Barringtons Hospital Organisational Standard Operating Policy / Procedure

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1 Barringtons Hospital Organisational Standard Operating Policy / Procedure SOP No: BHP02 Revision No: 03 Date: 21 March 2008 Revision: 21 January 2010 Revision: 14 January 2014 SOP Title: Complaints Policy Accreditation Reference; PFR.3 Written / Reviewed by: Niamh Sheehan Signature: Approved By: Denis Cahalane Signature: Title: Human Resources and General Hospital Administrator Title: Managing Director T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc

2 1.0 Purpose 2.0 Scope To ensure that all staff are aware of the comments, enquiries, complaints & appeals policy and procedures, operational at Barringtons Hospital. To encourage discussion and debate on communication issues within the organisation s service. To ensure that patients and their relatives/family/friends are provided with appropriate mechanisms should they wish to submit comments, make enquiries, make appeals or indeed submit a complaint about any aspect of the service. All staff members of Barringtons Hospital. 3.0 Definitions and Abbreviations Complaint: An expression or statement of dissatisfaction that requires a response. Complainant: A person who is entitled to make a complaint on his/her own behalf or on behalf of another. Patient: A person who is, or has been, in receipt of care in the Hospital 4.0 Responsibility Managing Director is ultimately responsible for the implementation and governance of this policy and ensures that all complaints are dealt with efficiently and effectively to obtain a positive outcome for the complainant and the hospital. Human Resources and General Hospital Administrator is responsible to ensure adherence to this policy by all parties and affect an outcome in line with the policy terms. Barringtons Hospital Staff are responsible to ensure adherence to this policy by reporting comments, enquiries, and complaints in line with the policy terms. Accreditation and Quality Manager is responsible to ensure adherence to this policy by reviewing the reporting and follow up of all comments, enquiries, and complaints in line with the policy terms. 5.0 Procedure Comments, suggestions and complaints are welcomed and valued. They allow us to continually monitor and improve our services. A complaint may be made verbally or in writing to any member of staff, or electronically to complaints@bhl.ie. Alternatively patients are encouraged to express any comments, enquiries or complaints by the following means: T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 2

3 Fill in the relevant 'Patient Satisfaction Survey' questionnaire which are available at the patient bedside, you can place this in feedback boxes provided in the ward areas. Barringtons Hospital the details of your experience of our services to complaints@bhl.ie Ask a member of staff for details of where to send a letter or fax with details of your experience of our services. Where a Third Party complains on behalf of the patient, consent should be received from the patient if it is anticipated that there is potential for a breach of patient confidentiality or if clinical details are likely to be discussed. (In certain circumstances this will not apply as in the case of deceased persons, unconscious patients, or at the express wish of next-ofkin/relatives). The Verbal Complaints Register (Appendix 1) must be completed and sent to the Human Resources and General Hospital Administrator within 48 hours. All staff will make every effort to resolve a complaint at local level. All staff will refer unresolved local complaints to their immediate line manager within 24 hours. Confidentiality will be maintained at all times and complaints and personal details will be handled in confidence without prejudice. Human Resources and General Hospital Administrator will appoint a member of staff who will look after your complaint/query where necessary. They will make sure it is handled fairly and properly. The complaints/query person for Barrington s Hospital is Human Resources and General Hospital Administrator. A written complaint is acknowledged within 5 working days of receipt of the complaint. Appendix 2. We will investigate all complaints within 28 working days. We will issue a clear written response to every formal written complaint. We will advise the complainant of their right to an independent internal review. This Complaints procedure is without prejudice to the complainant s statutory right to make a complaint elsewhere. In addition if you are unhappy about any aspect of our service or if you have a suggestion for improvement or wish to make any comment, you may alternatively do so through any of the following means: Litigation: T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 3

4 If a complainant reveals possible negligence or if it is thought that there is a likelihood of legal action being taken, the Human Resources and General Hospital Administrator must be informed and advice taken. Letters from Solicitors should be forwarded to the Human Resources and General Hospital Administrator who will ensure they are managed through the correct procedure. 6.0 Frequency of Review 3 Yearly 7.0 Method used to review operation of Standard Operating Procedure Accurate recording of complaints. Patient Satisfaction Survey. 8.0 References NA 9.0 Appendices Appendix 1 Verbal Complaints Register. Appendix 2 Holding Letter. Appendix 3 Complaint Process. Appendix 4 Document Revision Record T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 4

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6 T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 6

7 Appendix 1 T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 7

8 Ref Name Address Address Address Date Dear xxxx, Thank you for your letter dated XXXXXXXXX. I am sorry to read that you were not completely satisfied with some aspects of our services and as the person allocated to deal with any complaints received, I would like to look into your concerns. I will contact you again within the 28 working days with the outcome of my investigation, however, should you wish to contact me in the meantime, please do not hesitate to do so directly at the number detailed below. Yours sincerely, Niamh Sheehan Human Resources and General Hospital Administrator Telephone Fax niamh.sheehan@bhl.ie Appendix 2 T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 8

9 COMPLAINTS PROCESS VERBAL COMPLAINT WRITTEN COMPLAINT Report to Department / Ward Manager Resolution YES NO Pass to HR for recording and quality review FORWARD COMPLAINT TO HUMAN RESOURCES AND GENERAL HOSPITAL ADMINISTRATOR (Within 48hours using the Verbal Complaints Register form) Complaint Registered on Complaints Database Complaints Acknowledged within 5 Working Days Complaint investigated Resolution within 28 working days YES NO FORWARD COMPLAINT TO MANAGING DIRECTOR FOR REVIEW Resolution YES NO Complainant Advised of Options Available to Complain Elsewhere Appendix 3 T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 9

10 Document Revision Record Revision No: Reviewed By: Date: Changes Yes / No Reason For Revision: 02 Eileen Hayes 21 January 2010 Yes Revised 3 Yearly 03 Niamh Sheehan & Sarah O Sullivan 14 January 2014 Yes Clarification of procedure Appendix 4 T:\Accreditation\PDF Read Only Policies\Policies PDF\Organisation\BHP02 Complaints Policy.doc 10