Consumer Feedback Management in ACT Health Procedure



ACT HealthProcedureConsumer Feedback Management in ACT HealthContents TOC \o "1-2" \h \z \u Contents PAGEREF _Toc520715985 \h 1Purpose PAGEREF _Toc520715986 \h 2Scope PAGEREF _Toc520715987 \h 2Procedure Section 1 – Feedback capture and distribution PAGEREF _Toc520715988 \h 3Procedure Section 2 – Compliments, Comments and Complaints PAGEREF _Toc520715989 \h 3Procedure Section 3 – Local Management of Consumer Complaints PAGEREF _Toc520715990 \h 4Alerts PAGEREF _Toc520715991 \h 4Procedure Section 4 – Formal Complaints Management Process PAGEREF _Toc520715992 \h 5Procedure Section 5 – Timeframe for Responding PAGEREF _Toc520715993 \h 7Procedure Section 6 – Identification and Completion of Actions PAGEREF _Toc520715994 \h 8Procedure Section 7 – Incident and ACTIA notification PAGEREF _Toc520715995 \h 8Procedure Section 8 – Reporting and Evaluation PAGEREF _Toc520715996 \h 9Implementation PAGEREF _Toc520715997 \h 9Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc520715998 \h 9References PAGEREF _Toc520715999 \h 10Definition of Terms PAGEREF _Toc520716000 \h 10Search Terms PAGEREF _Toc520716001 \h 10Attachments PAGEREF _Toc520716002 \h 11Attachment 1: The Feedback Investigation and Response Process PAGEREF _Toc520716003 \h 12Attachment 2: Key Aspects of a Response Letter PAGEREF _Toc520716004 \h 13Attachment 3: Clinical Significant Incidents identified through Consumer Feedback PAGEREF _Toc520716005 \h 14PurposeThis procedure and associated policy outline ACT Health’s approach to managing consumer feedback and provide specific advice on systems in place to support all staff in responding to and acting on consumer feedback.It is widely recognised that well-managed consumer feedback can lead to:better understanding of the health care system;improved relationships with consumers;understanding of the consumer/carer perspective;prompt resolution of issues and prevention of clinical deterioration;enhanced quality and safety;service improvements;a culture of reporting and accountability;enhancement of the reputation of the health care service.This procedure emphasises the importance of receiving and responding to feedback promptly. Back to Table of Contents ScopeConsumer feedback includes complaints, compliments and comments, and all provide valuable insight into the provision of health care from the perspective of those who use services provided by ACT Health. Feedback received from any consumer, their family, carers or other interested parties regarding services provided by ACT Health is covered in this procedure. This policy and procedure are specific to management of consumer feedback to ACT Health about ACT Health services, and do not address:staff feedback on workplace issues;feedback about contracted services not directly provided by ACT Health (e.g. Calvary Health Care);feedback from external service providers regarding service level interactions with ACT Health;feedback from advocacy groups regarding systemic issues broader than the ACT; consultation feedback;external agencies who receive funding from ACT Health; orthe broader aspects of consumer and carer engagement and support; refer to the Australian Charter of Healthcare Rights.Back to Table of Contents Procedure Section 1 – Feedback capture and distributionACT Health encourages feedback to improve the healthcare experience and reduce the need for formal complaints. Consumers can provide feedback to ACT Health by:speaking to a staff member at the point of service;making contact by telephone;email;in writing;completing a consumer feedback form; andonline.ACT Health provides feedback forms and collection boxes at points throughout its hospitals and community based facilities. In addition to making contact directly with ACT Health, to provide feedback consumers may contact:the Minister for Health and Wellbeing;the Minister for Mental Health; andthe Health Services Commissioner. These agencies engage with ACT Health in the feedback process.The Consumer Feedback and Engagement Team (CFET) records all feedback in the Riskman Feedback Module for the purpose of tracking, trending and reporting. Feedback received by other areas of ACT Health should be forwarded to CFET for appropriate action.Back to Table of ContentsProcedure Section 2 – Compliments, Comments and ComplaintsCompliments and comments are recorded and distributed to the relevant areas, but are not acknowledged unless a response is requested by the author. Complaints are generally submitted because people:do not want their experience to happen to anyone else;have had an unpleasant experience with the health system;did not receive adequate information or explanation about the processes they encountered; orare unhappy with the outcome of their care.Poor communication between staff, healthcare consumers and their families and carers is one of the most common reasons for people to complain. Staff in operational areas should take the following actions to assist in the prevention of complaints:take the time to find out the consumer’s expectations;involve the consumer, and when appropriate their carer or family, in as many aspects of their care as possible;communicate effectively with consumers, families and carers about their health issues, treatment options and how care may be delivered; andensure the explanation is understood. Back to Table of Contents Procedure Section 3 – Local Management of Consumer ComplaintsIn the first instance complaints should, if possible, be managed face to face with the complainant at the point of service. When staff are engaging with another person on behalf of a patient, they are to observe the usual patient confidentiality requirements, ensuring that they have the permission of mentally competent adult patients to discuss their private information with the other person. In other cases, staff should ensure they are liaising with the patient’s legal guardian or representative.When engaging with consumers about their concerns, staff are encouraged to:listen to the person and show empathy;attempt to identify the problem and the outcomes sought by the person;as appropriate, provide a factual explanation and apologise (refer to ACT Health Open Disclosure Procedure);identify and offer solutions that are acceptable to the person;confirm with the consumer that they are satisfied, and if not, escalate the matter to a higher authority;if the complaint relates to another area, assist the person to engage with the area, or put them in contact with CFET for assistance; andforward documentation of complaints, actions and outcomes to CFET to be recorded in Riskman.Staff should remember that where they are unable to quickly resolve a complaint as soon as possible, they should involve their immediate supervisor promptly, to assist in investigation and resolution of the issue.Back to Table of Contents AlertsTo protect confidentiality, feedback is kept separate from consumer clinical records. An acknowledgement letter is sent to consumers within five working days of receiving feedback that requires a response. Back to Table of ContentsProcedure Section 4 – Formal Complaints Management ProcessAll negative feedback should be assessed as to whether open disclosure is required. See the Open Disclosure Procedure. A diagram of the feedback process is provided at Attachment 1.Upon intake, formal complaints are allocated to the office of the most appropriate Deputy Director General (DDG) or Executive Director (ED), to coordinate a response if required. All feedback not received directly by CFET should be forwarded to CFET to be recorded in Riskman. In some circumstances, ACT Health may decide to not respond to consumer complaints. See the Consumer Feedback Management plaints that require a response are acknowledged by CFET within 5 days of receipt, as long as adequate contact details have been provided. Acknowledgement can be by phone, email or in writing, and should include information about the feedback process and the contact details of CFET or the team coordinating the response.If the author of the complaint is not the patient or legal guardian, the patient must agree to another person receiving information about them. This can be arranged through the completion of a Release of Information (ROI) form, available through CFET. If the patient is deceased or this is not possible for some other reason, the author of the feedback must provide documentation of a legal instrument that establishes their right to access the patient’s private health information. Refer to Clinical Records Management Procedure for further rmation should be sought from the relevant service areas to respond to the issues raised in the complaint. Service areas may contact the consumer and respond verbally to the complaint. In this case, a summary of the response is provided to CFET, after which the feedback can be closed and no further response required.If feedback cannot be closed verbally, the responding area should draft a response to the consumer using the information provided. Attachment 2 provides a summary of key points to include in a response letter. Responses must be cleared and signed by the Director General or delegate before being sent to plaints received directly by ACT Health is responded to directly.Responses to complaints received through an ACT Government Minister are forwarded for progression through the Minister’s Office.Responses to complaints received through the Health Services Commissioner are provided to the Health Services Commissioner, who engages with the consumer. If a person complains about the same issue to more than one staff member or agency simultaneously, the areas determine who will respond and inform the consumer about who their point of contact will be. This is noted by CFET on Riskman.If the complaint relates to more than one area, the areas involved determine who will coordinate the response, and inform CFET of the decision. CFET allocates the feedback to that area in Riskman.Declining to Respond to a ComplaintACT Health may decline to respond to a complaint if:the same complaint has been raised by the same person on a prior occasion, investigated and a response provided;the complaint concerns a service based outside of ACT Health;the complaint is considered to be vexatious (this decision will be made collaboratively between the divisional ED and DDG and the Consumer Feedback and Engagement Team (CFET)the complaint is the subject of legal proceedings and is being managed through other processes; orthe complaint is deemed to be associated with the clinical condition of the person, and it is the opinion of a clinician that a written response would exacerbate or escalate the clinical condition.Prior to declining to respond to feedback, ACT Health must ensure that the concerns have been fully investigated. Where appropriate according to the terms of this policy, the author of the complaint will be advised in writing of the reason that a response will not be provided. Official Records After the complaints management process has been completed and closed, operational areas must ensure that these documents are sent to CFET for centralised filing. Outcomes of telephone conversations should also be sent to CFET for closure of the feedback and official filing. Documents relating to the investigation of staff conduct which arise from complaints are retained by the People and Culture Branch. Confidentiality of ConsumersThere are situations where a complaint is received from someone other than the consumer involved in the case. For example, a family member may lodge a complaint with or without the consumer’s knowledge. In accordance with the Health Records (Privacy and Access) Act 1997, no personal information about the care of a patient is to be provided to another person without verified sufficient legal grounds (the patient’s permission or a relevant legal instrument that proves legal grounds for accessing the information). Patient permission can be obtained through the Release of Information (ROI) process. If the patient does not agree to the ROI, the author cannot be given information about the patient. Legal grounds can be verified with the assistance of the ACT Health Insurance and Legal Liaison Unit.To protect confidentiality, feedback is kept separate from consumer clinical records. ACT Health staff will not know that a complaint has been lodged unless they are required to participate in an investigation. Confidentiality of Staff Any staff member identified in a complaint must be afforded privacy and natural justice by: having the opportunity to review the complaint in full, provide a response and be informed of any proposed actions and the reasons for that decision;their manager limiting discussion of the complaint to the level required for thorough investigation; andbeing provided with support and assistance from their manager, and offered external support services as necessary.Aboriginal and Torres Strait Islander PeoplesThe paper and electronic feedback forms ask consumers if they identify as Aboriginal and/or Torres Strait Islander. With the consent of the consumer, the Aboriginal and Torres Strait Islander Liaison Service can participate in the complaint resolution process by providing advice and assistance to the consumer and staff. Staff should ensure that consumers are aware of this service. Back to Table of ContentsProcedure Section 5 – Timeframe for RespondingAn acknowledgement letter is sent to consumers within five working days of receiving feedback that requires a response. A signed and dated response letter is sent to the complainant within 35 calendar days of receiving the feedback. It is acknowledged that in a small number of cases, the nature of the matter raised will be of sufficient complexity as to require more time. The responding team or officer is responsible for informing the consumer of delays. A copy of the final response should be forwarded to the CFET for closure on Riskman. If a staff member receives a request to comment on a complaint but is unable to do so for any reason, they should notify CFET or the office of the coordinating ED or DDG within two working days for reallocation.Outstanding responses are monitored by CFET through Riskman reporting, at a minimum of fortnightly intervals, with outstanding responses escalated to the office of the coordinating ED or DDG for action and completion.Back to Table of ContentsProcedure Section 6 – Identification and Completion of ActionsQuality improvement and corrective actions may be identified through the feedback and complaint investigation process. These should be provided to CFET for recording in Riskman as an outcome of the feedback or complaint.Responses should inform consumers about actions that have been taken as a result of their feedback or complaint. If a response indicates that any outstanding actions remain, the service area is responsible for the action and should inform CFET of an expected completion date, and advise CFET when the action has been completed. CFET records outstanding and completed actions in Riskman.Outstanding actions are monitored by CFET through Riskman reporting, at a minimum of fortnightly intervals, with outstanding actions escalated to the office of the coordinating ED or DDG for action and completion.Back to Table of ContentsProcedure Section 7 – Incident and ACTIA notificationClinical incidents that are related to consumer feedback should be recorded in the appropriate Riskman module as per the ACT Health Incident Management Policy and related procedure. If an incident rated as extreme or major as outlined in that procedure is alluded to or described in feedback, CFET or a relevant divisional ED is responsible for ensuring that the incident has been recorded in the relevant incident management module of Riskman by the service area. If an incident meets the significant criteria, the operational area should record the incident in the relevant incident management module of Riskman directly. See flow chart Attachment 3.If CFET or the office of the coordinating ED or DDG considers that feedback, or the response by the service area to address the consumer’s concerns, raises the potential for a legal liability risk to ACT Health, CFET should be notified and the medico-legal team should be contacted by CFET or the coordinating team. CFET will submit an ACT Insurance Agency (ACTIA) notification through Riskman, so that the incident is covered in the event that a legal liability claim is raised.Back to Table of ContentsProcedure Section 8 – Reporting and EvaluationData entered in the feedback module of Riskman is used to identify and support improvements in the quality and safety of the services we deliver. CFET can assist if an area requires a report of feedback received by ACT Health.Outstanding responses and actions are monitored by CFET through Riskman reporting, at a minimum of fortnightly intervals, with outstanding responses and actions escalated to the office of the coordinating ED or DDG for action and completion.Back to Table of ContentsImplementation This procedure will be available on the policy register, sent to DDGs and EDs, and tabled at the Consumer Feedback Meeting. We will request that DDGs and EDs ensure that the updated procedure is communicated through the relevant channels within their divisions.Back to Table of Contents Related Policies, Procedures, Guidelines and LegislationRelated Legislation Health Records (Privacy and Access) Act 1997Human Rights Act 2004Health Practitioner Regulation National Law (ACT) Act 2010Discrimination Act 1991Freedom of Information Act 2016Territory Records Act 2002Public Interest Disclosure Act 2012Mental Health Act 2015StandardsAustralian Commission on Safety and Quality in Health Care (ACSQHC) Standard 2- Partnering with Consumers Australian Charter of Healthcare RightsAustralian Standard on Complaint Handling (AS ISO 10002) Related Policies and ProcedureDMHU: Clinical Risk Assessment and Management – Violence and Aggression PolicyWork Health and Safety PolicyOpen Disclosure ProcedureQuality and Clinical Governance FrameworkEngaging and Consulting with the Aboriginal and Torres Strait Islander Communities in the ACTTowards Culturally Appropriate and Inclusive Services, a Co-ordinating FrameworkLanguage Services Interpreters ProcedureIncident Management PolicyIncident Management ProcedureBack to Table of ContentsReferencesAustralian Commission on Safety and Quality in Health Care Australian Charter of Healthcare RightsAustralian Commission on Safety and Quality in Health Care Patient Centred care: Improving quality and safety through partnerships with patient and consumersUnited Kingdom Department of Health Listening, Responding Improving: A guide to better customer care 2009Back to Table of ContentsDefinition of Terms ACTIA. ACT Insurance Agency. Consumer. Refers to any constituent, person, patient or client accessing the services of ACT Health, and their associates including family, carers and people who have the legal authority to act on their behalf. Consumer Feedback. Comments, compliments and complaints received from someone who has engaged with services provided by ACT Health, whether directly or indirectly. Natural Justice. Staff members are given the opportunity to prepare and submit responses to complaints, and all decisions must be unbiased and given in good faith. Riskman. In this procedure, this term refers to the database used to record and track feedback received by ACT Health. Vexatious. Without sufficient grounds and serving only to cause annoyance. Back to Table of ContentsSearch Terms Feedback, Complaint, Compliment, Comment, Suggestion, Consumer, Engagement, ExperienceBack to Table of ContentsAttachmentsAttachment 1 - The feedback investigation and response processAttachment 2 - Key aspects of a response letter Attachment 3 - Clinical Significant Incidents identified through Consumer Feedback Disclaimer: This document has been developed by ACT Health specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 5 April 2018Whole documentChris Bone DDG, CHHSPACThis document supersedes the following: Document NumberDocument NameDGD 12-012Consumer Feedback Management in ACT Health SOPAttachment 1: The Feedback Investigation and Response ProcessAttachment 2: Key Aspects of a Response Letter All formal responses to consumer feedback should:Thank the consumer for the feedback, noting the date the feedback was received;Be written in an empathetic tone, acknowledging their experience and feelings;Address each of the points raised;Include an appropriate level of explanation and detail about the investigation of the feedback, what was found as a result, and what action if any was identified;Include an appropriate explanation if there is a reason why an issue cannot be addressed;Offer a meeting with relevant staff if appropriate; Provide the full name, position and a contact telephone number of an ACT Health contact person for further questions or discussion; Offer options for further action available to the consumer if appropriate, for example contact with the Health Services Commissioner;Be factually correct and written in language comparable to the level of the language used by the consumer:Generally consumer communication should be simple, plain English, free from jargon, and include explanations of technical terms;Explanations should be as simple as possible and free from rambling writing or unnecessary informationIf writing to the Health Services Commissioner or a health practitioner, it is generally appropriate to use more complex language.Attachment 3: Clinical Significant Incidents identified through Consumer Feedback Note: Refer to the ACT Health Incident Management Procedure for definitions of incidents that are considered significant or high risk incidents, and the process (including timeframes) for Significant Incident reporting. ................
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