Reporting on Feedback

The HSE is a large organisation which handles thousands of complaints annually. In order to capture valuable information from these complaints in a way that benefits the entire organisation it is necessary to report, collate and analyse this information in a consistent quality assured manner. The HSE has addressed this requirement in partnership with the State Claims Agency by developing a Complaints Management System (CMS) which is described in detail below.

Quality outcomes from the CMS are reliant on the reporting of all feedback, including complaints, by each individual system user including Complaints Officers, Review officers, Complaints Managers, Consumer Affairs and the National Complaitns Governance and Learning Team. Each unique complaint reported from their service area, while perhaps not contributing significantly on an individual level, when compiled at local, regional and national levels may contribute to greater organisational learning and service improvements that will benefit our Service Users.

Complaints Management System

The Complaints Management System is a unified, standardised national database management system developed in partnership with the State Claims Agency. This web-based solution captures valuable real-time data from feedback; enables learning from complaints throughout the organisation and will be a critical part of the quality assurance process in both complaints management and in compliance with National Standards for Safer Better Healthcare.

The Complaints Management System will provide HSE sites with end-to-end complaint reporting, it will support the tracking of investigations, outcomes and recommendations and will enable all participating sites to report on, interrogate and interpret their data enabling them to take appropriate decisions in the light of accurate and up-to-date information so as to drive better complaints management standards in those sites and nationally throughout the HSE.

Benefits of using the Complaint Management System

  • Allows the HSE to actively manage a complaint throughout its lifecycle (Stages 1-4)
  • Provide individualised dashboards so Complaints Officers have an easy to read, real-time user interface, showing current status and trends at a glance.
  • Allows customised reports based on ‘live’ quality data to be generated at Community Health Organisation and Hospital Group level, supporting evidence-based decision making.
  • Support better complaints handling by enforcing adherence to the Complaints Management Pathways.
  • Data is accurate and complete, for example, recording the origin of complaints as opposed to where they are reported.
  • Enables trending identifying areas of excellence or specific areas of concern locally, regionally and nationally.
  • Enables comparative analysis across Community Health Organisations, Hospital Groups, locally, regionally and nationally.
  • Supports the identification of and reporting on severity levels of complaints for Hospital Groups.
  • Reduces the administrative burden on ‘inputters’ in relation to the collation of data.
  • Supports peer analysis and learning.

Recording Complaints

  1. Point-of-contact complaints are recorded by the recipient of the complaint as far as is reasonably practicable. In particular, point-of-contact complaints that indicate a particular trend or where quality improvements are required, must be recorded. Trends in relation to point-of-contact complaints when reported on the CMS (2018) will be observed via CMS Dashboards and reported to senior management by the Complaints Manager.
  2. All Stage 2 complaints must be recorded by the Complaints Officer/Delegated support staff. The steps for recording a complaint on the CMS are outlined below:
    1. Create the initial complaint record - (Occurrence) including the Complainant’s personal details and a summary of the complaint. This first stage of the record will also detail the timeframes that the complaints officer must adhere to in the management of the complaint. This information will inform the complaints officers’ personalised dashboard.
    2. Create a record for each issue of the complaint - (Incident) including the specific category and location of the complaint.
    3. Update the record of the complaint - Follow up on the complaint by recording when the acknowledgement is made, or when extension letters explaining the delay are sent.
    4. Upload all associated documentation - Such documentation should include (but is not limited to):
      1. Files
        • the initial complaint
        • the final investigation report
        • written evidence of the interaction between any people in relation to the complaint i.e. correspondence, transcripts of discussions and interactions with the Service User, the Complainant, the service area, relevant staff and/or any external agencies/significant others in relation to the complaint, including telephone calls, reminder calls, meetings etc.
      2. Notes
        1. Records of attempted communications
    5. Create a record of any recommendation(s) made - (Tasks) for each issue recorded as appropriate Document the progress, actions to be taken, complaint outcomes and changes to current practice
        1. Files
          1. correspondence with the Accountable Officer
          2. the implementation action plan
          3. the learning action plan
    6. Close all issues – indicating outcomes such as ‘Recommendation Made’
    7. Close the complaint

For the Complaints Management System User Manual and for details on training, go to the CMS Toolkit at: http://www.hse.ie/eng/about/QAVD/Complaints/ncglt/Toolkit/

Recording HSE Internal Reviews

Review Officers will develop their own reporting system in accordance with relevant Standard Operating Procedures and Guidelines developed by the Head of Consumer Affairs.

  1. All Stage 3 HSE Internal Complaint Reviews must be recorded by the Review Officer /Delegated support staff
    The steps for recording a review record on the CMS are outlined below:
    1. Access the initial stage 2 complaint. - (Occurance) and go to the Complaint Review screen. This stage of the record will also detail the timeframes that the review officer must adhere to in the management of the internal complaint review. This information will inform the review officers’ personalised dashboard.
    2. Update the record of the internal review. Follow up on the complaint by recording when the acknowledgement is made, or when extension letters explaining the delay are sent.
    3. Upload all associated documentation - Such documentation should include (but is not limited to):
      1. Files
        • the review request.
        • the internal review report.
        • written evidence of the interaction between any people in relation to the review i.e. correspondence, transcripts of discussions and interactions with the Service User, the Complainant, the service area, relevant staff and/or any external agencies/significant others in relation to the review, including telephone calls, reminder calls, meetings etc.
      2. Notes
        1. Records of attempted communications
    4. Create/Amend a record of any recommendation(s) made - (Tasks) for each issue recorded as appropriate, document the progress, actions to be taken, complaint outcomes and changes to current practice
      1. Files
        • correspondence with the Accountable Officer
        • the implementation action plan
        • the learning action plan
    5. Close the review– indicating outcomes such as ‘Recommendation Upheld’

Recording Independent Reviews

Stage 4 of the Complaints Management Process offers a Complainant the right to request an independent review. The CMS allows the user to create a record of complaints that are referred to the Ombudsman/Ombudsman for Children.

  1. All Stage 4 Independent Reviews referred to the Ombudsman/Ombudsman for Children must be recorded by the Complaint Manager /Delegated support staff
    The steps for recording an independent review record on the CMS are outlined below:
    1. Access the initial complaint record. - (Occurrence) and go to the Complaint Review screen. This screen includes details for both ‘HSE Internal Review’ and ‘Ombudsman/Ombudsman for Children Review’.
    2. Update the record of the independent review. The user can enter details of when the review was requested, when the Ombudsman completed the review and the outcomes.
    3. Upload all associated documentation - Such documentation should include (but is not limited to):
      1. Files
        • Ombudsman’s Report.
        • Associated correspondence between the Complainant and the HSE, the Complainant and the Ombudsman, the Ombudsman and the HSE.
    4. Create/Amend a record of any recommendation(s) made - (Tasks) for each issue recorded as appropriate, document the progress, actions to be taken, complaint outcomes and changes to current practice.
      1. Files
        • correspondence with the Accountable Officer
        • the implementation action plan
        • the learning action plan
    5. Close the independent review– indicating outcomes such as ‘Ombudsman’s Recommendation Accepted’