The backbone of any effective and efficient feedback process is having defined management structures supported by clear governance and accountability frameworks.
The HSE has a No Wrong Door approach in relation to Service User feedback. This means that a Service User can be confident that their feedback can be received by any staff member in the HSE and that it will be managed on their behalf.
All staff must be engaged in the feedback process and in particular, the complaints management process and their roles and responsibilities are detailed below.
Roles and Responsibilities
Roles and responsibilities underpin the effective implementation of Your Service Your Say, the Management of Service User Feedback for Comments, Compliments and Complaints 2017.
It is the role and duty of all management and staff to:
- Comply with this Policy.
- Ensure that this Policy is implemented and adhered to in their area and that the rights and legitimate interests of Service Users and staff are protected.
- Promote a culture and attitude that welcomes feedback and supports the effective resolution of complaints raised.
- Ensure that information on how to make a complaint is accessible and made widely available throughout all health service locations.
- Provide an efficient, effective, fair and accessible system for managing feedback and in particular for handling complaints.
- Support Service Users and staff in the implementation of the Policy and supporting guidance manual.
- Collect data and monitor feedback for the purpose of improving the quality of service delivery.
Role of the Director General and HSE Leadership Team
It is the responsibility of the Director General and the HSE Leadership Team to:
- Ensure the HSE is compliant with Part 9 of the Health Act 2014.
- Ensure that all HSE Service Managers and staff are aware of and comply with Your Service Your Say, the Management of Service User Feedback for Comments, Compliments and Complaints Policy 2017.
- Ensuring that the feedback process is clearly articulated, open and accountable to both Staff and Service Users.
- Ensuring strategic decision making is informed by service user feedback data.
- Ensuring the Policy is established, monitored and reviewed accordingly.
- Ensuring the analysis of comments, compliments and complaints inform and influence national strategies, planning
Role of the Executive Lead for Complaints Governance and Learning
It is the responsibility of the Executive Lead for Complaints Governance and Learning to:
- Ensure that a comprehensive system for the management of Service User feedback is in place and being implemented throughout the HSE and its relevant Service Providers.
- Ensure an effective communication process is in place to inform the service user of the feedback process and, in particular, complaints management.
- Ensure an effective process for the monitoring and evaluation of complaints exists and is communicated throughout the HSE.
- Ensure that appropriate reporting systems are in place between the HSE and relevant Service Providers in accordance with Part 9, Section 55(2) of the Health Act 2004.
- Prepare an annual report on complaints; identifying trends, KPI compliance and learning.
- Provide assurance by conducting feedback and, in particular, complaints management performance reviews and audits across the HSE.
Role of Chief Executive Officer (CEO) and Chief Officer (CO)
For the purpose of the implementation of this policy, the role of the Hospital Group Chief Executive Officer and Community Healthcare Organisation Chief Officer is to:
- Implement and maintain an efficient and effective feedback system which will ensure recording and tracking of data.
- Ensure feedback is appropriately assessed to generate action from the appropriate level.
- Ensure staff are aware of their responsibilities in relation to receiving and managing service user feedback and understand their role.
- Delegate Complaints Officers in their respective administrative area.
- Ensure issues identified through analysis of service user feedback are used for learning and shared at a local, regional and national level.
- Provide performance reports to the Quality Assurance and Verification Division in relation to management of feedback.
- Identify trends and system issues in comments, compliments and complaints.
- Publish feedback data and trends as part of their service annual report.
- Publish casebooks.
Role of the National Office for Your Service Your Say
For the purpose of the implementation of this Policy, the role of the National Office for Your Service Your Say staff is to:
- Acknowledge all feedback including complaints received into the National Office for Your Service You Say on behalf of the National Complaints Governance and Learning Team within 24 hours.
- Forward feedback including complaints to the appropriate Consumer Affairs Office and copy the nominated contact for complaints within Hospital Groups, Community Healthcare Organisations and National Divisions.
- Log all complaints received.
- Return monthly feedback statistics to the National Complaints Governance and Learning Team Office in Limerick.
Role of the Regional Manager for Consumer Affairs
For the purpose of the implementation of this policy, the role of the Regional Manager for Consumer Affairs is to:
- Ensure that the HSE Complaints Management Process is effectively implemented throughout their Administrative Area.
- Ensure that staff within their Administrative Area receive appropriate training in managing feedback and in particular, complaints handling.
- Ensure that standardised service user friendly information, templates, forms etc. are available for distribution by Complaints Officers in all locations of their Administrative Area.
- Act as a Review Officer as appropriate within their respective areas.
- Ensure that there is routine collection, analysis and communication of trends in complaints received within that Administrative Area.
- Evaluate the complaints data for the Administrative Area to ensure the correct and effective management of complaints.
- Ensure that relevant Service Providers (non-HSE) in their Administrative Area have an appropriate complaints management system in place as defined in the Health Act 2004 and have a vetted complaints policy signed off by Consumer Affairs as outlined under Schedule 8 of their Service Level Agreement.
- Liaise with the appropriate Quality and Risk personnel in their Administrative Area, to ensure that complaints management is linked with sustainable quality improvement.
- Participate in the evaluation of service user perception of the complaints management process in their Administrative Area.
- Ensure that a monthly statistical report on complaints is prepared and forwarded on a quarterly basis to the National Complaints Governance and Learning Team in the Quality Assurance and Verification Division, pending full implementation of the Complaints Management System (CMS).
- Collaborate with relevant Community Healthcare organisations and Hospital Groups on complaints management for their areas and bring to their attention any national issues which require local consideration.
- Be responsible for the development a National Complaints Officer Governance and Learning Forum.
- Act as a Liaison Office with the Ombudsman and Ombudsman for Children’s Office in relation to all complaints received by those respective offices.
Role of Consumer Affairs Area Office Staff
For the purpose of the implementation of this policy, the role of the Consumer Affairs Area Office Staff is to:
- Keep themselves appraised and fully briefed in the latest developments, policies, procedures, protocols and guidelines in relation to managing feedback including complaints management.
- Provide training to staff and Complaints Officers and voluntary organisations on all aspects of complaints handling at various levels of training from induction training through awareness training to full Complaints Officer training.
- Support, advise and guide Service Users/Complainants/Reviewers and HSE staff on the complaints management process.
- Ensure complaints received via the National Your Service Your Say Office are forwarded to the appropriate Complaints Officer for attention and copied to the designated contact person within each Community Healthcare Organisation / Hospital Group.
- Ensure that all written complaints received in the Consumer Affairs Area Office are logged, administratively acknowledged and forwarded to an appropriate Complaints Officer. In exceptional circumstances the complaint may need to be sent to the relevant service manager.
- Collect feedback and complaints statistics from Complaints Officers and forward them to the Regional Manager on a monthly basis.
- Collect monthly complaints statistics from voluntary agencies and hospitals and forward them to the Regional Manager on a quarterly basis pending full implementation of the Complaints Management System (CMS).
- Assist the Regional Manager Consumer Affairs in their role as set out in this Policy.
Role of Complaints Manager
For the purpose of the implementation of this policy, the role of the Complaints Manager is to:
- Be a champion for the feedback process including the complaints management process though an active and visible leadership role with key involvement in education, training and reporting arrangements.
- Be responsible for the routine monitoring and review of the Organisation’s feedback process including the complaints management process which is necessary to ensure and assure that the system works in line with the Your Service your Say, the Management of Service User Feedback for Comments, Compliments and Complaints policy.
- Promote a process of assurance through the generation of case books following Stage 3 HSE Internal Complaint Review and publish reports on the management of complaints by their area and the learning achieved as a result of same in conjunction with Regional Managers Consumer Affairs.
- Ensure processes are in place to support clinicians and staff to understand how complaints are handled.
- Upon notification from a Complaints Officer ensure that any risks identified as part of a complaint are notified to the relevant Head of Service (Accountable Officer) to ensure high risk complaints are appropriately assessed and investigated and that learning is achieved.
- Provide an overview and update on the management of service user feedback to Senior Management Teams, in relation to key performance indicators in line with national feedback data returns.
- Ensure that the lessons learned from feedback including complaints are used to improve the service and are implemented
- Determine the overall effectiveness of the complaints management process with their area of responsibility.
Role of Complaints Officers
For the purpose of the implementation of this policy, the role of delegated Complaints Officers is to:
- Ensure service user friendly information on how to offer feedback and, in particular, on how to make a complaint is widely available throughout the health service locations.
- Ensure that the complaints management process and process is implemented and being adhered to in their area and that the rights and legitimate interests of service users and staff are protected.
- Support staff and service users in the implementation of the complaints management process.
- Identify non-excluded matter of the complaint, and investigate.
- Ensure that any risks identified as part of a complaint are assessed and immediately notify the Complaints Manager of any high risk complaints to ensure appropriate investigation and learning.
- Inform relevant parties of decision to extend or not extend time frames.
- Find resolution of the complaint using approaches identified in Your Service Your Say, the Management of Service User Feedback for Comments, Compliments and Complaints Policy 2017 and Guidance Manual and through implementation of the complaints management process.
- Investigate and conclude within 30 working days or inform Complainant by due date and update every 20 days.
- Advise a person if a finding in the report is adverse to that person and afford them the opportunity to consider the finding and to make representations in relation to it.
- Make recommendations, which may also support organisational learning and improvement.
- Provide Complainant and relevant Head of Service (Accountable Officer) with a report of the complaint investigation.
- Advise the service user that they may seek a review of the complaint by requesting a HSE Internal Complaint Review (Stage 3) or by contacting the Office of the Ombudsman/Ombudsman for Children’s Office (Stage 4).
- Where a complaint has been withdrawn the Complaints Officer may bring this to the attention of the relevant Head of Service (Accountable Officer) to determine if the investigation should continue.
- Determine the overall effectiveness of the complaints management process within their area of responsibility.
- Generate anonymised complaints data and disseminate this information as appropriate.
- Submit reports as appropriate to the Office of Consumer Affairs for their respective areas.
- Co-ordinate complaints where both Your Service Your Say and clinical judgment elements are involved.
- Ensure complaints data is recorded on the Complaints Management System (CMS) or forward monthly complaints statistical data to Consumer Affairs Area Office Staff pending full implementation of the Complaints Management System (CMS).
Role of Review Officer
Review Officers are appointed in line with the Health Act 2004 (Complaints) Regulations 2006. Upon an application for review being made the Complaints Manager will appoint a Review Officer to review the recommendations made by Complaints Officers after the investigation of a complaint. It is the role of the Review Officer to:
- Engage with the Complainant as appropriate throughout the review process.
- Determine the appropriateness of the recommendations by reviewing the processes used to investigate the complaint and having regard to all aspects of the complaint and its investigation.
- Uphold, vary or make a new recommendation.
- Complete the review within 20 working days. A Review Officer may request in writing an extension and indicate the additional time considered necessary for completion.
- Prepare a report on the review and circulate same as appropriate under the Your Service Your Say, the Management of Service User Feedback for Comments, Compliments and Complaints Policy and Guidance Manual.
- Advise a person if a finding in the report is adverse to that person and afford them the opportunity to consider the finding and to make representations in relation to it.
- Advise the service user that they may seek a further review of the complaint by contacting the Office of the Ombudsman/Ombudsman for Children’s Office.
Role of Staff
All HSE and relevant Service Providers’ staff have an obligation to deal effectively with all feedback and, in particular, to attempt to manage complaints made to them and this includes;
- Ensuring they are aware of the Your Service Your Say, the Management of Service User Feedback for Comments, Compliments and Complaints Policy and processes.
- Participating in complaints management training.
- Managing a complaint in a timely manner either by dealing with it at the point of contact in line with Policy or forwarding same to the Complaints Officer for management.
- Participate in the investigative process of a complaint on the request of a Complaints Officer / Review Officer.
- Supporting and facilitating improvement initiatives within their service.
- Providing data relevant to feedback to service mangers and national divisions.
Role of relevant Head of Service (Accountable Officer)
Relevant Heads of Services (Accountable Officers) will receive a copy of the complaint investigation report from the Complaints Officer setting out the findings and the recommendations. The relevant head of Service (Accountable Officer) will then:
- Write to the Complainant and Complaints Officer within 30 days detailing their Recommendation Action Plan, and
- Advise if any recommendation(s) are rejected, amended or if alternative measures are being taken and set out the reasons for the decision
- Ensure recommendations are implemented
- Advise Complainant of the suspension of implementation of recommendations where a request to review the outcome of the complaint investigation has been received
