Policy and Procedure for Handling and Learning from Feedback, Comments, Concerns and Complaints

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1 Policy and Procedure for Handling and Learning from Feedback, Comments, Concerns and Complaints Author: Shona Welton, Head of Patient Affairs Responsible Lead Executive Director: Endorsing Body: Governance or Assurance Committee Irene Barkby, Executive Director of Nurses, Midwives and Allied Health professionals Healthcare Quality Assurance & Improvement Committee Lanarkshire NHS Board Implementation Date: 9 April 2015 Version Number: 2 Review Date: Responsible Person April 2018 or as required by legislation or organisational change Shona Welton, Head of Patient Affairs Version No. 2 Date 09/04/15 Page 1 of 16

2 CONTENTS i) Consultation and Distribution Record ii) Change Record 1. INTRODUCTION 2. AIM, PURPOSE AND OUTCOMES 3. SCOPE 3.1 Who is the Policy Intended to Benefit or Affect 3.2 Who are the Stakeholders 4. PRINCIPAL CONTENT 4.1 Roles and Responsibilities 4.2 Encouraging, handling and learning from feedback, comments and concerns 4.3 Encouraging, handling and learning from complaints 5. ROLES AND RESPONSIBILITIES 6. RESOURCE IMPLICATIONS 7. COMMUNICATION PLAN 8. QUALITY IMPROVEMENT MONITORING AND REVIEW 9. EQUALITY AND DIVERSITY IMPACT ASSESSMENT 10. REFERENCES Version No. 2 Date 09/04/15 Page 2 of 16

3 Contributing Author / Authors CONSULTATION AND DISTRIBUTION RECORD Shona Welton, Head of Patient Affairs Irene Barkby, Executive Director of Nurses, Midwives and Allied Health Professionals Consultation Process / Stakeholders: Patient Affairs Managers (Version 1 of Policy) Distribution: NHS Lanarkshire website Intranet Executive Directors CHP and Acute Management Teams for dissemination Patient Advice and Support Service CHANGE RECORD Date Author Change Version No. 10/04/12 S Welton Draft Draft #1 03/05/12 S Welton Minor typographical amendments to draft Draft #2 07/05/12 S Welton Minor typographical amendments following Final CMT approval 20/03/15 S Welton Updated: V.2 Draft 1 throughout reflect name of current Responsible Lead Executive Director at to reflect changes in the range of feedback media at to reflect changes to staff titles at to reflect that the Charter of Patient Rights and Responsibilities is in place Version No. 2 Date 09/04/15 Page 3 of 16

4 1. INTRODUCTION The Patient Rights (Scotland) Act 2011 aims to improve the experiences of patients using the health service, and to support people to become more involved in their health and health care. The Act, which came into force on 1 April 2012, introduced a legal right to provide feedback, comments, concerns and complaints about NHS services. NHS Lanarkshire welcomes feedback, comments, concerns and complaints as key indicators of the quality of service it is delivering. They are pivotal in determining whether services are person-centred, safe and effective. This policy and procedure is based on: The statutory Regulations and Directions issued under cover of Chief Executive Letter CEL 7 (2012) Patient Rights (Scotland) Act 2011 Secondary Legislation and the Charter of Patient Rights and Responsibilities, issued on 28 March 2012 The guidance on handling and learning from feedback, comments, concerns and complaints about NHS health care services, issued under cover of Chief Executive Letter CEL 8 (2012), issued on 28 March AIM, PURPOSE AND OUTCOMES This policy and procedure is intended to: Ensure that patients, their representatives and staff are aware of the arrangements for handling feedback, comments, concerns and complaints Ensure that patients, their representatives and staff are aware of the support available to those who wish to provide feedback or comments or raise a concern or complaint Ensure the appropriate level of confidentiality of information throughout the handling of feedback, comments, concerns and complaints Maximise opportunities for the prompt and thorough investigation of concerns and complaints Maximise opportunities for learning from feedback, comments, concerns and complaints Ensure that these arrangements are reviewed and updated on an ongoing basis. 3. SCOPE 3.1 Who is the Policy intended to Benefit or Affect? The policy and procedure is intended to benefit: Patients and their representative(s) Staff Version No. 2 Date 09/04/15 Page 4 of 16

5 Other health care providers (including those providing services under contract) and other statutory authorities, for example local authorities with which services are jointly provided. 3.2 Who are the Stakeholders? NHS Lanarkshire must comply with the legislation on handling feedback, comments, concerns and complaints. These arrangements have therefore been drawn up with the legislation in mind. The Patient Affairs Managers were given the opportunity to review and comment on this policy and procedure. Arrangements will be made to share this document with, and discuss if requested, the Public Partnership Forums and the Disability Engagement Group. 4. PRINCIPAL CONTENT 4.1 Roles and Responsibilities The Chief Executive is ultimately responsible for the quality of care delivered by NHS Lanarkshire The Executive Director of Nurses, Midwives and Allied Health Professions will act as the Feedback and Complaints Manager and is responsible for assuring compliance with the arrangements for handling and learning from feedback, comments, concerns and complaints. The Director is also responsible for ensuring that action is taken as necessary in response to feedback, comments, concerns and complaints The Head of Patient Affairs will act as the Feedback and Complaints Officer and is responsible for the management and handling of feedback, comments, concerns and complaints. The Head of Patient Affairs is supported by Patient Affairs Managers whose principal role is to manage concerns and complaints on a day-today basis, liaising with patients, their representatives and staff in order to resolve issues. They will act as Feedback and Complaints Officers on a day-to-day basis 4.2 Encouraging, handling and learning from feedback, comments and concerns Definition of feedback, comments and concerns Patients and their representative(s) may offer feedback, comments and raise issues of concern without wishing to make a complaint. They may simply wish to give their views on the service provided. Positive feedback helps to identify areas of good practice and ensures that good experiences are maintained. It can also identify shortcomings and areas for improvement. Not all feedback, comments and concerns will need a response. Feedback may be in the form of views expressed orally or in writing, for example as part of a survey, patient questionnaire or through the Patient Advice and Support Version No. 2 Date 09/04/15 Page 5 of 16

6 Service (PASS). It may describe the patient or carer s experience of using services and may include suggestions as to how things could have been done better or identify areas of good practice. Comments (including compliments) may be offered orally or in writing by patients, relatives or visitors and reflect how someone felt about the service. They may also be received on suggestions forms or through the PASS. Concerns may be expressed to staff or through the PASS about: Proposed treatment. Patients may need reassurance or further explanation and information to help them understand why a particular course of action is being suggested. Any aspect of the service. Staff should use their discretion and judgement in supporting people to decide whether this should be escalated to a complaint. There could be circumstances where the nature of the concern is sufficiently serious to warrant full investigation. Staff should make the person aware of the separate process available for dealing with complaints. The individual should have the opportunity to consider whether they would prefer to raise a complaint. This can be done by staff making available the information leaflet Making a complaint about the NHS (which is available in a range of formats) and / or providing them with the contact details for the Feedback and Complaints Officer. If staff are in any doubt they should seek advice from their line manager or the Feedback and Complaints Officer Handling feedback, comments and concerns The emphasis should always be on early and local resolution. Staff should respond positively and appropriately and: Acknowledge the feedback, comment or concern in an open and honest way. Ensure the patient s immediate health care needs are being met as appropriate before dealing with the issue Clarify the nature of the feedback, comment or concern using the most appropriate method of communication for the situation and the individual Establish what outcome the person giving the feedback, comment or concern is looking for Discuss the matter with the patient, encouraging them to speak freely Provide an honest and objective response Responding to feedback, comments and concerns Responses, where one is requested or needed, may be given verbally or in writing depending on the circumstances. Where the issue is raised by someone other than the patient or their authorised representative, staff should take into account the need to preserve patient confidentiality (see 4.3.8). The Feedback and Complaints Officer can provide advice and guidance if needed. Staff should make a judgement on appropriate action and on the response required based on their assessment of the situation; the nature of the feedback, comment or Version No. 2 Date 09/04/15 Page 6 of 16

7 concern; and their knowledge of any previous similar situation. It may be appropriate to give a verbal response on the spot or, where this is not possible, within seven working days or within a timescale agreed with the patient. The response should include an explanation, an apology where appropriate and indicate any service improvement that has been identified. Any verbal or written response about a clinical matter must be agreed with the relevant clinician. Where the staff member who receives the feedback, comment or concern feels unable to respond themselves, they should ask for support from an appropriate senior colleague or offer the patient the option of speaking with someone not directly involved in their care. If the person is raising a concern and remains unhappy after receiving a verbal or written response, staff should explore the options with them. This might include offering a meeting with a senior manager or whether the person should more appropriately be advised to make a complaint. Staff should seek advice and assistance from the Feedback and Complaints Officer Record keeping The information, themes and good practice from feedback, comments and concerns will be collected, recorded and disseminated. This will ensure that patients views and experiences are used to improve service quality. In the first instance these data will be gathered from feedback, comments and concerns raised through the Patient Affairs Managers, feedback leaflets, the general enquiry line, national and local patient experience surveys and platforms such as Patient Opinion Monitoring, learning and improvement Feedback, comments and concerns provide a wealth of information that can be used to inform service improvement, share good practice, increase patient safety and reduce the number of complaints. NHS Lanarkshire will publish annually details summarising the action which has been taken or is to be taken to improve services as a result of feedback, comments or concerns. This will cover information on its own services and on the health service providers in its area. 4.3 Encouraging, handling and learning from complaints Definition of a complaint Complaints should be valued alongside other forms of feedback and actively welcomed and encouraged to help to improve the delivery, quality and safety of health services. They should be handled as quickly and closely to the point of origin as possible. The emphasis should be on early and local resolution, ensuring that the learning is shared and improvements acted upon as soon as possible after the issue that gave rise to the complaint. Version No. 2 Date 09/04/15 Page 7 of 16

8 A complaint, which may be made verbally or in writing, is defined by the Scottish Public Services Ombudsman (SPSO) Model Complaints Handling Procedure as an expression of dissatisfaction about an action or lack of action or standard of care provided What does the complaints procedure cover? The potential subject of a complaint is wide and each complaint must be taken on its own merit and responded to appropriately. A patient (or someone acting on their behalf) or any person who is affected by or likely to be affected by an action or omission of NHS Lanarkshire may raise a complaint about the service provided. Where the complainant is uncomfortable making the complaint directly to a health service provider (such as a Family Health Services practitioner or body contracted to provide a service), the complaint can be made to NHS Lanarkshire. NHS Lanarkshire will agree with the complainant and the health service provider how the complaint will be managed Issues handled under other procedures and processes The complaints procedure does not cover the following circumstances: Complaints from one NHS body to another in relation to any matter connected with the exercise of that body s functions A complaint made by a health service provider which relates either to any matter connected with the contract or arrangement under which the service provider provides health services A complaint made by an employee of NHS Lanarkshire in relation to any matter relating to the contract of employment A complaint that is being or has been investigated by the SPSO A complaint arising from an alleged failure to comply with a request for information under the Freedom of Information Act 2002 A complaint about which the complainant has stated in writing that they intend to take legal proceedings A complaint about which NHS Lanarkshire is taking or proposing to take disciplinary proceedings in relation to the substance of the complaint against the person who is the subject of the complaint A complaint which has already been investigated under this or a former complaints procedure. If a complaint is received on any of these matters it should be referred immediately to the appropriate person. The complainant should be informed in writing as soon as is reasonably practicable that the complaint will not be investigated under the NHS complaints procedure and be given information as to the appropriate procedures to be followed for raising such a complaint. Where NHS Lanarkshire considers that an aspect of such a complaint could be investigated under the NHS complaints procedure, NHS Lanarkshire will satisfy itself that this would not compromise or prejudice the matter being investigated under the separate arrangements. Version No. 2 Date 09/04/15 Page 8 of 16

9 4.3.4 Complaints that span more than one service or sector Where the complaint relates to the actions of NHS Lanarkshire and one or more other NHS Scotland bodies, NHS Lanarkshire will endeavour to reach agreement with the other body/bodies on who will take the lead in co-ordinating the complaint. In these circumstances the complainant will be advised who will take the lead in dealing with the complaint and will be advised that where possible a joint response will be provided. Where a complaint relates to services delivered in the community jointly by NHS Lanarkshire and local authority partners, NHS Lanarkshire will agree with the relevant local authority who will take the lead and will work with that authority to ensure that all matters raised are investigated and learning opportunities are taken. The complainant will be advised of the different complaints procedures that currently operate, particularly where this may impact upon the response time, and that where possible a joint response will be given Timescales for making a complaint Complaints are normally made at the time the individual becomes aware of an issue and should be dealt with immediately. However, it is not always possible to make a complaint immediately. Given the difficulties the passage of time can make to the resolution of a complaint, the timescale for accepting a complaint is within six months from the date on which the matter of the complaint comes to the complainant s notice, provided that this is no later than twelve months after the date on which the matter of the complaint occurred. The timescale for accepting a complaint may be extended if the Feedback and Complaints Officer considers it would be reasonable in the circumstances. Where the decision is taken not to extend these timescales and the complainant is dissatisfied with the decision, they may appeal to the SPSO Managing the complaints process Complaints can be made to any member of staff. A member of staff receiving a verbal complaint should establish whether the person wishes the matter dealt with under the NHS complaints procedure by explaining the process, offering the contact details for the Feedback and Complaints Officer and / or providing a copy of the information leaflet Making a complaint about the NHS which includes details of the PASS. It is important at this stage to try to find out what the person wants to happen as a result of their complaint in order to establish whether those expectations can be met. Where the person does wish to make a complaint under the NHS complaints procedure, the member of staff should immediately contact the Feedback and Complaints Officer for advice on handling the complaint. Equally any member of staff receiving a written complaint should immediately contact the Feedback and Complaints Officer for advice on handling the complaint. Where a complaint is reasonably straightforward and non-complex it may be managed without a detailed investigation. If the complaint has been successfully Version No. 2 Date 09/04/15 Page 9 of 16

10 resolved to the complainant s satisfaction within three working days and the outcome has been communicated to the complainant either by face-to-face, telephone or communication there is no additional requirement to send further written confirmation or to carry out a detailed investigation. Complaints that fall into this category must be reported to the Feedback and Complaints Officer so that they can be recorded as normal to support organisational learning Acknowledging a complaint Complaints that cannot be resolved within three working days (see 4.3.6) should be acknowledged within three working days of receipt by NHS Lanarkshire using the complainant s preferred method of communication. Communication may be sent to the complainant electronically where they have consented to this in writing and the consent has not been withdrawn. The written acknowledgement of a complaint will include the following: Name and contact details of the Feedback and Complaints Officer Details of the advice and support available to the complainant including the PASS Information on the role and contact details for the SPSO Confirmation that the complaint will normally be investigated within twenty working days of receipt or as soon as reasonably practicable. Where the complaint is made verbally to a member of staff, the complaint will be summarised in the acknowledgement and the complainant will be asked to confirm that the complaint has been correctly interpreted before the complaint is formally accepted and the investigation commences Patient Consent Where someone other than the patient or their authorised representative wishes to make a complaint on behalf of the patient NHS Lanarkshire will check whether consent has been received from the patient: For that person to act on behalf of the patient and receive a response to the complaint For staff to access the patient s personal health information to the extent necessary to investigate and respond to the complaint. In the event that consent is not received this will be taken into account when handling the complaint, and will inform the extent of the investigation that can be carried out and the information that can be passed on. Where the patient has died or does not have capacity to consent, for example if they are a child or an adult with incapacity, a check will be carried out to make sure that the person making the complaint has a legitimate interest in the patient s welfare and that there is no conflict of interest. Version No. 2 Date 09/04/15 Page 10 of 16

11 The information leaflet Making a complaint about the NHS is available in a range of formats to assist those who may not be able to consent (for example children, young people and adults with incapacity) to understand the complaints process Negligence Claims In some cases a complaint may be raised with the support of a solicitor. This may, for example, be the case when the health care was delivered in a prison health centre or where the patient has additional support needs. It must not be assumed that a person making a complaint has decided to take formal legal action and the matter must be treated in the same open and honest way as complaints received directly from patients. However, if the complainant indicates in writing an intention to instigate or actually instigates legal proceedings the complaints procedure must be immediately suspended. The complainant must be advised in writing as soon as reasonably practicable that the complaint will not be investigated under the NHS complaints procedure and given the identity of the person who will be handling the correspondence Investigating the complaint The investigation of the complaint will be led by the Feedback and Complaints Manager or Officer or staff nominated to act on their behalf. In most cases these will be the Patient Affairs Managers. They will identify the most relevant members of staff to investigate the complaint using the approach(es) most appropriate to the complaint. This may include face-to-face meetings, obtaining written statements and using alternative dispute resolution such as mediation or conciliation. Anyone identified as the subject of a complaint should be provided with the reasons for the investigation and the opportunity to discuss their involvement with the investigators. Where it becomes clear during the investigation that another process should be used (see 4.3.3) the complainant should be advised of this as soon as reasonably practicable and provided with a report of the investigation up to that point and an indication as to the expected timeframe for the other investigation process. The report will balance the need to provide reassurance that the complaint has been dealt with thoroughly and satisfactorily with the need to protect the right of staff to confidentiality. Any outstanding unresolved element of the complaint may recommence when the other investigation has concluded Unreasonable behaviour by complainants People may act out of character in times of trouble or distress and staff should respond with patience and empathy. Behaviour should not be viewed as unacceptable just because a patient, carer or service user is forceful or determined. However, there will be times when nothing further can reasonably be done to assist them or rectify a real or perceived problem. Examples of behaviour that may be considered unacceptable include: Version No. 2 Date 09/04/15 Page 11 of 16

12 Persistent refusal to accept a decision made in relation to a complaint Persistent refusal to accept explanations relating to what can or cannot be done about the complaint Continuing to pursue the complaint without presenting any new information Aggressive or intimidating behaviour towards staff. Aggressive or abusive behaviour Violence or abuse towards staff will not be accepted. This includes aggressive or intimidating behaviour or language (verbal or written) that causes staff to feel afraid, threatened or abused. The threat or use of physical violence, verbal abuse or harassment of staff is likely to result in direct contact with the complainant being ended and may be reported to the police. If a member of staff feels that an individual is being aggressive, abusive or offensive on the telephone, they will be told their behaviour is unacceptable and that the call will be ended if it continues. Correspondence that is abusive to staff or contains allegations that lack substantive evidence will not be accepted. The complainant will be advised of this, will be asked to stop using such language and will be advised that no response will be sent to their correspondence if that action or behaviour continues. Unreasonable demands A demand is considered to be unreasonable when it starts to (or when complying with the demand would) impact substantially on the work of NHS Lanarkshire such that it takes up an excessive amount of staff time and so disadvantages other patients and complainants. This includes repeated demands for responses within an unreasonable timescale; insisting on seeing or speaking to a particular member of staff when that is not possible; or repeatedly changing the substance of the complaint or raising unrelated concerns. Unreasonable levels of contact This can occur when a complainant makes a high number of contacts or contacts of long duration. The level of contact becomes unreasonable when the amount of time spent talking to a complainant or handling the complaint impacts on the ability of staff to deal with the complaint or with complaints from other people. Unreasonable use of the complaints process Individuals have the right to complain about the services delivered by or on behalf of NHS Lanarkshire, including the right to complain more than once if they are unhappy about more than one interaction with the service. However, this will be considered to be unreasonable when the effect of repeated complaints is to harass. In all circumstances NHS Lanarkshire will take the minimum action needed to resolve the situation, taking into account the individual circumstances. This may involve: Limiting contact to telephone calls from the complainant to set times of the day Restricting contact to a nominated member of staff who will deal with future calls and correspondence Seeing the complainant by appointment only Restricting contact from the complainant to writing only Returning any documents to the complainant Version No. 2 Date 09/04/15 Page 12 of 16

13 Where continuing correspondence received is felt to be excessive, advising the complainant that only a certain number of issues will be considered in a given period and asking them to limit or focus their requests accordingly In all cases the complainant will be advised of the action being taken and why. A decision to restrict contact (except in the immediate case of aggressive or abusive behaviour which will be addressed at the point at which it occurs) will be taken by the Feedback and Complaints Manager. Wherever possible the complainant will be given the opportunity to change their behaviour or action before such a decision is taken. When a decision to restrict contact is taken the Feedback and Complaint Manager will advise the complainant in writing (and by other means if written communication is not the most appropriate form) why the decision has been reached, what the restrictions are and, if appropriate, how long they will be in place. The complainant can appeal this decision to the Chief Executive who has discretion to uphold the appeal or vary the restrictions. The Chief Executive will advise the complainant in writing of the outcome of the appeal Alternative dispute resolution The use of alternative dispute resolution, such as mediation or conciliation, will be considered to help resolve appropriate complaints when agreed by both parties. NHS Lanarkshire will make available alternative dispute resolution when requested by a primary care service provider. NHS Lanarkshire will, after consultation with any relevant area professional committee, establish and maintain a list of persons from which the alternative dispute resolution provider may nominate a professional adviser to assist them in the process. The professional adviser will be a member of the same profession as the person who performed the service which is the subject of the complaint. The process of organising and facilitating alternative dispute resolution may mean that the twenty working day timescale for responding to the complaint will not be met Report of the investigation The Feedback and Complaints Officer will review the case to ensure that all necessary investigations and actions have been taken. Where the complaint involves clinical issues, the draft report should be shared with the relevant clinicians to ensure the factual accuracy of any clinical references. Once the Feedback and Complaints Officer is satisfied that the investigation process has been completed and has fully investigated all the issues raised, a report of the investigation will be issued. The report will include: the conclusions of the investigation an explanation of any technical terms an apology where things have gone wrong Version No. 2 Date 09/04/15 Page 13 of 16

14 details of any area of disagreement and an explanation as to why no further action can be taken information as to any remedial action taken or proposed as a consequence of the complaint details as to how the complainant can contact the SPSO if they are not satisfied with the outcome of the investigation contact details for a named member of staff if clarification is required. Responsibility for signing off and issuing reports is delegated as follows; For Board decisions: Chief Executive. This may be delegated to an Executive Director For operational decisions: Health leads for North and South Lanarkshire Health and Social Care Partnerships; the Director of Acute Services; and the Feedback and Complaints Manager. For logistical reasons this may be delegated to General Managers. Where it is not possible to respond within twenty working days the complainant will be provided with an explanation as to why there is a delay and, where possible, a revised timetable. They will also be advised that the SPSO may be willing to review the case at this stage if they do not accept the reasons for the requested extension Record keeping The Patient Affairs Managers will maintain a written record of all complaints, including those that are resolved to the complainants satisfaction within three working days. These records will be kept on the Datix risk management recording system Monitoring and reporting of complaints, learning and improvement Complaints received by NHS Lanarkshire and its health care service providers will be monitored to identify areas for action and improvement. NHS Lanarkshire will gather and review information on complaints about its own service and that delivered by its health service providers on a quarterly basis. These reports will include: The number of complaints received The number of complaints where alternative dispute resolution was used Confirmation as to whether the twenty working day response period was met A summary of the key themes from complaints received A summary of what action has been taken to improve services as a result of complaints. The Feedback and Complaints Manager or a senior manager acting on their behalf will be involved in a review of these quarterly reports at least twice a year with a view to identifying areas of concern, agreeing remedial action and improving performance. The review will also consider any recommendations made by the SPSO. Version No. 2 Date 09/04/15 Page 14 of 16

15 NHS Lanarkshire will publish on an annual basis anonymous details of patient feedback, comments, concerns and complaints, including: The number of complaints received The number of complaints where alternative dispute resolution was used Confirmation as to whether the twenty working day response period was met A summary of the key themes from complaints received A summary of what action has been or is being taken to improve services as a result of feedback, comments, concerns and complaints. The annual report will be sent to Scottish Ministers, the local PASS, Healthcare Improvement Scotland, SPSO and, where appropriate, the Scottish Prison Service. Statistics gathered through the quarterly reports will be sent to the Information and Statistics Division within three months of the year end Support for and protection of staff Support and guidance on the application of this policy and procedure are available to staff from the Feedback and Complaints Manager, Feedback and Complaints Officer and Patient Affairs Managers and on the Board s intranet. Training and awareness sessions on receiving and responding to all forms of feedback are delivered to staff at induction and as part of their personal development. A national Partnership Information Network (PIN) guideline sets out the right of staff to be treated with dignity and respect. This is supported by the Charter of Patient Rights and Responsibilities. 5. ROLES AND RESPONSIBILITIES The Executive Director of Nurses, Midwives and Allied Health Professionals, as Feedback and Complaints Manager, is responsible for the development, implementation, monitoring and review of this policy and procedure. The Director is responsible for assuring compliance with the arrangements for handling and learning from feedback, comments, concerns and complaints. The Head of Patient Affairs, as Feedback and Complaints Officer, is responsible for the operational management and handling of feedback, comments, concerns and complaints. 6. RESOURCE IMPLICATIONS The staffing arrangements in place to manage feedback, comments, concerns and complaints will be monitored to ensure that they are sufficient to deliver the requirements of this policy and procedure. Version No. 2 Date 09/04/15 Page 15 of 16

16 7. COMMUNICATION PLAN Once endorsed, this policy will be publicised through the following mechanisms: Staff brief The Pulse Firstport Senior Charge Nurse forums Medical Education 8. QUALITY IMPROVEMENT Monitoring and Review The Corporate Management Team will monitor and review this policy and procedure. 9. EQUALITY AND DIVERSITY IMPACT ASSESSMENT This policy meets NHS Lanarkshire s EDIA. 10. REFERENCES X (tick box) The Patient Rights (Scotland) Act 2011 CEL 7 (2012) Patient Rights (Scotland) Act 2011 Secondary Legislation and the Charter of Patient Rights and Responsibilities, 28 March 2012 The Patient Rights (Complaints Procedure and Consequential Provisions) (Scotland) Regulations 2012 The Patient Rights (Feedback, Comments, Concerns and Complaints Directions 2012 CEL 8 (2012) Guidance on Handling and Learning from Feedback, Comments, Concerns and Complaints about NHS Health Care Services, 28 March Version No. 2 Date 09/04/15 Page 16 of 16

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