Gisborne Hospital Report - Health and Disability Commissioner

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Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure 5.4 Tairawhiti Healthcare has an appeal process for complaints management where the complainant disputes the outcome. The investigation team requested documents relating to the appeal process for the period covered by the terms of reference. It was advised that the appeal process had not been used. The policy does not state that consumers can be referred to the Health and Disability Commissioner or a Health and Disability Services Consumer Advocate where they dispute the outcome of the THL inquiry complaints process. 5.5 Tairawhiti Healthcare has a separate database for tracking the management of complaints. The database was introduced late in 1999. Copies of all correspondence are forwarded to the complaints co-ordinator. There is no statement in the policy as to how long the complaint documents should be stored, or about the safety and security of their storage. 5.6 Complaints are grouped into eight categories: • access to service • adverse outcome • communication • cultural • facilities • privacy • services • system error. 5.7 Complaints entered on the database are presented to the Q&RMC as percentages in the categories described. The December 1999 report to the Q&RMC noted that “Group Co-ordinators/team leaders have been invited to identify the information they wish to have reported for their services”. 5.8 Of 127 complaints entered on the database and provided to the investigation team, 87, or 68.5 percent had outcomes entered. Sixty-two percent of those outcomes involved a letter rather than a meeting as the main contact with the complainant. THL does not appear to have a culture of meeting complainants. It was also not possible to tell from the database information given to the investigation team which manager was responsible for the stewardship of each complaint. 5.9 Complaints to Tairawhiti Healthcare are handled by the Quality Co-ordinator. She advised the investigation team: 57
Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure “Sometimes the Quality Co-ordinator responds to the complaint and sometimes a senior manager or other person who is dealing with the complaint responds to the complaint. Medical staff seldom respond, but sometimes write reports on complaints that involve them.” 5.10 Consumers have the option of taking their complaints to the hospital, the Health Consumer Trust Advocate or the Health and Disability Services Consumer Advocate. The Chair of the CQG, in his capacity as Maori Health Manager, advised the investigation team that if people discuss their concerns with him and then wish to make a complaint, he assists them with their complaint by filling out an incident form and passing it to the Quality Coordinator. If they are not satisfied with the outcome of the complaint he advises them to come back to him, and he will then follow up where possible. If thereafter further follow-up is required, he will assist complainants by referring the matter on to the independent Health and Disability Services Consumer Advocate. 5.11 People working within THL appeared to have very different impressions of how the complaints system operated depending on their place in the organisation. The former Group Manager (Hospital) (Ms Rachel Haggerty) described there being “quite structured processes around reviewing complaints, including reviewing clinical records, identifying process changes that need to be made and following up on those. They had a reasonably good level of closure with consumers. I would meet personally with the patients and their whanau. Very few people would just get a letter .…” However, this view was not shared by others. Complaints review procedures 5.12 The 1998 Stage One Internal Clinical Audit noted in the section on complaints/systematic learning that, while there was learning from individual complaints, it was unclear whether there was “systematic learning from a regular analysis of the overall frequency and nature of the complaints”. The Group Manager (Hospital) noted in response: “there is regular analysis with review of complaint[s]. Trends are looked at but there is at present no link to QA mechanisms.” 5.13 The Stage Two Internal Clinical Audit conducted in August 1999 noted that a PC-based computerised database “has been operating for 2 weeks. Data will be analysed and action taken via Clinical Board and/or Executive Management.” There was no evidence of any discussion of complaints in the Clinical Board or Senior Management Group minutes provided to the Commissioner’s investigation team. 5.14 A monthly report on complaints is made to the CQG, with a quarterly summary to the Audit Committee. This report includes a summary of complaints reported and reviews of those complaints. There was no evidence from the CQG minutes supplied to the investigation team of any discussion on the monthly complaints report. There is no evidence that the Board of Directors receives a regular summary of the complaints being handled by Tairawhiti Healthcare. 58
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GISBORNE HOSPITAL 1999 - 2000 A rep
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Table of Contents Page Executive Su
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1. BACKGROUND EXECUTIVE SUMMARY 1.1
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3. THE ENVIRONMENT 3.1 My investiga
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pathologist, staff shortages and pr
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Gisborne Hospital 1999 - 2000 Intro
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Gisborne Hospital 1999 - 2000 Intro
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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