divisions to enable their analysis
of specific quality and risk issues.
Develop templates and resources to ensure quality and consistency in
complaint and feedback management, response and improvements.
Interim District
Receive complaints and compliments and forward them immediately to
Director / Chief
Feedback Central.
Medical Officer/
Chief Medical Officer – The owner of the complaint management process.
Executive
Chief Nurse and Director of Patient & Whaanau Experience- To have visibility
Leadership Team
of major complaints and provide input when necessary.
(or delegate)
Executive Professional Leads to have visibility of all moderate and major
complaints relating to their professional groups and provide input when
necessary.
Legal Adviser /
Ensure the requests of the Privacy Commissioner and Health Disability
Privacy Manager
Commissioner are responded appropriately during the complaints process.
Liaises with the Te Whatu Ora Counties Manukau District’s insurer as
needed (e.g. where litigation is threatened or claims for compensation
are made).
Provide advice and input in relation to complex complaints/responses when
requested or on own initiative.
Clinical Director/
The complaint owners for their division and may delegate the tasks below
General Manager/
to others to complete but will be accountable and responsible for successful
Divisional Lead
management, investigation and resolution and closure of each complaint
within their division.
Can designate 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))
Sign off on all complaint responses
They or the Designated staff member -
Consider whether a personal phone call to the complainant is
appropriate or whether another action is required such as obtaining
further information or commencing a full investigation.
May allocate a few key roles within the division as “Service Complaints
Investigators (SCI)”
e.g. “Charge Nurse Managers” for investigating nursing concerns,
“Services Managers” for investigating issue related to the medical care
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 3 of 21
provided etc.
Within a division, the SCIs will be in-charge of ensuring that the
complaint is investigated. This will involve identifying what occurred,
the underlying reasons, and preventative measures.
The SCIs for the various services within a particular division should be
communicated to the Feedback Central team. The Feedback Central
team will include the SCIs in their initial correspondence to the division
(If practicable) to ensure that complaints are investigated in a timely
manner.
Work closely with the Feedback Central team to help set up a process
to improve complaints management
Delegate actions as appropriate, with clear time frames and
expectations for the resolution process.
Investigate and complete the investigation report/response letter.
Review the final response letter.
Enter response details into the Feedback Reporting System.
Ensure that corrective actions arising from complaints are
appropriately followed
Provide feedback to staff on issues raised, resolution and any changes
made as a result of the complaint.
Duty Managers
Receive telephone complaints after hours and at weekends and forward details of
complaint and their immediate response by email to Feedback Central for logging
and acknowledging.
Complaints Management
All complaints must be assessed to determine the most efficient and appropriate method of addressing the
concerns that have been raised. This may include immediately calling the complainant, undertaking some
preliminary enquiries into the matter, commencing a full investigation, or a combination of approaches.
Care should be taken to ensure that responses are personalised to a specific situation.
Complaints should be responded professionally and in the most appropriate manner given the severity of
the complaint and with consideration of the consumer’s preference of how they would like their concerns
resolved. The opportunity for the desirability of immediate action (e.g. existence of contemporaneous
clinical issue requiring an immediate response) and the need for an individualised response should be
possible. In some cases, a full investigation will be appropriate, but the prime aim is to avoid unnecessary
bureaucracy and identify the most efficient way to address the concern that has been raised by the patient
and provide an opportunity for wider system improvement.
If a complaint is deemed to have an adverse event linked to it, the feedback and the incident files within
SafetyFirst need to be linked (complaints and the adverse event process). After the initial
acknowledgement of the complaint, the adverse event investigation must be completed first as per the
incident reporting and management procedure followed by the complaint’s management process.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 4 of 21
When a formal complaint is received by any Te Whatu Ora Counties Manukau employee, that person is
responsible for ensuring that the complaint is forwarded to the Feedback Central team, within the Office of
the Chief Medical Officer (CMO) soon as is practicable.
Complaints process based on the source of Feedback
General complaints
All complaints directly from consumers should be managed as per appendix 2
Complaints addressed to or received via the Interim District Director or Corporate offices (e.g. MP’s)
The Feedback Central team will immediately notify the Interim District Director’s office on receipt of
such complaints. The complaint will be triaged and sent to the designated staff member within the
division(s) for further investigation. The file owner responsible for keeping an oversight over the
complaint is determined at this stage and is included in the above correspondence. Once investigated
the final response is signed off by the Interim District Director and is sent out via the Office of the
Interim District Director. A copy of the response will be sent to the Feedback Central team by the
Interim District Director’s office to file into SafetyFirst and to close the complaint (Appendix 3). All
complaints received via the Interim District Director or Corporate office are categorised as Major
complaints.
Health and Disability Commissioner
All Health and Disability Commissioner Complaints are received directly by the CMO office, where the
Executive Assistant (EA) to the CMO will log and send it to the Clinical Director/General
Manager/Designated staff member of the division(s) involved and the Feedback Central team. The file
owner responsible for keeping an oversight over the complaint is determined at this stage and is
included in the above correspondence. All complaints received via the Health and Disability
Commissioners office are categorised as Major complaints. Appendix 4 provides the detailed
management process for these complaints.
Privacy Commissioner and/ Ombudsman Complaints
The Feedback Central team will immediately notify the Privacy Manager of the organisation on receipt
of such complaints. The Privacy Manager is assigned as the file owner. If a complaint is related to a
breach in privacy or a breach in privacy is noted along the course of the investigation the Privacy
Manager needs to be notified by the file owner of the complaint. If a breach is confirmed it should be
reported separately within the SafetyFirst system as an incident.
Ombudsman Complaints are sent to the Interim District Director’s office who then sends it to the OIA
Specialist for actioning
Grading, Logging and Acknowledging complaints
All new complaints are reviewed and triaged by the Feedback Central team based on the information in the
complaint, within two working days of receipt of the complaint, or receipt of consent (if required). This
triage process helps to identify the concerns raised in the complaint, determine the grading (according to
Consumer Related Complaints and Feedback policy) and identify the division/services/departments
involved.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 5 of 21
Once graded the complaints are logged into SafetyFirst by the Feedback Central team. Within the systems
the concerns raised are grouped as themes and the relevant divisions are added to added. This process may
involve reviewing clinical files, checking details related to their admission, appointments and tests
performed using applications such as Clinical Portal, i.Patient Manager and Eclair. Once the divisions and
issues are confirmed a “file owner” is designated to keep oversight of the complaint. The file owner is
usually a Feedback Central Quality Liaison Officer or the designated staff member within a division (CQRM
or a CQC).
All the complaints are then formally acknowledged within 5 working days. A formal acknowledgement
letter should be sent via email or post. If both forms are not practicable the acknowledgement can also be
done via a phone call or in-person. The acknowledgement letter provides the complainants with a brief
description of the complaints process and response timeframe. It also includes a brochure outlining the
Health and Disability Services Consumer Rights and the contact details for the Nationwide Health &
Disability Advocacy Service and the Health and Disability Commissioner whom they can contact for further
support. The acknowledgement letter sent must be recorded in the SafetyFirst system
If it is observed that the consumer is an inpatient at the time of receiving the complaint, the Feedback
Central team immediately escalates it to the relevant division/service staff member e.g. Charge Nurse
Managers, Team Leaders and Service Managers to acknowledge it directly with the consumer. It is our
expectation that the staff members try to resolve complaints at the point of service within the scope of
their practice.
Consent
If the complaint is made by a third party, consent must be obtained from the patient prior to the logging of
the complaint. The consent obtained must be recorded in the SafetyFirst system
Consent from the patient is not required if the person who is raising the complaint is the patient’s attorney
specified in an Enduring Power of Attorney (EPOA) for care and a welfare guardian appointed by a court
order.
There may be some situations where general information can be provided in response to a complaint
without including specific consumer details or where it is appropriate to provide a more detailed level of
information even in the absence of specific consumer consent. Please check with the Te Whatu Ora
Counties Manukau Legal Adviser and Privacy Officer if you have any questions about what is appropriate in
a particular case.
Where the complaint relates to a deceased consumer, any information (other than general information)
relating to the diagnosis, treatment or circumstances relating to the death should be provided to the
deceased individual’s personal representative, for example, the administrator or executor of the deceased
estate. Again, there may be cases where a more pragmatic approach is required or appropriate and any
queries should be referred to the Te Whatu Ora Counties Manukau Legal Adviser and Privacy Officer.
Communication to the Relevant Divisions
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 6 of 21
Once a complaint is logged and acknowledged the Feedback Central team sends an email to the designated
staff member within the division(s) involved in the complaint and to the SCIs (if established) for further
investigation. The file owner responsible for keeping an oversight over the complaint is determined at this
stage and is included in the above correspondence
The email contains a copy of the complaint, the concerns identified, and the actions taken up till now
(logged, acknowledged and consent being obtained (if required)). The email also mentions the staff
member (file owner) to whom the response (results of the investigation) should be sent along with a due
date.
Investigation
The investigation process should consider the patient's points of view of the care provided and involve to
all the relevant staff members (clinical and non-clinical staff members). The investigation may also include
input and guidance from a senior clinical staff when needed (Clinical Heads, Allied Health, Scientific,
Technical Professions, Nursing, Medical and Midwifery). This must be done in conjunction with a review of
a patient’s clinical records and hospital policy and guidelines available.
The issues raised will need to be thoroughly investigated, and where necessary, cultural guidance should be
obtained. The details of the investigation should be sent through to the complaint file owner.
If the complaint is unlikely to be investigated and resolved within 20 working days, the consumer must be
notified of this delay. The file owner must ensure that any possible delays are communicated to the
Feedback Central team who will send out an extension letter to the consumer.
Drafting Response to the complaint
A response to a complaint can be in the form of a written letter, a phone call or via face-to-face meeting.
If the consumer is an inpatient the resolution of complaints is encouraged at the point of service , wherever
possible and within the scope of their role and responsibility.
If it is determined that a written response to the complaint is the best method to respond, a formal
response letter should be drafted. This can be done either by the File owner or the SCI performing the
investigation.
All response letters must include the following information:
An Apology for the consumers experiences or that their expectations were not met
Acknowledgement of the concerns raised (especially if many)
An explanation of the occurrences to ensure that they may understand what is being addressed.
Acknowledgement of instances where treatment given did not meet acceptable standards
Any corrective actions/changes made as a result of their feedback.
Details of whom to contact for further clarification/information (usually Feedback Central)
Should be in simple English and avoid the usage of undefined medical acronyms
Once drafted the response should be sent to the relevant staff members who contributed to the
investigation for comments and changes. Following the incorporation of comments into the response, a
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 7 of 21
final version is sent to Clinical Director/General Manager for approval and sign-off (if the complaint involves
only a single divison). The signed response needs to be sent to Feedback Central to send out to the
consumer
For all complaints involving multiple divisions, Feedback Central Quality Liaison Officers will co-ordinate and
draft the response. They will liaise with the designated staff member within the divisionand the SCIs during
this process. The Feedback Central Quality Liaison Officers may also support with drafting responses for
Minor or Moderate complaints for a few divisions. All Moderate and Major multi-division complaints are
signed off by the Chief Medical Officer and the Minor multi-division complaints are signed off by the
Feedback Central Manager. The Feedback Central team will send out the final signed response to the
consumer.
If a meeting is necessary to resolve a complaint in person rather than in writing, the file owner will work
with the consumer and the appropriate staff members form the divisions to find a mutually convenient
date. A representative from Feedback Central team can also attend the meeting upon request from the
division or the complainant. If a complaint is a regarding the clinical care and the options of treatment it
may be addressed via a further consultation with an appropriate clinician.
It is recommended that the Feedback Central Quality Liaison Officers meet with the designated staff
member within the division on a weekly/monthly basis to discuss complaints, actions taken and timeframes
for their division.
Corrective Actions and Recommendations
Corrective Actions and Recommendations arising from complaints should be recorded in the relevant
section within SafetyFirst by the file owner once the complaint response has been signed off.
A Responsible Owner from the division should be assigned for the corrective action and is responsible for
ensuring the completion of the recommendation. Recommendations should be followed-up by the
Feedback Central Manager on a monthly basis.
Consumers Unsatisfied with the response
A consumer may be unsatisfied with the response or may require further clarification. On receipt of such
communication the complaint file is re-opened by the Feedback Central Team. The concerns raised are
resent to original division(s) for further clarification and it follows a similar process as explained above. In
such instances a complainant meeting may be necessary.
If further assistance is not possible the consumers can be directed to the Health and Disability
Commissioners Office.
Compliments Management
When a compliment is received by any Te Whatu Ora Counties Manukau employee, that person is
responsible for ensuring that the compliment is forwarded to the Feedback Central team, within the Office
of the Chief Medical Officer (CMO) as soon as is practicable.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 8 of 21
Logging and Closing of compliments
All compliments are logged by the Feedback Central team in the SafetyFirst systemas soon as practicable. A
copy of the compliment is attached to the SafetyFirst file and the file is closed. A copy of the compliment is
also sent to the designated staff member within the division to disseminate.
Enquiry Management
An enquiry is a question or request for clarification of information or process. If practicable it is always
encouraged to contact the person by a telephone call to help resolve their query. This can be done by the
Feedback Central team or the division (as appropriate). If the enquiry cannot be resolved with a simple
phone call it is entered into the SafetyFirst system.
Logging and Acknowledging and closing of enquiry
An enquiry is logged and classified as
General Enquiry
These are queries or requests from consumer which would need to be followed up with the relevant
division/service/department. The Feedback Central Team log an enquiry and send it to the designated
staff member within the division. The outcome of the enquiry is communicated back to the consumer
either via a letter or a phone call by the file owner.
Coronial Requests
All Coronial requests go directly to the Office of the CMO who will send them to the designated staff
member within the division for investigation and resolution and the Feedback Central team. The
Coroners report is reviewed by the Te Whatu Ora Counties Manukau Legal team and sent out via the
Office of the CMO. Timeframes mentioned in the requests need to be adhered to. Appendix 5 provides
the detailed management process for these complaints.
Ministry of Health Death Stats
All Ministry of Health Death Stats request go directly to the Office of the CMO office who will send them
to the designated staff member within the division for resolution and copy the Feedback Central team.
The report is then sent back out via the Office of the CMO. Timeframes mentioned in the requests need
to be adhered to.
Suggestion Management
Te Whatu Ora Counties Manukau welcomes suggestions to improve or change the way we function as an
organisation. All suggestions are recorded by the Feedback Central team in the SafetyFirst system. A copy
of the suggestion is sent to the designated staff member within the division for their consideration and the
file is closed.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 9 of 21
Associated Documents
Other documents relevant to this procedure 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
Te Whatu Ora Counties
Policy: Consumer Related Feedback and Complaints
Manukau District Documents Policy Open Disclosure with Patients 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
Procedure: Disclosure Of Health Information -How A Third
Party Requests Personal Health Information About A
Patient
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 10 of 21
Appendix 1
Complaints timeframes:
Complaint Received:
Immediately / 1 working day
When a complaint is made to any Te Whatu Ora Counties
Manukau staff members, they are responsible for ensuring that
the complaint is forwarded to Feedback Central
[email address]
Triage, Log and Obtain Consent (if required)
1-2 working days
Feedback Central will log the details into the Feedback reporting
system - SafetyFirst
Within 5 working days from
Acknowledge:
receipt by Feedback Central of
Feedback Central will acknowledge the complaint.
the complaint
Investigate & Respond:
Within 20 working days from
Feedback Central will send complaint to the appropriate division
receipt by Feedback Central of
for their investigation and response.
the complaint
Single Division Response:
The division collate all information and prepare a draft response.
Multi Division Response:
Within 20 working days from
For complaints across multi-division Feedback Central will co-
receipt by Feedback Central of
ordinate and draft the response for the contributors to review.
the complaint
Review and Send response:
Within 20 working days from
The division to send the signed response to Feedback Central who
receipt by Feedback Central of
will send the response out to the complainant. If more time is
the complaint
required, then the complainant must be informed of this and kept
up to date with progress. After sending the response the
complaint should be closed.
Corrective Actions and Recommendations:
Within 90 working days
When findings and recommendations identified, learning and
from resolution of the
correction action plan for improvements to be completed. Plan to
complaint (It can vary).
include specific changes with measureable outcomes.
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
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Procedure: Complaints Resolution and Management of Consumer Feedback
Page 11 of 21
Appendix 2
General Complaints-
Management Process-
Feedback Central (FC); FC Quality Liaison Officer (QLO); Chief Medical Officer (CMO); CMO Executive
Assistant (CMO EA); Designated staff member within the division (DSD, usually CQRM’s)
Actions
Responsibility Timeframe
Complaint Received
Triage complaints daily –use FC triage criteria and meet to
FC
1 working day of receipt
discuss the complaints ..\Complaints Process -Triage
Tool\2022.08.17 Triage tool.pdf
Log
Log complaint in feedback system- SafetyFirst
FC
1-3 working day of
Link to previous feedback if any
receipt
Make up w: drive for patient as per naming conventions.
Consent / third party consent obtained as required
Acknowledge
Send acknowledgement letter to complainant –
FC
5 working days from
acknowledgement template
receipt of complaint
Email with attached letter or post to correspondence
address in iPM
Identify Divisions involved
Identify areas to be investigated and addressed
FC
Within 5 working days
from receipt of
complaint
Single Division Complaints
Send the complaint to the designated staff member within FC
Within 20 working days
the division collate information and draft response
DSD
from receipt of
Division to collate information and draft response
complaint
Multi -Division Complaints (Complaints more than one
division (Medicine/ED etc.) are involved
Sends the complaint to appropriate divisions cc FC QLO.
FC
Within 20 working days
Division’s collate information send through to QLO
from receipt of
FC QLO draft response and sends draft response back to
FC
complaint
contributors/General Manager/Clinical Lead /DSD for
review
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 12 of 21
FC – send extension letter to complainant if the response
FC
will not be completed by due date
Sign Off
Single Division Complaint -DSD to send approved draft to
DSD
Within 20 working days/
General Manager or Clinical Lead for sign off
or by due date
Save final signed response in SafetyFirst file/ w:group
folder.
DSD sends final signed response to Feedback Central
Multi-division complaint – FC QLO sent response to CMO
CMO
Within 20 working days/
EA for sign off
or by due date
CMO review and sign off major complaints. FC Manager
FC
signs off minor complaints
FC sends final response to complainant
Save final signed response in SafetyFirst file/ w:group
folder
Corrective Action Plans and Recommendations
If Findings and Corrective Action Plan are identified they
FC QLO/DSD
90 working days from
need to be completed as per the Resolution & Correction
resolution of complaint
Action Plan document
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
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Procedure: Complaints Resolution and Management of Consumer Feedback
Page 13 of 21
Appendix 3
Interim District Director’s Office complaints/ Corporate Office complaints –
Management Process
Feedback Central (FC):FC Quality Liaison Officer (QLO); Chief Executive Officer (CEO); Interim District
Director’s Executive Assistant (IDD EA);Designated staff member within the division (DSD, usually CQRM’s)
Actions
Responsibility
Timeframe
Complaint Received
The EA for Interim District Director receives complaints and sends
FC / IDD EA
1 working day
to FC for logging or if FC receive the complaint directly, they
of receipt
inform the EA for Interim District Director about the complaint
Triage complaints by using FC triage criteria ..\Complaints Process
-Triage Tool\2022.08.17 Triage tool.pdf
Log
Log complaint in feedback system- SafetyFirst
FC
1-3 working day
Link to previous feedback if any
of receipt
Make up w: drive for patient as per naming conventions. Ensure
Consent is obtained if required
Identify areas to be investigated and addressed
Acknowledge
Send acknowledgement letter to the complainant or Corporate
FC / IDD EA
5 working days
Office
from receipt of
complaint
Single Divisions complaints
Send the complaint to appropriate division DSD
FC
Within 20
Division to collate information and draft response
DSD
working days
Division to send approved draft to FC to organise sign off
DSD (oversight)
from receipt of
FC – send extension letter to complainant if the response will not FC
complaint
be completed by due date
Multi Divisions Response (Complaints more than one Divisions
(Medicine/ED etc.) are involved
Sends the complaint to appropriate divisions cc FC QLO.
FC QLO
Within 20
Division’s collate information send through to QLO
DSD (oversight)
working days
FC QLO draft response and sends draft response back to
FC QLO
from receipt of
contributors/General Manager/Clinical Lead /DSD for review
complaint
FC QLO
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 14 of 21
FC – send extension letter to complainant if the response will not
be completed by due date
Sign Off
FC QLO to send all approved drafts to the EA for Interim District
FC QLO/ IDD EA
Within 20
Director for sign off
working days/
or by due date
Resolution & Correction Action Plan
If Findings and Corrective Action Plan are identified they need to FC QLO/ DSD
90 working days
be assigned a responsible owner within the Division.
(oversight)
from resolution
of complaint
It needs to be completed as per the Resolution & Correction
Action Plan document
Complaint closing
EA for Interim District Director or FC sends final response to the
IDD EA /FC
Within 20
complainant or the corporate office
working days
EA for Interim District Director sends copy of final response to FC
FC
from receipt of
to be saved in SafetyFirst file and w: drive folder
complaint
FC close the complaint
FC
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 15 of 21
Appendix 3
HDC complaints and formal investigation –
Management Process
These processes are applicable for managing all sections of HDC complaints and formal investigation.
Feedback Central and the Te Whatu Ora Counties Manukau Legal team will provide co-ordination and
oversight of the process.
Feedback Central (FC); FC Quality Liaison Officer (QLO);Chief Medical Officer’s Executive Assistant (CMO
EA); Designated staff member within the division (DSD, usually CQRM’s); Te Whatu Ora Counties Manukau
Legal Team (LT)
Section 14(1)(m) To gather information
Actions
Responsibility
Timeframe
Receive & Log
Log complaint in SafetyFirst
CMO EA
Within 3-5
Link to previous complaints/ coronial requests
working days of
Send to key people within the division (s) i.e. CD/GM/
receipt of
DSD outlining the complaint and the lead co-ordinator (in
complaint from
case of Multi-division complaints)
HDC
Copy in Feedback Central team
[email address]
Make up w:group shared folder
FC
For multi-division/complex complaints set up meeting
FC QLO
with DSD and key people as appropriate
Single Divisions complaints
Identify the division investigation lead
DSD
7-10 days before
Division to collate information and draft responses
due date
Division Clinical Director/General Manager approves final
response to be submitted to legal.
Save responses in w: drive and SafetyFirst
Multi Divisions Response (Complaints more than one
Divisions (Medicine/ED etc.) are involved
Division’s collate information send through to QLO
FC QLO/ DSD
7-10 days before
Save responses in w: drive and SafetyFirst
oversight
due date
FC QLO draft response and sends it back to
contributors/General Manager/Clinical Lead /DSD for
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 16 of 21
review
Legal review
All draft responses are sent through to the legal team for
DSD/FC QLO
7 days before due
review
date
Any suggested changes in legal review are discussed with LT
contributors/ Clinical Director/ General Managers/ DSD/
FC QLO
Medical notes to be sent to CMO EA for copying
DSD/FC QLO
Sign Off
Send the final draft to CMO EA
FC QLO/DSD
3-4 days before
due date
Chief Medical Officer to review and sign off
CMO
2 days before due
date
Scan and save original copies in Safety First.
CMO EA
2 days before due
Send final response to HDC
date
File is closed while we wait for HDC outcome
CMO EA
Request for extension
Email CMO EA noting reason why we are seeking an
DSD/FC QLO
1 week Prior to due
extension. HDC needs this information to grant or decline
date
the request. This applies for all sections
Section 34 (1)(d) Referral of complaint to health care provider to whom the complaint relates and
can be appropriately resolved by the provider.
Actions
Responsibility
Timeframe
Receive & Plan
Responsibility
Timeframe
Log complaint in SafetyFirst
CMO EA
Within 3 working
Link to previous complaints/ coronial requests
days of receipt
Send to key people within the division (s) i.e. CD/GM/
DSD outlining the complaint and the lead co-ordinator (in
case of Multi-division complaints)
Copy in Feedback Central team
[email address]
Make up w: group shared folder
FC
5 working days
Acknowledge the complaint and check how the
complainant would like their complaint resolved (written
response or meeting)
FC co-ordinates responses for multi-Division complaints
FC (QLO)
Single Divisions complaints
Identify the division investigation lead
DSD
7-10 days before
Division to collate information and draft responses
due date
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 17 of 21
Send final draft response to General Manager or Clinical
Director for sign off.
Legal Team can be contacted for support
Multi Divisions Response (Complaints more than one
Divisions (Medicine/ED etc.) are involved
Division’s collate information send through to QLO
FC QLO/ DSD
7-10 days before
Save responses in w: drive and SafetyFirst
oversight
due date
FC QLO draft response and sends it back to
contributors/General Manager/Clinical Lead /DSD for
review
Approved response is sent to CMO for sign off
Legal Team can be contacted for support
Respond & Sign off
Single Divisions complaint responses can be signed off by DSD/ GM/CD
3-4 days before
the General Manager or Clinical Director.
due date
Multi Divisions complaint responses is signed off by the
FC QLO/CMO
CMO.
The final response sent to the complainant
FC
1-2 days before
due date
Send a copy of the Final response to CMO EA to send out
FC /CMO EA
1-2 days before
to HDC for 34 (1)(d)
due date
Close file in Safety First
CMO EA
1-2 days before
due date
Section 37 Commissioner may refer complaint to Health and Disability Advocacy Division. Commissioner
may refer the complaint to an advocate for the purpose of resolving the matter by agreement between the
parties concerned.
Actions
Responsibility
Timeframe
Receive & Plan
Responsibility
Timeframe
Log complaint in SafetyFirst
CMO EA
Within 3 working
Link to previous complaints/ coronial requests
days of receipt
Send to key people within the division (s) i.e. CD/GM/ DSD
outlining the complaint and lead co-ordinator (in case of
Multi-division complaints)
Explain that we will be waiting for a letter from the
Advocacy services
Copy in Feedback Central team
[email address]
FC
Make up w:group shared folder
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 18 of 21
Once the Advocate’s letter is received, add it to same
FC
Within 5 working
complaint file in SafetyFirst
days of receipt
Send acknowledgement letter to the complainant and
copy the Advocate
Send to key people within the division (s) as above
FC co-ordinates responses for multi-division complaints
Single Divisions complaints
Identify the division investigation lead
DSD
7-10 days before
Division to collate information and draft responses
due date
Send final draft response to General Manager or Clinical
Director for sign off.
Legal Team can be contacted for support
Multi Divisions Response (Complaints more than one
Divisions (Medicine/ED etc.) are involved
Division’s collate information send through to QLO
FC QLO/ DSD
7-10 days before
Save responses in w: drive and SafetyFirst
oversight
due date
FC QLO draft response and sends it back to
contributors/General Manager/Clinical Lead /DSD for
review
Approved response is sent to CMO for sign off
Legal Team can be contacted for support
Respond & Sign off
Single Divisions complaint responses can be signed off by
DSD/ GM/CD
3-4 days before
the General Manager or Clinical Director.
due date
Multi Divisions complaint responses is signed off by the
FC QLO/CMO
CMO.
Final response sent to complainant and copy the Advocate FC
1-2 days before
due date
Close file in SafetyFirst
FC
1-2 days before
due date
Section 62 (1) Formal Investigation the commissioner may require any person to give information
relating to any matter under investigation
Actions
Responsibility
Timeframe
Re-open and update the relevant complaint in Safety First CMO EA
Within 3 working
Send to key people within the division (s) i.e. CD/GM/ DSD
days of receipt
outlining the complaint and lead co-ordinator (in case of
Multi-division complaints)
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 19 of 21
Chief Medical Officer to inform the Interim District
CMO
Director of any notification received regarding a formal
investigation.
Investigate
Identify areas to be investigated and addressed
DSD/ FC
7-10 days before
Perform thorough investigation
QLO/GM/CD
due date
Discuss complaint with Legal if necessary
Send final draft response for Legal review once drafted
DSD /QLO for
7-10 days before
and reviewed by authors
Multi-Division
due date
Any suggested changes in legal review are discussed with
contributors/ authors/ Clinical Director/ General
Managers/ CQRMs/ FC QLO
Medical notes to be sent to CMO EA for copying
Notify the DHB’s insurer of any investigation and the draft LT
3 days before due
final response will need the Insurer’s approval before
date
being sent
Chief Medical Officer’s review and sign off
CMO
Close file in Safety First
CMO EA
1-2 days before
due date
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 20 of 21
Appendix 4
Coronial Process
Guideline for requesting and managing the completion of Coroners reports across the Te Whatu Ora
Counties Manukau District.
Feedback Central (FC)/ FC Quality Liaison Officer (QLO)/ Chief Medical Officer’s Executive Assistant (CMO
EA)/ Designated staff member within the division (DSD, usually CQRM’s)/ Te Whatu Ora Counties Manukau
Legal Team (LT)
Actions
Responsibility
Timeframe
Receive request
Review request and log it in SafetyFirst Feedback system as
CMO EA
Within 3
an enquiry; link to other requests as appropriate.
working days
Send email to key people within the division (s) i.e. CD/GM/
of receipt
DSD outlining the complaint and copy in Feedback Central
team [email address]
If multiple divisions are required to provide reports this will
be clearly identified in the initial email notification.
Feedback Central to make up folder in W/group/ CMDHB
FC team
CMO Feedback Central.
Medical Notes
Responsibility for ordering notes from CRS
DSD
Report
Doctor completes report as word document and email draft
SMO
report to DSD.
Note in the report if there is an internal review/adverse
event investigation/SIRP underway.
Author of the report to be provided with the
report
template.
Review & Respond
DSD completes review of draft report; ensure that the report DSD
7 days prior to
is grammatically correct, answers all the coroner’s questions
the due date.
and formatted in the correct report template.
Email the draft report to Legal along with a copy of the
Coronial Request letter, and copy in CMO EA
Legal completes review and emails edits/comments to DSD
LT
4-7 days prior
for the author to review/accept legal edits, if any.
to the due
Copy in CMO EA
date.
Questions for the Coroner
If you have any questions for the coroner, wanting a copy of the PM Report etc these are relayed
via the CMO’s office.
Request for extension
Email CMO EA noting reason why we are seeking an
DSD
4 days prior to
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
Procedure: Complaints Resolution and Management of Consumer Feedback
Page 21 of 21
extension. The Coroner needs this information to grant or
due date
decline the request.
Sign off
DSD to drop off the Final signed report and the medical
DSD
2 days prior to
notes to CMO EA
the due date.
Final review by the CMO & sign off
CMO EA
Close SafetyFirst file
scan final report; upload in Clinical Portal
Inquest
Process manage by the CMO and Legal
LT
Document ID:
A6180
CM Revision No:
6.0
Service:
Office of the CMO
Last Review Date:
05/10/2022
Document Owner: Feedback Central Manager
Next Review Date:
05/10/2025
Approved by:
Clinical Governance Group (CGG)
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
