QUA103 Complaints Policy.pdf

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QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

Query
An  inquiry  or  question  about  some  aspect  of  the  service  that  expects  a
response. It is not a complaint.
Incident
An internally reported event which:
  Has resulted in harm to client/consumer, kaimahi or other persons; or
  Could  have  resulted  in  harm  to  client/service  user,  kaimahi  or  other
persons; or
  Contravenes NMO policy, protocol, or procedures; or
  Is inconsistent with generally acceptable service / professional standards;
or
  Results in serious harm as defined by the Health and Safety at Work 2015;
or
  Results in, or could have resulted in, loss or damage to property and/or the
environment; or
  Results in loss to systems or process.
Open Complaint
The complaint that has been received by the organisation.
Closed
Where a response has been sent to the complainant following investigation,
Complaint
detailing the outcome of the investigation, and any action that has or is to be
taken as a result. If it does not elicit a further response from the complainant,
a closed complaint requires no further action from the organisation.
Resolved
A  resolved  complaint  is  one  that  is  resolved  to  the  satisfaction  of  the
Complaint
client/service  user  as  evidenced  by  written  acknowledgment,  or  verbal
acknowledgment that has been documented.

3.  POLICY
All  complaints  received  by  NMO  are  managed  and  responded  to  in  a  fair,  simple,  speedy  and
efficient manner for resolution, consistent with NMO obligations under the Code of Health and
Disability  Services  Consumers'  Rights  (1996)  (the  Code),  the  Privacy  Act  2020,  the  Health
Information Privacy Code 2020 and associated legislation.
All complaints will be managed:
  To encourage kaimahi to resolve complaints at the point of contact with the complainant.
  To ensure that clients and kaimahi are aware of the complaints procedure and it is easy for
clients and kaimahi to access and use.
  To ensure that all complaints are investigated so that the rights of both the complainant and
identified kaimahi are respected throughout the investigation process.
  To ensure that the confidentiality and privacy of the individual is maintained at all times.
  To regard complaints as opportunities to continually improve service delivery.
  To  ensure  that  issues  arising  from  the  complaints  process  are  forwarded  to  the  Quality
Manager or designated authority.
Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 2 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

4.  RESPONSIBILITIES
Kaimahi
Kaimahi receiving complaints from clients are accountable for forwarding them to the Managing
Director within 48 hours of receipt.
  If  the  complaint  is  verbal,  they  are  required  to  make  a  file  note  and  forward  it  to  their
Managing  Director  within  48  hours  of  receipt.    The  file  note  should  record  the  date
communication  occurred,  a  summary  of  the  complaint  resolution  if  applicable  and  any
subsequent action taken.
  Kaimahi are required to initiate immediate resolution where practicable.
  If the complainant chooses to make a written complaint, the kaimahi will provide support
and advice. A written complaint can be made by letter or by utilising the NMO complaints
form and will be submitted to the Managing Director.
  The  Managing  Director  will  delegate  the  management  of  the  complaint  process  to  the
Quality Manager or delegated authority.
Kaimahi who have a complaint are encouraged to initiate resolution through discussion with the
Managing Director or the Quality Manager in the first instance.
  If the kaimahi member chooses to make a written complaint they should do so via a letter or
by  utilising  the  organisation’s  Complaints  Notification  form  and  submit  to  the  Managing
Director.
  The  Managing  Director  will  delegate  the  management  of  the  complaint  process  to  the
Quality Manager or delegated authority.
  Kaimahi  need  to  be  aware  that  the  investigation  process  may  require  that  any  person’s
named in the complaint may  need to be interviewed (in confidence) to enable the Quality
Manager or delegated authority to reach an impartial and fair outcome.
Refer to 14. Complaints Procedure Flowchart and QUA200 Complaints Notification Form.

Quality Manager
  The  Quality  Manager  or  delegated  authority  has  responsibility  for  the  complaint
management process and is accountable for:
  Ensuring information pamphlets and posters are displayed throughout the services
informing /clients/service users about the complaints procedure.
Refer to QUA300 Complaints Process Information
  Receiving all complaints.
  Maintaining a record of all complaints received.
  Liaising with relevant kaimahi to ensure the complaint is resolved.
  Providing support and advice in complaint resolution process.
Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 3 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

  Coordinating the investigation into complaints.
  If a facilitated meeting is to be held, facilitating that meeting if required, and keeping
notes of that meeting.
  Recording all outcomes, follow-up actions and whether they are completed by the
set date.
  Providing a feedback loop to kaimahi.
  Monitoring  the  complaint  resolution  process  to  ensure  it  is  client  focussed,  and
meets the  requirements of the Code. In the case of kaimahi, the  process  needs to
ensure compliance with relevant employment standards.

5.  COMPLAINTS REVIEW
All complaints are reviewed at senior management team meetings, which ensures that:
  Complaints  presented  at  meetings  are  monitored  to  ensure  compliance  with  the  Code,
relevant employment standards and this policy.
  Quality improvement opportunities arising out of the complaint process are identified.
Bi-monthly  reports  are  submitted  by  the  Managing  Director  to  the  Trust  Board,  outlining
activities and resolutions as appropriate.

6.  SERIOUS COMPLAINTS
A  serious  complaint  is  where  there  is  any  serious  allegation  against  NMO.    The  following  are
examples of what may constitute a serious complaint:
  A complaint which has the potential risk of a legal claim.
  Any  allegation  regarding  the  breach  of  legislation,  regulations,  or  an  ethical  code  of
conduct e.g. breaches of the Code of Rights regulations.
  Discrimination  according  to  race,  gender,  age,  etc.  including  allegations  about  being
neglectful, or otherwise having acted improperly.
  Where kaimahi appear to be practicing outside of a NMO policy.
  A complaint that has attracted media attention.
All  serious  complaints  must  be  brought  to  the  immediate  attention  of  the  Managing  Director.
This is to protect both kaimahi and the organisation.

7.  LEGISLATIVE REQUIREMENTS
a)  5 Working Days
All  complaints  are  acknowledged  in  writing  within  five  working  days  of  receipt,  unless
resolved  to  the  satisfaction  of  the  client  within  that  period.  Complaint  resolution  must  be
documented.

Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 4 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

b)  20 Working Days

All complaints are responded to in full, within 20 working days, or the client is informed in
writing of the need for further time in writing.
c)  Over 20 Working Days
The client is given monthly written updates if the process takes longer than 20 working days.
Minimum information must include:

Acknowledgement of receipt of the complaint.

Advising the complainant who will be investigating the complaint.

Informing the complainant of the complaint management process, timeframes and
appeal process.

Informing  the  complainant  about  the  Health  and  Disability  Consumers  Code  of
Rights and provides contact details.

Advising  the  complainant  about  the  Health  Advocates  Trust  and  the  Health  and
Disability Commissioner and provides contact details.
The response letter must:
  Advise  the  complainant  who  were  consulted  in  the  course  of  investigating  the
complaint.
  Identify the issues the complainant complained about.
  Respond to each issue.
  Advise what actions will be taken to follow up the issues complained of.
  Request the complainant to confirm whether or not they are satisfied with the response.
  Provide the complainant with contact details for the Health and Disability Commissioner
and or Privacy Commissioner as appropriate, if dissatisfied with the response.

8.  HABITUAL OR VEXATIOUS COMPLAINTS
The key consideration when dealing with habitual or vexatious complaints is to ensure that the
complaints  procedure  has  been  correctly  implemented  and  that  no  material  element  of  a
complaint has been overlooked or inadequately addressed. In doing so it should be appreciated
that  even  habitual  or vexatious  complainants  may  have  issues  which  contain  some  substance.
The need to ensure an equitable approach is crucial.
If  it  is  considered  that  all aspects  of  the  complaint  have  been  addressed,  the  complainant  has
been  offered  the  opportunity  to  appeal  the  complaint,  and  still  persists  in  stating  their
dissatisfaction; they should be reminded of the opportunity to access the Health and Disability
Commissioner or the Privacy Commissioner as appropriate for an independent investigation into
the complaint.

Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 5 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

9.  SECURITY AND RETENTION OF INFORMATION
Material collected as part of the investigative process is centrally filed with the Quality Manager.
Access  is  limited  to  authorised  kaimahi.    All  closed  complaints  are  to  be  filed  in  one  central
location. Material is retained indefinitely.
Complaints are to be stored in a secure confidential location.

10. PRIVACY IMPLICATIONS
Complaints may contain personal information about the client, kaimahi or other people. Under
the  Privacy  legislation,  this  means  that  the  information  should  only  be  used  in  ways  that  are
necessary  to  manage  the  complaint.    Appropriate  steps  must  be  taken  to  keep  personal
information  secure  e.g.  complaints  should  not  be  discussed  in  public  areas;  complaint
information  should  be  stored  in  a  secure  location  such  as  the  Operations  Manager’s  office.
Consent for disclosure of personal information must be obtained from the  person implicated if
complaints are lodged by a third party.

11. PERFORMANCE MEASURE
Ultimate  responsibility  for  the  organisation  including  complaints  rests  with  the  Managing
Director who is responsible to their Board of Trustees for legal compliance.

12. RELATED DOCUMENTS
National
Health & Disability Sector Standards 8134:2008
Health and Safety at Work Act 2015
Privacy Act 2020
Health Information Privacy Code 2020
New Zealand Public Health and Disability Act 2000
The Code of Health and Disability Services Consumers Rights (1996)
Policy
SD101 Privacy Policy

SD102  Health Information Privacy
Forms
QUA203 Complaints Notification Form

Resources
QUA303/1 Complaints Process Information Sheet

QUA303/2 Complaints Process Flowchart

Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 6 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

13. COMPLAINTS PROCEDURE FLOWCHART
Task
  Action

Responsibility

Timeframe
Kaimahi  must  attempt  to  resolve  issues  using
solution focused skills.

File note completed that includes:
  a record of the date communication occurred,
Verbal Complaint

Kaimahi

  a  summary  of  the  complaint  resolution  if
applicable, and
  any subsequent action taken.

File note submitted to Managing Director and copy
to Quality Manager.



If  issue  not  resolved,  provide  support  to
complainant  and  advise  on  written  complaint
Within 48
process.
hours
Document verbal complaint (preferably utilising the
(1) Written
NMO  Complaints  Form  but  a  letter  from  the
Complaint
complainant will suffice) that includes the following
received through
details:
Managing

kaimahi and/or
  date communication occurred
Director
Managing
  summary of complaint
Director
  any subsequent action taken.
Submit the written complaint:
  to Managing Director
  copy to Quality Manager



(2) Written
Letter of complaint received by any kaimahi:
Kaimahi
Complaint
    submitted to Managing Director and discussed

Managing

received directly
with Quality Manager.
Director



Letter of acknowledgement sent to complainant. To
Acknowledgeme
include:
Quality
Within 5

nt
  Acknowledge receipt of the complaint.
Manager
working days
  Advise the complainant who will be
Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 7 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

Task
  Action

Responsibility

Timeframe
investigating the complaint.
  Inform the complainant of the complaint
management process, timeframes and appeal
process.
  Inform the complainant about the Health and
Disability Consumers Code of Rights.
  Advise them about the Health and Disability
Commissioner.



Quality Manager to carry out investigation that may
involve (with the consent of both parties):
  Individual interviews.
  Mediation.
   Liaison  with  other  kaimahi  who  may  have
Within 20
Investigation

been affected.

  working days
Quality Manager responsible for:
  Keeping  notes  of  all  meetings,  recording
outcomes and follow up actions.
  Providing  a  feedback  loop  to  all  parties
involved as appropriate.



  If it becomes obvious that the investigation will
Ongoing

need  further  time,  the  complainant  must  be
Quality

Investigation
provided with monthly documented updates.
Manager



Letter  provided  to  advise  the  complainant  who
were  consulted  in  the  course  of  investigating  the
complaint, and:
Over 20
  Identifies  the  issues  the  complainant
working days
complained about.
Resolution
  
Responds to each issue.

  Advises what actions will be taken to follow up
the issues complained of.
  Requests the complainant to confirm whether
or not they are satisfied with the response.
  Informs  about  the  in-house  appeals  process  if
Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 8 of 9

QUALITY IMPROVEMENT MANUAL
QUA103 COMPLAINTS POLICY

Task
  Action

Responsibility

Timeframe
they wish the complaint to be reviewed.
  Informs  complainant  that  if  they  are  not
satisfied they have the right to refer the matter
to the Health and Disability Commissioner.
Report  provided  to  the  executive  team  as  the
appropriate quality improvement forum where:
  Complaints  presented  at  meetings  are
Senior
monitored  to  ensure  compliance  with  the
Management
Review

Code  of  Health  &  Disability  Services

Team
Consumers'  Rights,  and  NMO  Complaints
meeting
Policy.
  Quality improvement opportunities arising out
of the complaint process are identified.
Quality



Manager
Complaint recorded in Complaints Register which is
Report

Monthly
included in the monthly Quality Trust Board report.



  Material  collected  as  part  of  the  investigative
Security &
process is centrally filed.
Retention of
  

As required

Access is limited to authorised kaimahi.
Information
  Material is retained indefinitely.

Document Ref: QUA103 Complaints Policy
Folder: Quality Manual
Approved by: MD
Version: 1
Last Review: May 2021
Next Review: May 2024
Page 9 of 9