Local complaints management for Victoria s public mental health services. October 2009 discussion paper

Transcription

1 Local complaints management for Victoria s public mental health services October 2009 discussion paper

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3 Local complaints management for Victoria s public mental health services October 2009 Discussion paper

4 Accessibility If you would like to receive this publication in another format, please phone using the National Relay Service if required, or This document is available in PDF format on the internet at: < Victorian Government Department of Health, Melbourne Victoria. Copyright State of Victoria, 2009 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. Also published at < October 2009 (090904)

5 Contents 1. Introduction 1 2. Providing feedback 2 Part A 3 1. A new way to manage complaints: using a quality improvement approach 3 2. Indicators of good complaints management 4 Part B: Implementing better practice 6 Goal 1: There is a firm commitment to consumers (and their carers) and service improvement Leadership and governance Complaints policy Staff training and awareness Importance of good communication Information about what consumers can expect from the mental health service The role of a complaints manager 8 Goal 2: Enhance access to complaints information and processes Policy promotion A variety of ways to give feedback Special needs and CALD communities 9 Goal 3: Promoting a responsive approach Shared responsibility Formal complaints Minimising conflict Timeframes Tracking 12 Goal 4: Ensuring effective assessment Understanding the problem Resolution options Assessing risk Performance of individuals External referrals 14

6 Contents - continued Goal 5: Ensuring appropriate resolution The issue of fairness and natural justice Negotiating and problem solving Investigating complaints Notifying complainants and others Providing outcomes that are just and fair 16 Goal 6: Ensuring privacy and open disclosure Confidentiality Open disclosure Privacy Access to case notes 19 Goal 7: Effective gathering and use of information Recording informal concerns Formal complaints records Reporting 20 Goal 8: Improvement in services Opportunities for improving services The need for routine monitoring and review Evaluation Clinician, staff, consumer and carer involvement 25 References 26

7 Mental Health Complaints Review Project 1 1. Introduction The right to mechanisms of complaint and redress is a fundamental aspect of most mental health service systems and is enshrined internationally in the Principles for the protection of persons with mental illness and the improvement of mental health care adopted by the United Nations in 1991, and nationally, in the Mental health statement of rights and responsibilities (1991) and the National Standards for mental health services (1996). Mental health consumers, their families and carers and advocates can reasonably expect to have access to complaints mechanisms that are accessible, responsive and fair and will be informed about these mechanisms by their mental health service. Under the Mental Health Act 1986 a mental health consumer may complain about standards of treatment and care and be provided with access to complaint mechanisms. The Charter of Human Rights and Responsibilities Act 2006, which came into effect on 1 January 2008, aims to strengthen the human rights of mental health consumers and reinforce legal mechanisms and policies that protect or enhance consumer rights, including access to complaint mechanisms. In 2009 the Mental Health Ministerial Advisory Committee commissioned a complaints management project to review the complaints management processes at selected mental health services. In response to the committee s recommendations the Minister for Mental Health approved the development of a complaints management framework for resolving complaints locally. This discussion paper begins the process of consultation with consumers and carers and the mental health sector. Work relating to complaints management has also been undertaken by the Australian Council for Safety and Quality in Health Care. In July 2005 the council released the Complaints management handbook for healthcare services. The council engaged the NSW Health Care Complaints Commission to undertake the project on behalf of the Australasian Council of Health Care Complaints Commissioners, working with the Royal Australasian College of Physicians and the Health Issues Centre. The project reviewed research on good complaints management, surveyed 53 health care organisations, conducted consultations and drew upon existing policies, standards and laws to develop the Better practice guidelines on complaints management for health care services. The Complaints management handbook was developed (as part of the project) to assist organisations in implementing the guidelines. This discussion paper uses the elements and descriptors contained in the handbook as well as the findings of the Ministerial Advisory Committee Complaints management review report to invite feedback on the opportunities to enhance local complaint resolution in Victoria s mental health services. Complaints management in the health sector is informed by a number of agencies that promote safety and quality in health care. Guiding principles for complaints management are articulated in various publications including Better practice guidelines on complaints management for health care services published by the Australian Council for Safety and Quality in Health Care in Principles include accessibility, responsiveness, fairness and respect for privacy. An effective complaints process will go beyond the resolution of individual complaints and collectively provide the service with an insight into consumer satisfaction that can inform service quality improvement efforts. An effective complaints management process at local service level requires not only appropriate policies and procedures but a culture of openness, quality and effective engagement and support for consumers and carers.

8 2 Mental Health Complaints Review Project 2. Providing feedback This discussion paper provides details on issues and actions to each area of focus and raises questions for further consideration. These questions serve as a guide and should not limit the scope of the feedback. This discussion paper is also available electronically on the department s website at < Please forward your written submission to <amy.szczygielski@dhs.vic.gov.au> or post to: Sector Quality and Workforce Development Unit Mental Health and Drugs Division Department of Health GPO Box 4057 Melbourne 3001 The closing date for written submissions is 31 January A series of face-to-face forums will also provide an opportunity to discuss the focus areas. Further information is available at < Please <amy.szczygielski@dhs.vic.gov.au> or telephone (03) to be added to our mailing list and to receive updates and notification of the consultation events.

9 Mental Health Complaints Review Project 3 Part A 1. A new way to manage complaints: using a quality improvement approach There is a sound research and policy basis for taking a quality improvement approach to consumer and carer complaints. A quality improvement approach involves considering feedback within a broader risk management and quality improvement framework, rather than dealing with complaints as separate and isolated cases. Comments and complaints provide services with important information about the needs of consumers and the quality of care they receive. Actively encouraging feedback from consumers and carers about the service can make a significant contribution to the safety and quality of the service, promote a culture of reporting and accountability, and enhance trust and confidence in the service. Important components of a quality improvement approach include: a culture of listening and learning (actively encouraging feedback and open discussion of consumers concerns) fairness (decisions and processes are seen to be fair and based on transparent practice) a willingness to learn from complaints and reporting and review processes that enable improvements to the systems of care to be implemented promoting a safety culture that allows individuals and the service to learn from its mistakes an open attitude where complaints are viewed as opportunities for improvement rather than attacks on individuals and where consumers are encouraged to provide comment on whether or how well their needs are being met consumer participation (consumers need to be encouraged to be active participants in their care and at each stage of a complaint process).

10 4 Mental Health Complaints Review Project 2. Indicators of good complaints management The Australian Council for Safety and Quality in Health Care has highlighted the following as indicators of a good complaints management system and we would like to see these indicators applied in mental health services: principals and executive managers demonstrate support for consumer and carer feedback about the quality of the service, including complaints (see Figure 1) all clinicians and staff are trained in complaints resolution and understand their responsibilities for dealing with complaints consumers, carers and their families are aware of the complaints policy and feel comfortable using it the service promotes awareness for how consumers and carers can provide feedback including access to the Health Services Commissioner and the Chief Psychiatrist prompt and appropriate resolution of complaints takes place, using a joint problem-solving approach complaints are recorded to support effective management of individual complaints and analysis of trends in all types of complaints all complaints are assessed for risk and appropriate steps are taken complaints are investigated to determine the events that occurred, the causes and to identify preventive strategies complaints resolution procedures reflect the principles of fairness and natural justice clinicians and staff routinely discuss complaints and other incidents complaints are reported to the community as part of quality improvement reporting the performance of the complaints management system is monitored and regularly evaluated with advice from consumers, carers and families, clinicians and staff complainants, clinicians and staff are satisfied with the complaints process and outcomes changes are made to improve the service in response to issues raised in complaints.

11 Mental Health Complaints Review Project 5 Figure 1: The consumer, carer and family feedback loop Complaint/incident Acknowledge Clarify Investigate Change Monitor Consumer s and carer s experience of the metal health system Consumer and carer feedback Acknowledge receipt of feedback Clarify issues Provide advice of outcome of the investigation Advise of changes in administrative practice Monitor through quality committees Analysis of performance Change in practice Improved mental health care service for all Questions Q1 Q2 What are the key areas of focus required to help develop and sustain a culture of openness to complaints? How different are these indicators to your current practice/experience?

12 6 Mental Health Complaints Review Project Part B: Implementing better practice Goal 1: There is a firm commitment to consumers (and their carers) and service improvement What we want to see 1.1 Leadership and governance Leaders have an important role in enhancing the quality and consumer experience of mental health services. There will be a governance framework for managing complaints with clear lines of accountability. Every organisation has its own unique culture, characterised by its beliefs and values about why and how it behaves, reacts and responds. The visibility of the leadership team in promoting service improvement and responding to consumer-focused care is critical. Good complaints management will be regarded as a genuine priority consistent with organisational values and a good investment of their time. Leadership within a group of clinicians will be evident. All staff with a management or supervisory role will have complaints management as part of their job description. All staff, clinicians and managers will be responsible for understanding the tasks required and ensuring adherence to policies and procedures. 1.2 Complaints policy There is a formal complaints policy that promotes consistency and transparency in practice. The features of the complaints policy will clearly articulate how: the service encourages feedback and complaints risk assessment and follow-up occurs complaints are investigated complaints are recorded and reported serious complaints are dealt with complaints can lead to improvement in the quality of service. The policy will be specifically relevant for mental health services and developed through a participatory model using an experience-based paradigm where staff, clinicians, consumers and their carers are engaged in developing or revising the policy.

13 Mental Health Complaints Review Project Staff training and awareness Priority is given to complaints management and training about the complaints management process and will be included as part of the induction/orientation program and in subsequent training on organisational procedures. In accordance with best practice principles, complaints will primarily be resolved at the point of contact with the service. Accordingly clinicians and staff dealing with informal complaints will be trained and supported in customer service, communication and dispute management techniques. Opportunities for discussing complaints among staff and clinicians are identified to promote improved awareness and understanding of the complaints process. 1.4 Importance of good communication A major trigger for complaints is poor communication. Effective communication with consumers and their carers is fundamental to good mental health care. The presence of a written policy on informed consent and communication with consumers will be evident to support good practice. The policy will have the following features: effective approaches to communication highlight the subjective nature of comprehension, particularly in stressful circumstances techniques to check the level of understanding of information use of written information sheets recording the details of what has been communicated. 1.5 Information about what consumers can expect from the mental health service Good communication includes a clear understanding about processes and behaviours that consumers, carers and families can expect of the mental health service. It serves as reminder to staff of the values and behaviours (culture) of the organisation and provides information to consumers about how they can expect to be treated. This information will be publicly visible.

14 8 Mental Health Complaints Review Project 1.6 The role of a complaints manager Every good complaints management program requires a senior clinician or staff member to have the specific responsibility for making sure it works properly. There will be a description of the sufficient authority and skill set required of the role including the responsibility for: attempting to achieve a satisfactory resolution of complaints assisting complainants to describe their concerns and to understand complaints procedures and responses that the service may provide assisting clinicians and staff to gather information about individual complaints, and any strategies for improvement in service as a result ensuring clinicians and staff understand the complaints policy and know how complaints are handled ensuring risks are assessed and immediately notifying senior management of any high-risk complaints ensuring the lessons learned from complaints are used to improve the service. Questions Q3 Q4 Q5 Q6 Are there areas that require further elaboration? If so, please specify. Does this section adequately cover the commitment required to consumers and carers? If not, please explain. In making this commitment, what might be the implementation issues for your service? What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

15 Mental Health Complaints Review Project 9 Goal 2: Enhance access to complaints information and processes What we want to see 2.1 Policy promotion People are reluctant to complain about health care services; accordingly, mental health services will reflect a culture that values and welcomes complaints and feedback. Mental health services will adopt the best strategy for promoting the sharing of experiences, which is by direct discussion between clinicians, consumers, carers and families. Mental health services will provide encouragement, training and support to clinicians to facilitate this. Consumers of mental health services will be actively encouraged to provide feedback through brochures or posters that state the intention of the complaints policy. The messages will be clear and easy to understand by consumers and their carers 2.2 A variety of ways to give feedback Mental health services will provide a range of options and methods to obtain feedback and complaints including: direct discussion between staff, clinicians and consumers; a suggestion box; and consumer experience-of-care surveys. The service will also ensure that consumers, carers and families and others are given the option to give feedback or complain anonymously. 2.3 Special needs and CALD communities Mental health services will support and provide resources to those who may have difficulties in giving feedback for reasons such as language difficulties and cultural barriers. For example, interpreters will be provided for people with limited fluency in English and young people may require a support person. Questions Q7 Q8 Q9 Do these areas adequately cover the requirements that will have to be considered by mental health services to enhance access to information and complaints processes? If not, please explain. What might be some the challenges and solutions? What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

16 10 Mental Health Complaints Review Project Goal 3: Promoting a responsive approach What we want to see 3.1 Shared responsibility Managing complaints needs to be a whole-of-service responsibility and will be part of the servicewide consumer and carer communication and quality strategies. The development of a structured complaint management system will include steps to listen, resolve, record and analyse the complaint to improve the transparency and quality of the mental health service. There will be a tiered complaint handling process that clearly delineates roles across levels for clinicians, administrative staff, managers and executive management. Consumers or carers with a complaint about their mental health care provider can expect to be properly acknowledged, treated with respect and dignity, and taken seriously. There will be a positive attitude from all clinicians and staff when responding to complaints. There will also be a process for managing the various levels of complaints: informal, formal and serious and unresolved. Informal complaints refer to straightforward matters that are able to be resolved by clinicians and staff at the point of service. Formal complaints may include more complex issues that may need a further response involving input from a supervisor of complaints manager. Serious and unresolved complaints involve matters that require external bodies, such as regulatory bodies, to assist in the complaint resolution process alongside principals or senior management. Staff will be prepared, where possible, to resolve complaints immediately at the point of service on the ward, in the community care setting, during an outreach visit or at a residential care unit. Responding to a complaint immediately can help reduce frustrations that may develop and worsen a situation when delays are experienced. To build confidence and expertise clinicians and staff will have access to complaints handling training and support so they are aware of the local complaints handling framework and designated colleagues or supervisors to assist with more complex complaints. A mental health service s complaints management policy will outline the procedures to clearly define how clinicians and staff will respond to consumers and carers appropriately for each level of complaint and provide information about when to refer complaints that are not resolved at the point of service to designated complaints handling staff or external bodies. All complaints and outcomes, whether informal or more complex, will be recorded as part of the individual health record and additionally as part of a service complaints record to enable evaluation. Formal discussions with designated complaints handling staff and related committee members will periodically review trends in compiled complaints.

17 Mental Health Complaints Review Project Formal complaints If a complaint is not resolved at the point of service, and the complainant wishes to pursue the matter, a follow-up letter acknowledging the issues will be sent. Where the complaint has been written, either via post or , there will be a written acknowledgement. In addition to outlining the complaint issues, information about the complaints procedure that will be followed, how long the process is likely to take, contact details of the staff who can be contacted with questions and enquiries, and privacy and information sharing practices will be included in the follow-up letter. Written communication will be clear, using everyday language, and allow additional time for a response. As trust between consumers or carers and mental health services can be established more effectively when telephone or face-to-face contact is offered; this will be the practice in conjunction to written correspondence. Staff will aim to maintain contact with the consumer and/or carer to ensure the complaint is resolved in a meaningful way, sensitive to the personal circumstances and context of the situation. 3.3 Minimising conflict To move towards resolving the problem with minimal conflict, clinicians and staff will consider the following points: provide their name, be open and respectful be attentive and courteous and listen to the complaint without interrupting be empathetic and recognise the consumer or carer s distress use clear language and avoid inflammatory language provide and accept feedback. When the complaint has been described, the information provided will be reiterated to confirm the basis of the complaint. Clarification or questions to identify the desired outcome will then be pursued. 3.4 Timeframes Delays in resolving the complaint or the failure to keep the complainant informed of the progress of their case are the most common causes of dissatisfaction. Therefore, target timeframes are an essential component of complaints management policy. Timeframes will vary according to the size and nature of your service. Each complaint will be considered according to its individual merit; timeframes may need adjusting depending on the level of complexity.

18 12 Mental Health Complaints Review Project Target timeframes will outline: the length of time before complaints are acknowledged once received (within two days is good practice) how much time will elapse before complaints are assessed as serious and referred to external agencies (no more than three days) the timeframe within which complaints are likely to be discussed, investigated and resolved how often information and progress updates will be provided to the complainant. In smaller services (in most cases) resolution will be possible within days. For large mental health services, where investigation may involve more people, a longer timeframe will be necessary. The current practice in large mental health services is 30 days. 3.5 Tracking Implementing a paper or computer-based system to help with handling complaints will provide assist in tracking progress and the status of complaints in accordance with the complaints management policy. A tracking sheet will include a summary of the issues and what contact and correspondence has occurred to address and attempt to resolve the complaint. The tracking system also provides valuable information to assist with care continuity to support various staff across internal or external settings while maintaining more informative contact with the consumer or carer involved. Questions Q10 Are there other dimensions in providing a responsive approach that should be included? Please explain. Q11 Would sample charts, policies, letters or tracking sheets be useful for mental health services to improve the complaints management system? Please specify. Q12 How might your service address some of the training needs required to promote a responsive approach? Q13 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

19 Mental Health Complaints Review Project 13 Goal 4: Ensuring effective assessment What we want to see 4.1 Understanding the problem Assessing all complaints will ensure the most appropriate course of action is determined and make sure serious complaints receive immediate attention. Initial assessment needs to occur within the point of service setting, where clinicians and staff determine whether they can deal with the issues locally. A risk assessment is conducted by the designated staff member for all complaints at this level. In order to assess risks the important first step is to gain a thorough understanding of the problem. Consumers or carers may not articulate a clear or specific issue in their initial written or verbal complaint. Often additional time and attention may be required to determine the underlying issues that require action. Consultation with the complainant will clarify what they want and reassure them that their concerns warrant attention in order to improve the standard of clinical care. 4.2 Resolution options Once the background events and matters are investigated a simple process of negotiation will resolve most complaints. Although, at times, it may be more appropriate to refer a complaint to the Health Services Commissioner or an independent mediator. As some consumers or carers may require assistance or support during the resolution process it is important to ask them who they would like to involve before proceeding further. The complaints manager will be familiar with these options, what they involve and the expected duration to resolve complaints using external bodies. The reasons a complaint might be referred for external resolution include: matters involving a large number of people or those of a complex or technical nature that goes beyond the level of expertise available internally serious issues that would be more appropriately handled by an impartial external body situations where the matter may be compromised as the complaint involves the complaints manager. 4.3 Assessing risk An important element of assessment is identifying and minimising potential risks. The aim of risk assessment is not necessarily to reduce or eliminate risk but to understand and consciously manage it. Immediate assessment of all formal complaints is necessary to determine the level and nature of risk involved and the appropriate course of action required. As risks may raise significant safety, legal or regulatory issues senior management will be notified immediately of all high-risk complaints.

20 14 Mental Health Complaints Review Project The consequences or probable likelihood of the incident recurring or the problem continuing will consider factors such as the: level of injury to the complainant failure of administrative systems, for example, loss of test results level of injury to staff (for occupational health and safety incidents) level of financial losses, perhaps due to litigation or adverse publicity level of harm to the consumer and/or carer relationship. The severity or seriousness of a complaint will be rated using a scale range from minor to serious or rare to frequent. 4.4 Performance of individuals Risk assessment not only screens risks to the service but will also assess the behaviour and actions of individual clinicians or staff to identify unsatisfactory professional conduct. Where an individual s performance has been unprofessional the complaint manager will consult the Health Services Commissioner or professional registration boards. 4.5 External referrals The complaints policy will clearly delineate when mental health services are obliged to notify regulatory bodies, such as coroners. It will also outline circumstances when consultation will be initiated with professional registration boards and the Health Services Commissioner regarding an individual s professional conduct. The CEO or principal will consult with relevant professional boards or commissioners where behaviour raises a significant risk or concern to the consumer or carer involved. All staff will be made aware of the complaints policy and which member of staff is responsible for notifying external bodies or third parties. Questions Q14 Are there other dimensions in ensuring an effective assessment that should be included? Please specify. Q15 What supports are required for staff to effectively assess the complaint? Q16 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

21 Mental Health Complaints Review Project 15 Goal 5: Ensuring appropriate resolution What we want to see 5.1 The issue of fairness and natural justice The principles of fairness and natural justice are obvious when investigations into complaints are conducted in a fair and even-handed way. Decisions will be based on relevant material, and the decision will be free of prejudice or bias. The process for investigating and resolving complaints will be clear to ensure complainants, clinicians and staff who are directly affected can follow what is happening. Uncertainty and delays will be avoided by setting timeframes for completing the key stages of each process. Natural justice requires the complainant and any clinicians and staff directly affected by a complaint to be informed of the nature of the claims that have been made and they will be given the opportunity to provide information relating to the complaint. Policy and procedures will be followed so the process is well known and predictable. Decisions made will be based on relevant information and will include the views of the complainant, clinicians and staff directly involved. All those affected will be informed of the decisions and the reasons. 5.2 Negotiating and problem solving Negotiation will be an important process and undertaken after an investigation into the complaint. In most instances, there will be a continuing relationship between the complainant and the mental health services; accordingly, a joint problem-solving approach is preferable. 5.3 Investigating complaints Complaint investigation will include the following process: 1. collecting relevant facts and interviewing those affected by the complaint 2. collecting relevant records, accessing policy and procedure documents and examining the environment or equipment as relevant 3. analysing the information collected 4. making findings about the events and the underlying causes of the complaint 5. considering strategies and making recommendations for improvements. In serious matters, timeframes will be developed to capitalise on fresh memory and before material relevant to the case is lost or destroyed.

22 16 Mental Health Complaints Review Project The person conducting the investigation, who is usually a service manager, will be impartial. Confidentiality and ensuring that no judgement is made against individuals is an important part of the assessment process. Assistance to support complainants will be considered in order for them to present their views and contribute to an investigation. 5.4 Notifying complainants and others Soon after an investigation, the results will be provided to the complainant and any clinicians and staff directly involved. In adhering to the Open disclosure standard 1, the services will provide consumers with: an expression of regret for the harm suffered clinical and other relevant facts details of the concerns raised by the consumer a summary of the factors contributing to the adverse event information on what has been done and will be done to avoid repetition of the adverse event how this will be monitored. The information may be provided in a letter or a face-to-face meeting, or both. Care needs to be taken to ensure it is presented in a sensitive and clear manner. If sensitive information is discussed during or after an investigation, the people who discuss the information with the complainant will be: already known to the complainant familiar with the facts senior and credible able to communicate well and offer reassurance and feedback. 5.5 Providing outcomes that are just and fair The Australian Council for Safety and Quality in Health Care has stipulated that the action a health service is prepared to take to resolve a complaint will be just that is, it will be appropriate and respond to the needs of participants as far as possible. A policy of aiming to achieve the best outcome for everyone is fair 2. Services will confirm the complainant is satisfied with the outcome of the complaint by telephone or letter. However, should a complaint be not resolved everyone will have a clear understanding about what the next steps might be. 1 Australian Council for Safety and Quality, Open disclosure standards: a national standard for open communication in public and private hospitals, following an adverse event in health care, July Australian Council for Safety and Quality, Complaints Management Handbook for Healthcare Services, July 2005, p 28

23 Mental Health Complaints Review Project 17 A letter will be sent to the complainant confirming the service understands that the matter remains unresolved and information will be provided informing them of access to the options that are available to them. Questions Q17 Are there other dimensions in ensuring appropriate resolution that should be included? Please specify. Q18 What supports are required for staff to effectively resolve the complaint? Q19 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

24 18 Mental Health Complaints Review Project Goal 6: Ensuring privacy and open disclosure What we want to see 6.1 Confidentiality Confidentiality and fairness are important principles for any complaints management system. These principles can create a tension between keeping some information confidential while being open with consumers, carers and families. The service s complaints policy and procedures will provide clear guidance on these issues. It is important that information gathered during the course of an investigation will generally be kept confidential. This will help people feel safe about coming forward with a complaint, as their name will not be disclosed (unless they want this to happen). Keeping information confidential also prevents incomplete or inaccurate information from being released until all the facts are established and this will help protect individual reputations from being harmed by unsubstantiated allegations. A request for additional confidentiality will be respected and acted on where possible. However, at the end of an investigation process, the principles of natural justice and fairness require that people who are directly affected be provided with information about the conclusions that have been reached and the reasons for those decisions. Victoria s privacy and confidentiality laws impose obligations of confidentiality on people employed in the public health sector and, in some circumstances, the law may compel organisations or individuals to disclose information. 6.2 Open disclosure The Open disclosure standard provides for consumers and their nominated family member to be given information, including the following, when they have suffered harm as a result of an adverse event: an acknowledgement that an adverse event has occurred the known facts about what has happened information about further treatment required an explanation of how the adverse event will change anticipated care and short-term effects advice that an investigation will occur and how feedback from the investigation will be provided. The standard advises that while disclosure is required where harm has occurred, it may also be appropriate to disclose where an incident has occurred, but no harm is immediately apparent. This is a matter of judgement by the mental health treating team. Once the investigation has been completed, consumers and nominated support person/s will be given information on the established facts about the incident, a summary of the contributing factors or causes of the incident and recommended measures to prevent similar incidents occurring again.

25 Mental Health Complaints Review Project Privacy Privacy obligations apply to personal information, including personal information collected and used for the purpose of resolving a complaint. Personal information is information that identifies or could identify an individual, and is not limited to their name, address and Medicare number. It could be a combination of information, for example, about a person s condition, dates of treatment, place of treatment, age, gender and postcode. The key elements of privacy relevant to managing complaints records are: keeping complete, accurate and up-to-date records of complaints collecting only the information that is relevant to the complaint keeping records secure and confidential informing the complainant at the outset about how their personal information is likely to be shared with others, such as insurers and other clinicians. Care is taken to exclude any information that identifies individuals in reports about complaints, whether for internal or public use. 6.4 Access to case notes Providing people with access to their medical records and an explanation of what they mean is often important in addressing misunderstandings that have led to a complaint. Your service s privacy policy will set out how to deal with requests by consumers for access to their records, and requests from family members. The complaints manager needs to be familiar with the privacy policy and have access to medical records to help facilitate a resolution. Questions Q20 Does this section adequately cover the areas of privacy and open disclosure? If not, please explain. Q21 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

26 20 Mental Health Complaints Review Project Goal 7: Effective gathering and use of information What we want to see 7.1 Recording informal concerns Informal complaints and concerns that have been resolved at the point of service will be captured because they are enormously valuable for quality improvement purposes. By analysing the types of issues raised in these complaints and the outcomes agreed, the service will recognise recurring problems and devise strategies to prevent them recurring. A quick and easy method will be used to promote and encourage staff and clinicians to record informal complaints and concerns. 7.2 Formal complaints records Records of formal complaints need to be complete, but do not need to be elaborate a simple paper file is sufficient for smaller mental health services. The Australian Council for Safety and Quality in Health Care proposed that the record will need to: identify the person responsible for managing the complaint track the progress of the investigation and resolution of the complaint record the views of the complainant about the events that have occurred and the outcome they are seeking keep a log of conversations, correspondence and other documents outline how and when risk was assessed and follow-up action taken, including any notifications to managers, to insurers and to others record decisions about the facts and the cause(s) of the complaint record the outcomes for the complainant record any recommendations for change and how they will be implemented. Complaints managers who administer the complaints records will distinguish established facts from speculation or claims. 7.3 Reporting The extent of reporting information will be variable based on the size of the organisation. In large organisations statistical reports on the number and types of complaints are likely to be provided on a monthly or three-monthly basis, whereas in smaller services with small numbers of complaints, statistical information may only be useful on an annual basis. Coding will be used to identify issues and strategies are developed to address them. Consistent with the experience-of-care approach to service feedback, narrative reporting of complaints or case studies will be used to assist clinicians, staff and managers to better understand the consumer s experience of the mental health service and the failings resulting in a complaint.

27 Mental Health Complaints Review Project 21 Reporting to staff and management Services will have structured time for clinicians and staff to discuss consumer complaints and other incidents. This commitment of time is important for encouraging and supporting a quality improvement culture in a mental health service. Statistics on trends and narrative reporting of individual complaints will provide a useful contribution to discussion about the issues and help to reinforce the role of staff and clinicians in resolving complaints and service improvement. Services will maintain complaints and incidents as standing agenda items at staff and clinical review meetings and present case studies in staff newsletters or on notice boards. Mental health services will have a process for immediately referring serious matters to senior management as well as providing regular reports on complaints to senior clinicians and management. These reports will address governance and organisational performance issues as indicated by the council and include: the number and type of complaints (formal and informal) in a specified period (in larger organisations provide this for each service unit or department) trends in the number and types of complaints over time and factors influencing the trends significant individual complaints that highlight systemic problems information about the risk ratings of complaints the time taken to resolve formal complaints compared with timelines in the complaints policy the types of outcomes achieved for complainants recommended improvements whether previous recommendations have been implemented monitoring the impacts of changes that have been implemented. Reporting to the public Publicity on the outcomes of complaints in service improvement activities will encourage consumers to speak. Complaints information will be incorporated into annual reports or in standalone quality improvement reports. Smaller services will look to other simpler processes for reporting such as in general publicity information. Reports to the public will offer useful information such as: the number and type of complaints in the current year compared with previous years the common types of outcomes from complaints initiatives taken to address consumer complaints or feedback the impact of improvements made as a result of the complaints process the performance of the complaints process when compared with the complaints policy.

28 22 Mental Health Complaints Review Project Mental health services will also include a summary of the results of consumer satisfaction or consumer experiences surveys. Questions Q22 Are there further inclusions required in this section? If so, please specify. Q23 Can you identify an effective way to collect information on informal complaints? Please explain. Q24 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?

29 Mental Health Complaints Review Project 23 Goal 8: Improvement in services What we want to see 8.1 Opportunities for improving services The governance committee and executive management will regularly receive reports on complaints so they can analyse trends and identify where and how complaints are addressed within the organisation. The focus will be directed at organisational systems, such as work flow and systems of care that create those trends, and not on individuals. Complaints and consumer feedback information will be used when making strategic and operational decisions about planning, professional development and quality improvement. Valuing consumer feedback and complaints will appear in strategic and business plans, annual reports and mission statements. Complaints and other incidents rated as high risk will always be notified promptly to designated senior clinicians or executive managers. Responsibility to respond appropriately to these notifications will be included in job descriptions and assessed regularly in performance appraisals. The responsibilities are to instigate investigation, reporting, analysis, review and implementation of follow-up action. 8.2 The need for routine monitoring and review Routine monitoring and review of each mental health service complaints system is necessary to check that the system works in the way the complaints policy intended. We would like to see performance reports compiled regularly against preset performance criteria. The Australian Council for Safety and Quality in Health Care has mandated the following criteria: how long it takes to resolve formal complaints compared with the timeline in the complaints policy levels of clinician, staff and consumer awareness of the complaints process, measured through the results of spot quizzes how high-risk complaints were managed by senior clinicians or managers recommendations from board meetings or principal partners meetings arising from complaints reports recommendations that have been implemented and the impacts monitored trends in the number and types of complaints, formal and informal, and factors that may have influenced trends, such as specific quality improvement initiatives levels of complainant, clinician and staff satisfaction with the processes and outcomes of complaints. Mental health services will also consider that the relevant measure of success may be an increase in the number of complaints, not a decrease.

30 24 Mental Health Complaints Review Project The performance of the complaints management system will also be checked against external criteria such as that stipulated by the Better practice guidelines on complaints management for health care services and standards used by accreditation schemes. 8.3 Evaluation Mental heath services will conduct a detailed evaluation of the complaints system every few years to identify areas of strengths and weakness and make improvements as required. This evaluation process will include: asking people who have used the complaints system what they thought of the process and the outcomes asking all consumers, carers and families what they know about the complaints process and what they expect using statistical information to check timelines, the number and types of complaints that have been made and how this has changed over time, and the outcomes of individual complaints using complaints records and reports to determine the changes that have been implemented and how they have been monitored comparing your complaints system against external standards and, where possible, with services of similar size and nature. The evaluation questions will include the following dimensions of quality. Safe How safe do consumers and carers feel about making a complaint? Appropriate How appropriately are the complaints resolved/managed? Responsive How responsive is the mental health service in considering the experience of consumers and their carers? Efficient How efficient is the mental health in resolving the complaint/meeting the timeframes? Accessible How accessible is the complaints management process? Are consumers and their carers aware of the process? Capable Do staff and clinicians have the skills to play their part in the complaints management process? Mental health services will also have processes to revise the complaints policy and procedure if there is significant changes in the organisational structure.

31 Mental Health Complaints Review Project Clinician, staff, consumer and carer involvement Mental health services will ask clinicians and staff about the adequacy of training and support and whether they are comfortable with dealing with complaints. Mental health services will use a variety of ways to engage consumers and their carers to provide feedback on the complaints process through a special purpose discussion group or focus group and use the experience-based paradigm that includes staff, consumers and carers coming together to re-design and improve services. The views of existing staff advisory committees and consumer or community advisory committees will form part of the evaluation. Questions Q25 Does this section adequately cover the considerations required for evaluation of the complaints management process? If not, please explain. Q26 What are some of the opportunities for developing an open and positive culture for effective engagement with consumers and carers to achieve this goal?