1.2.16 Possibility of complaint

Goal and purpose

• Introduction of a hospital-wide complaints management system
• Prompt response to complaints
• Processing of complaints
• Structured and evaluative reporting to the Management Board
• Triggering corrective measures following complaints
• Prevention of repetition
• Tracking down reasons for customer dissatisfaction and other weak points.
• Avoidance of opportunity costs of other forms of response
• Conflict resolution
• Identification of the complainant's legitimate interest. Satisfaction of the complainant, explanation of why the disproportion occurred,
• Recognising complaints about events that could lead to criminal charges or civil claims.
• Stimulation of complaint behaviour

Application

Complaints, objections and claims from patients, relatives, referring physicians and other customers or stakeholders that concern the Board of Directors and the Medical Director as Chairman with overall responsibility.

Complaints concerning problems that affect more than one centre or clinic

Written complaints or complaints in writing addressed to the administration, the Board of Directors, the Medical Director or the Ombudsman.

For complaints made in direct contact with patients/customers ("point of service" complaints), recommendations are given on how to deal with complaints in the departments and clinics.

Collective passing on of recurring complaints.

Special complaint processing, such as complaints about technical services in the laboratory, are not discussed here.

Employees are referred to the official channels for lodging complaints, with the involvement of staff representatives if desired.

Description of the process

Record complaints

Receipt in written form

Complaints in written form are signed off by the recipient and stamped with the date of receipt. After assessment by the recipient of the complaint, the letter is forwarded to QMK as the central complaints office - possibly with additional information - or processed by the recipient themselves.

Complaints for the record

Verbal complaints are recorded on the complaint form (appendix) by the person to whom the complainant turns. The complaint is forwarded to QMK via the line manager.

Complaints in the clinic, the institute

The Board of Directors does not wish to impose detailed regulations on clinics/institutes regarding the handling of complaints. However, it recommends seeking advice from QMK, the Ombudsman and/or JUSTITIAR when responding to complaints.

The clinics/departments should forward complaints to QMK if they are directed against circumstances for which the clinics/institutes are not solely responsible.

In the event of complaints that may result in criminal or civil law consequences, the clinics/departments should seek advice from V 8.

If, in the case of complaints, it is apparent that the complainant is initially interested in a clarifying discussion with an impartial dialogue partner, the complainant should be made aware of the possibility of a discussion with the ombudsman.

Increase willingness to express customer opinions

It is generally known that only in a few cases is criticism openly expressed and complaints made in hospitals. However, dissatisfaction with this or that service or behaviour is much more common than the number of complaints would suggest. This is not due to a supposed belief in authority. The inhibition of many people to express themselves to helpers and thus appear ungrateful plays a much greater role. Modern complaint management aims to increase the willingness to criticise the hospital and thus contribute to improvement. Complaints must not be suppressed.

The Board recommends that clinics and institutes use a questionnaire with general and specific questions to encourage patients and other "customers" to express dissatisfaction. A sample questionnaire is presented in VA 5.1.12.

For the questionnaires, informal expressions of opinion or anonymous letters, a "complaint box" can be placed in a prominent position. The boxes must be emptied regularly and the letters analysed.

In some clinics, complaint books have proved their worth.

Complaints of general interest should be reported to QMK, possibly anonymised.

The questionnaires are not to be statistically analysed. A comparison between the clinics is not intended. Any criticism expressed therein will be investigated.edit

Complaints in direct customer contact

Most complaints are made in direct patient or customer contact during the provision of a service (point of service). Often the person to whom a complaint is addressed is completely innocent of the event complained about, is not prepared to respond appropriately and is not responsible for corrective action. The correct behaviour in such situations is difficult and must be learned. Most complaints are made with a considerable emotional component. Those who find themselves unprepared in such a situation often get carried away with statements or actions that are inappropriate to the subject matter and do not help in further dealings.

QMK is commissioned to organise training courses on dealing with customers who make complaints in cooperation with the Human Resources Development department, the Nursing Vocational Training Centre and the Human Resources department. The clinic and institute directors are recommended to ask employees to participate.

Point of service complaints should continue to be dealt with preferably under personal responsibility or by the clinic/institute management.

However, if the content of the complaint concerns circumstances,

• for which the clinic or department is not responsible
• are always the same (e.g. food, structural defects)
• that harbour considerable potential for conflict with other departments

The content of the complaint should be reported to QMK so that the responsible department can be informed and corrective measures initiated.

Repeated complaints with the same content or complaints that indicate a particular problem situation at a clinic or institute should be reported to QMK collectively if necessary.

Centralised reporting

The Executive Board commissions the QMK,

• to collect the recorded complaints and the reports from the clinics and institutes
• to clarify the facts of the case,
• to answer according to instructions
• Propose corrective measures
• Track corrective actions
• To summarise and evaluate the complaints and reports of the clinics in a structured manner and to report to the Board of Directors annually
• Offer training on how to deal with complainants in direct customer contact
• Further develop methods for stimulating discomfort

The legal advisor will inform QMK of all cases in which claims for damages are made (also in anonymised form) so that QMK can clarify the facts (if necessary) and initiate corrective measures.

In special cases (serious adverse event, special incident, complaint with significant public impact or similar), QMK has the right to report directly to the Medical Director.

Clarification of the facts

Depending on the circumstances, QMK clarifies the facts that led to the complaint by questioning the persons or institutions of the HOSPITAL concerned and - if necessary - the complainant. QMK may request statements from the persons concerned.

During the investigation, it must be checked whether the complaint relates to actual errors in performance, the behaviour of persons or the process organisation. It should be asked at an early stage whether criminal charges or civil claims can be derived from the event complained about or whether the complainant is threatening to do so. In this case, the legal department must be involved immediately.

If the clarification of the facts of the case indicates that the event complained about is of public interest or if the complainant announces that the public will be informed, the press office should be informed immediately.

If the complaint indicates a threat to the safety of the HOSPITAL, its public perception or other dangers, the Board of Directors must be informed immediately by means of a special incident report.

Answer

The clinic, administrative department or QMK respond to each complaint with a letter confirming receipt and announcing a response. QMK can ask the departments themselves or specially authorised bodies to respond to the complaints.

Within a reasonable period of time, a letter expresses understanding for the complainant and explains the background to the undesirable event or situation. The conclusions or corrective measures are stated. If reasonable, the complainant is asked for understanding and forbearance. The reply should always express thanks for the fact that the complainant has helped to draw attention to a particular issue.

QMK draws up sample texts for responding to complaints and makes recommendations for the processing procedure.

The response letter should be made known to the departments involved in processing the complaint. A copy of the response letter is given to QMK if further measures are necessary or have been initiated.

Corrective measures

The Medical Director or the Executive Board commission QMK to analyse the causes of the complaints and propose solutions. Measures to prevent a recurrence of the event complained about can also be proposed to QMK by the department concerned or to the Executive Board via the members of the Executive Board. Depending on the scope of the measures required, QMK will pursue the corrective measures itself or act in accordance with a decision by the Management Board or other management bodies or decisions by the administration.

QMK draws up a list of the corrective measures initiated or decided upon and sets a date by which the progress of the measures introduced is reviewed.

In the annual management review, QMK reports on the corrective measures implemented and still outstanding during the reporting period.

Time required

It takes approximately 1 hour to clarify the facts of a complaint, 1 hour to respond and 1 hour to follow up on corrective measures.

At present, approximately 5 complaints are processed per month. In recent years, however, there have been accumulations that may delay processing.

Responsibility, qualification

Directors of the clinics and institutes: Processing of complaints, insofar as they relate only to events in the clinic/institute. Requesting advice from QMK or the Legal Advisor. Forwarding complaints with an impact on other departments in the HOSPITAL or of general significance to the QMK or Medical Director. Coordination of immediate response and further clarification with QMK.

All departments of the HOSPITAL: Notification of complaints to QMK.

The Executive Board commissions QMK with the function of a central complaints office.

Legal advice from JUSTITIAR-.

Tracking of corrective actions: QMK

Annual report in the management review: QM coordinator of the clinic, QMK for the board of directors

Informal dialogue: Ombudsman

Medical Director: Decision on forwarding to ZBS Edit

Documentation

Filing of complaints together with documentation of processing by serial number in an annual folder at QMK

Table for corrective actions for QMK

Report on the progress of complaints during the year with an assessment of events in the annual management review at QMK

Correspondence on complaints in the clinics, institutes, administrative areas

Notes and comments

Applicable documents

Literature, legislation

Stauss, Bernd; Seidel, Wolfgang Beschwerdemanagement - Fehler vermeiden - Leistung verbessern - Kunden binden Carl Hanser Verlag Munich, Vienna 1996

KHGG NRW § 5 (1); QM-RL G-BA:2015 § 4 sentence 4, 11; DIN ISO 10001 and 10002

Terms

Complaint
Expressions of opinion - verbally or in writing - on a suspected non-conformity of services or processes or behaviour of persons, with or without an emotional component or "articulations of dissatisfaction that are expressed to the company or third party institutions with the purpose of drawing attention to a provider's behaviour that is subjectively perceived as harmful, to achieve compensation for impairments suffered and/or to bring about a change in the criticised behaviour" (Stauss 1996).

Complaint
"Subset of complaints in which customers explicitly or implicitly link complaints about a product or service in the follow-up phase with a claim under sales law, which can be legally enforced if necessary" (Stauss 1996)

Complaint Expression of dissatisfaction expressed to an organisation (3.2.1) in relation to its product (3.7.6) or service (3.7.7) or the complaint handling process (3.4.1) itself, when a response or clarification is explicitly or implicitly expected [from ISO 10002:2014].

Customer satisfaction
(customer satisfaction) DIN EN ISO 9000:2015 and DIN EN 15224:2017
The customer's perception of the degree to which the customer's expectations have been met.
Note 1: The customer expectation may be unknown to the organisation or even to said customer until the product or service is delivered. In order to achieve high customer satisfaction, it may be necessary to fulfil a customer expectation, even if it is neither defined nor usually assumed or mandatory.
Note 2: Complaints are a common indicator of customer dissatisfaction, but their absence does not necessarily mean high customer satisfaction.
Note 3: Even if customer requirements have been agreed with the customer and fulfilled, this does not necessarily mean that customer satisfaction is ensured. [from DIN EN ISO 9000:2015]
Note 4: Patient satisfaction based on needs and expectations is an overarching goal for an organisation. The patient cannot always evaluate all aspects of healthcare process outcomes due to limitations. Some aspects of services must be evaluated by healthcare professionals. [from DIN EN 15224:2017]

Corrective action (corrective action) DIN EN ISO 9000:2015
Action to eliminate the cause of a nonconformity (3.6.9) and prevent recurrence
Note 1 to entry: There may be more than one cause of a nonconformity. Note 2 to entry: A corrective action is taken to prevent the reoccurrence of a nonconformity, while a preventive action (3.12.1) is taken to prevent the nonconformity from occurring.

Action to eliminate the cause of a detected nonconformity or other undesirable situation.
Note 1: There can be more than one cause for a nonconformity.
Note 2: Corrective action is taken to prevent recurrence whereas preventive action is taken to prevent occurrence.
Note 3: There is a distinction between correction and corrective action.edit

Attachments