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Quality Assurance: learning from serious events & complaints

Quality Assurance: learning from serious events & complaints

What is Quality Assurance

Quality Assurance is about making sure that everyone has confidence in the services provided at Waitemata DHB, we have the appropriate processes in place and that these processes and the care we provide meet national and international standards.

"Simply put, Quality Assurance is nothing more (and nothing less) than a management system, in compliance with a standard, that gives the customer confidence that what they want they will get (and perhaps a little more)”. - L Michailidis (1995)

Quality Assurance includes:

  • managing and learning from complaints and serious events
  • managing feedback processes
  • making sure we comply with Health & Disability Service Sector Standards
  • tracking and monthly reporting of key quality measures, including identifying themes or trends

Why is learning from serious events & complaints important?

Waitemata DHB Value: Better, Best, BrilliantWhen things go wrong, patients and their families want an acknowledgement that something happened. They want to know what has happened, how it happened, the possible consequences, and what will be done to stop it happening to anyone else.

There are considerable benefits in recognising and responding to complaints and serious events. Reporting allows us to identify patient safety themes, gaps and inadequacies in the system and enables improvements in service quality and patient safety.

Many of our local quality improvement initiatives, along with regional and national quality improvement initiatives are the direct result of complaints and serious event analysis. A good example is the reducing harm from falls initiative with analysis of serious events highlighting the relatively high frequency of falls in hospitals across the country (falls in hospital are the most frequent serious incident reported nationally). [View more about our Falls prevention programme Part I and Part II]

Good reporting and investigation processes build open and honest relationships and provide assurance to patients, families and external agencies (e.g. Health & Disability Commissioner) that we are committed to finding out what happened and to making necessary changes.


What can you do to help us?

If you require information or want to raise any concerns, ask to speak with the ward or unit charge nurse or manager. We encourage and support questions or queries to be voiced at the time of contact as this gives us the opportunity to respond immediately. We are very keen to ensure that your contact with our services is always a positive experience.

Our Customer Service Advisors are available to listen to your concerns and discuss your options for further actions. They can be contacted by email at customer.feedback@waitematadhb.govt.nz or telephone on (09) 486 8920 extn 3153.

Feedback forms are also available and can be located in the main entrances of North Shore and Waitakere Hospitals.

[Download our brochure “What will happen with your complaint”]

 

What did we find?

A review by Professor Ron Paterson in 2012/2013 found that our complaints and serious events management processes generally work well and that the approach taken at Waitemata DHB is consumer-centred.

The review also found that there is a willingness within the DHB to accept when something has gone wrong and to apologise. Our CEO and Chair give a clear message that complaints and serious events need to be taken seriously and that responding promptly and helpfully to them is a priority.


How are we doing?

The DHB has a target of responding to complaints less than 15 days (including weekends). We monitor this closely and report the results to the Board.

Waitemata DHB Complaints Average Days to Respond Chart
Chart showing our average days to respond to complaints and improvements made following changes to complaints process


Waitemata DHB serious & sentinel events report for 2013/2014

Waitemata DHB’s FY 2013/2014 national serious and sentinel event report for 2013/2014 can be found here - [view our serious & sentinel events report for 2013/2014 ].


What have we done?

When complaints are made, or serious events occur, the services involved, with the help of the quality assurance team, are responsible for managing investigations, implementing any necessary changes, and communicating with patients and families / whānau. Investigations of the most serious incidents involving patients (these are called serious and sentinel events) are overseen by the Serious and Sentinel Events Committee.

Quality Assurance Team

The Quality Assurance Team oversees our quality assurance processes to make sure that we meet our DHB and national standards.

The Quality Assurance Team works with the relevant clinical leaders and managers to ensure that:

  • investigations are undertaken
  • recommendations and improvements to services are made
  • learning is shared with the relevant people

Complaints & serious event management processes

Following reviews of our complaints and serious event management processes, we have updated these processes and made some key changes including:

  • having consistent DHB-wide processes
  • having a central team (Quality Assurance Team) to oversee both the complaints and incident management process, including a single point-of-entry for all complaints within the DHB
  • having a consistent way of identifying the level of complaints or serious events (e.g. minor, moderate, major) to ensure that the investigation reflects the level of the complaint and that the right people are notified
  • allocating an owner to each complaint or serious event to ensure that they are appropriately managed
  • setting a target of investigating and responding to all complaints within 15 calendar days; and a target of 100% of all serious events are completed within 70 working days

The key principles of these processes are:

Key Principles of Complaints & Serious Events management

Our high-level process steps for complaints and serious events management are:

Complaints & serious events high level process


Where to from here?

We want to make sure that we are getting it right for our patients and families. We will be introducing regular surveys of people who have submitted a complaint to Waitemata DHB to find out if our complaints process has met their needs. From this feedback, we will be able to determine if any changes need to be made.

The serious events management process will undertake a similar review in 2015.


Key Contacts

Health & Disability Commissioner

This is an independent office available to any person or group who believes that they may have had their rights breached under the Health and Disability Services Consumers’ Code of Rights.

PO Box 1791, Auckland
Phone: (09) 373 1060
Free phone: 0800 11 22 33
Website: www.hdc.org.nz

Nationwide Health & Disability Advocacy Services

This is a free, independent advocacy service available to assist anyone who may need help with a complaint.

Free phone: 0800 555 050
Free fax: 0800 2787 7678
Email: advocacy@hdc.org.nz