scope of the document - isd scotland | information … · web viewj11. opticians 01 optometrist /...

NHS Complaints

Definitions document for new NHS Complaints dataset

VERSION: 27.5

Document contacts: Name: Karen Smith, Information Manager, Data Management E-mail: [email protected]

NHS Complaints Information Services DivisionNational Services Scotland

Last updated May 2015 Stacey MoffatVersion 27.5

2


Document Control:

Document ControlVersion Complaints Definitions V27.5Date Issued 07 May 2015Author(s) Frank Clarke

Karen SmithOther Related Documents \\Stats\complaints\Documentation\New IT system

work\ISD System and SWIFT issues\SWIFT validation rules v2.doc

Comments to [email protected]


3


CONTENTS PAGE

1 Scope of the Document.................................................................................42 Background........................................................................................................43 Content of the Document............................................................................44 List of fields and definitions........................................................................5

4.1 About the Complaint............................................................................................54.2 About The Complainant.......................................................................................84.3 Details of the “Complained Against”:................................................................104.4 Details of the Complaint....................................................................................104.5 Outcome of the Complaint.................................................................................12

APPENDICES.............................................................................................................151. Complaint Category Tables.........................................................................15

Table 1: Staff Group................................................................................................21Table 2: Service Area...............................................................................................23Table 3: Patient Admission Type............................................................................24Table 4: Specialty.....................................................................................................24Table 5: Received Method......................................................................................27Table 6: Health Sector.............................................................................................28Table 7: Outcome Of Complaint.............................................................................28Table 8: Actions Taken...........................................................................................28Table 9: Who submitted the complaint?.................................................................29Table 10: Risk Rating..............................................................................................30Table 11: Complaint Type.......................................................................................30Table 12: Has the Diversity Form been sent?.........................................................30Table 13: Has the complaint reference number been put on the Equality and Diversity form?........................................................................................................30Table 14: Are PASS involved in the complaint?....................................................30Table 15: Relationship to patient............................................................................31Table 16: Is consent required?................................................................................31Table 17: Reason why complaint has taken longer than 20 days to resolve? Non mandatory.................................................................................................................31Table 18: Has a service improvement been made or is there longer-term plan to be put in place?.............................................................................................................32

2. Example On How Codes Will Be Used.....................................................33


4


1 Scope of the Document

The purpose of this document is to provide definitions of each field within the nationally agreed NHS Scotland Complaints Dataset. NHS Staff who deal with complaints will be able to refer to this document in conjunction with their own IT system whilst inputting data, or to seek clarification on the Complaint definitions or categories.

This document will be updated and circulated round the Compliant Offices if any new fields are added to the national dataset.

2 Background

Currently in NHS organisations across Scotland, there is a lack of consistency when using codes to record complaints made against an NHS service. Each Complaints Office follows general guidance about complaints recording within the NHS, but may also use their own local set of categories to register the details, or have their own interpretation of how to complete the dataset.

With the development of the new national dataset and the creation of the new IT system, ISD will provide an NHS Complaints system containing a set of codes and detailed definitions. These definitions and codes will be used nationally to ensure consistency with recording practices from Board to Board within the NHS.

3 Content of the DocumentThis document contains a list of all data items and their definitions to be used by Complaints Officers from 1st of April 2008. All NHS Complaint Officers should use these definitions regardless of which data collection system they use. There are a number of different complaint systems across Scotland to record complaints, each of which has their own documentation.

The complaints definitions covered in this document are:

1. About the complaint2. About the complainant3. Details of the ‘Complaints Against’4. Outcome of the complaint

There is also an appendix listing the new complaints categories and codes. These categories are:

1. Reasons why a complaint is made about the NHS2. Staff group which the complaint was made against3. Service area 4. Patient admission type5. Specialty


5


4 List of fields and definitions

4.1 About the Complaint (Both mandatory and non mandatory field, (*) indicates a mandatory field):

Field Ref. No Field Name Definition

A1 The NHS Organisation dealing with Complaint (Lead Organisation) (*)

This is the NHS Organisation who has ownership of investigating the complaint.

The header on the SWIFT DVL file will have the provider code of the NHS Board that is submitting the file. This field is mandatory on the SWIFT DVL submission.

Health Board Area This field will be derived by the system following the code of the NHS Organisation dealing with the complaint.

A2Reference Number of the Complaint (*)

This will be a unique number (or alpha numeric) used by the Complaints Office to identify the complaint. There is no set format of the number although it has been recommended that the first 4 digits correspond to the year and the quarter the complaint was received. The complaints officer should assign the following 8 digits. For example, 200804000001.

A3

Type of contact made with the Complaints Office (*)

Suggestion Enquiry Only (consent not

received) Informal complaint Formal complaint

The user will be presented with the following headings on a drop down menu:

Suggestion: To advise a way of improving an individual service or group of services within the NHS without using the NHS Complaints Procedure.

Enquiry: This can be a complaint that has been submitted by someone other than the patient and where consent has not yet been given. Once consent has been received, the complaint should be changed to ‘Formal Complaint’. It can also be a query that someone has made to the Complaints Office.

Informal: This a complaint where the complainant does not wish to instigate the full formal NHS Complaints Procedure, but where lessons still have to be learned.

Formal: This is a complaint that follows the NHS Complaints Procedure and consent has been received.

ISD will only extract Formal Complaints from the local systemsDrop down menu will be provided. See table 11 in the appendix for details

A4 Lead Complaint / Investigating Officer involved in the case

Person responsible for resolving the complaint. This will usually be the complaint officer.

A5 Unit / Team Free text for the complaints officer to add notes.

A6

How was the complaint received? (*) In writing – letter In writing – email In writing – fax Suggestion form / card Web site form Phone; In person; Other;

The system will contain a predefined pick list for recording the method by which the complaint was received.

Drop down menu will be provided. See table 5 in the appendix for details

A7Does the complaint involve treatment at another Board / NHS Organisation, different to the one listed in A1? A pick list of NHS Boards will be supplied to record where

patients start their treatment at one site and then are referred


6


onto another site in different NHS Board area, e.g. Orkney patients referred down to

mainland / Golden Jubilee patients.

A8Does the complaint involve treatment received at another type of organisation?

A pick list of non NHS Organisations will be supplied to record patients treated out with the NHS (for example, Local Authorities)

4.1 About the Complaint contd

Field Ref No.

Field Name Definition

A10 Main Health Sector of Complaint (*): Health Board Special Health Board Acute Hospital Services Community Health Services Mental Health Services Family Health Services (GP etc) National and Support

Organisations Hospitals for Care Of The

Elderly Learning disabilities Rehabilitation Respite Outside of Scotland

This field refers to the Main Health Sector of the complaint.

Health Board: Current provision of healthcare is the responsibility of 14 geographically based local NHS Boards.

Current list of NHS Scotland Health Boards:

Borders Lothian Lanarkshire Dumfries and Galloway Greater Glasgow and Clyde Forth Valley Tayside Highland and Argyll Orkney Shetland Western Isles Grampian Ayrshire and Arran Fife

Special Health Board: NHS Special Health Boards do not have responsibility for a particular geographical area, but are responsible for improving patient care across NHS Scotland.

Current examples of Special Health Boards are:

1. NHS Quality Improvement Scotland2. NHS Health Scotland3. NHS Education Scotland4. Golden Jubilee National Hospital5. Scottish Ambulance Service6. State Hospitals Board for Scotland 7. NHS24

Acute Hospital Services: Hospitals providing acute medical care excluding psychiatric treatment.Community Health Services: The community health service comprises two types of service:

1. Patient/client care in the community:

This encompasses the provision of medical/dental care (except primary care); nursing care and AHP care to patient/clients in need.

The care is usually provided in the patient/client's home or other residential setting, or community health premises.


7


people with an identifiable physical condition or mental illness or disability

expectant or nursing mothers people whose general condition of health means that

they need help in order to remain living in the community.

2. Health services to the community:These encompass services of prevention, intervention or health promotion which are provided as a matter of public policy.Examples of these services are breast screening, immunisation, child development surveillance, family planning and the dental health service

Mental Health Services: Services providing mental health care. This encompasses services from; Community Services, Outpatient Clinics, psychiatric hospitals, inpatient services and the State Hospital for Scotland.Family Health Services: Medical services provided by General Practitioners and Dentists.

National Support Organisations: Organisations providing support to NHS Scotland.

Current list of National & Support Organisations:

Chief Scientist Office National Services Scotland Health Economics Research Unit Health Services Research Unit Implementation Support Group Nursing Council on Alcohol Nursing Research Initiative for Scotland Public Health Institute of Scotland Queen Elizabeth National Spinal Injuries Unit, Scotland Scottish Health Council Scottish Government Scottish Medicines Consortium Scottish MRSA Reference Laboratory Scottish Nutrition and Diet Resources Initiative Scottish Practice Nurses Association Scottish Resuscitation Group


A11Date the suggestion / enquiry / complaint was received by the NHS Organisation (*)

This is the date that the complainant first contacted the Complaints Office with the suggestion, enquiry or complaint.

A12Date the complaint was acknowledged by the NHS Organisation (*)

The date that the NHS organisation acknowledged that the complainant has raised a complaint under the NHS Complaints Procedure, and wrote back to the complainant.This is should be done within 3 working days of the complaint being received.


8


A13 Date formal complaint was received with consent. (*)

The date that the organisation dealing with the complaint received notification of consent, if the complaint was being made on behalf of a patient.

A14

Has an Equality and Diversity form been sent out to the complainant? (*)

A reminder for the Complaints Officer to send out an Equality and Diversity form. The complaint reference number and the NHS organisation dealing with the complaint need to be included in the form.


A15Has the complaint reference number been put on the Equality and Diversity form?

A reminder for the Complaints Officer to put on the complaint reference number on the Equality and Diversity form. This number will be the same that has been entered on field A2 ‘Complaint Reference Number’. This reference number is crucial to allow analysis of the Equality and Diversity forms.


A16 Complaint / Investigating Officer Notes

Optional free text box: for complaints officer to make general notes

A17Date referred to the Investigating Officer

(ISD System)

The date that the complaint was referred to an investigating officer.

A1820 day letter sent

(ISD System)

The complaint should take no longer than 20 working days to complete. However, a letter must be sent at 20 days to agree a new deadline with the complainant. A drop down menu will be provided containing ‘yes’ and ‘no’

A1920 day letter sent date

(ISD System)The date that the 20 day letter was sent to the complainant.

4.2 About The Complainant (All non-mandatory fields):

Field Ref No Field Name Definition

B1 Who has submitted the complaint?

Patient or former patient; Appropriate person in respect of

a patient who had died (e.g. next of kin);

Someone on behalf of a patient or former patient o Parent, carer, other relative,

friend;o Partner;o Advocate;o MSP or MP;o Local Councillor;o Solicitor;o Media;

This refers to the person who has contacted the organisation to make the complaint

PatientPerson who requires, is receiving, or has received medical care.

Person responsible for a deceased patient (e.g. next of kin)

On behalf of a patient or a former patientPerson acting as an agent for the patient or former patient

Parent, carer, other relative, friend Partner – husband, wife, partner etc Advocate – from an agency or support group MSP or MSP – any member of the Scottish or UK parliament Local Councillor – member of local authority


9


o GPo Minister/Priesto Veteran

Submitted by Independent Advice and Support Organisation (e.g. CAB);

Visitor to NHS Organisation (i.e.

complainant not a patient) / local resident / member of the public;

Armed Forces Veteran Other

Solicitor – lawyer representing the patient or former patient Media – press enquiry on behalf of complainant GP – complainant’s family doctor Minister/Priest – complainant’s church representative

Independent Advice & Support OrganisationsOrganisations such as Citizens Advice Scotland that give free, confidential information and advice to help and support people with their complaint regarding the NHS.

Visitor to NHS OrganisationPerson submitting the complaint who is not a patient or submitting a complaint on behalf of a patient (e.g. Local resident or member of the public)

Armed Forces Veteran

A person who has served in the armed forces

OtherFor people who don’t fall in the above categories


B2Are Citizen Advice Bureau (CAB)

involved in the complaint / are they supporting the complainant?

A yes or no field to record if CAB, or an IASS worker, is involved in the complaint. See table 14 in the appendix for details.

Contact details of the complainant – not necessarily the person who contacted the complaints officer.

B3 Title Mr / Mrs / Dr / Prof / … etc

B4 Forename (s)

B5 Surname

B6 AddressB7 Date of BirthB8 Telephone Number (s) / e-mail

address

B9 Patient Hospital Number (if applicable)

A patient identifier is a code (set of characters) used to uniquely identify a patient within a health register or a health records system

B10 CHI Number

Patients are identified using a 10 digit number know as the Community Health Index (CHI) This number is normally formed using the patients Date of Birth followed by 4 numbers 2 numbers generated at random, a number identifying Gender at Birth (men are odd, women are even) and a check digit

Person who contacted the complaints officer if different from above

B11 Has consent been received from the patient? This field will be ticked if consent form has been received from patient.

B12 Title Mr / Mrs / Dr / Prof / … etcB13 Forename (s)B14 Surname B15 Address B16 Telephone Number (s) / e-mail addressB17 Relationship to patient

The user will be asked to state relationship to the patient (e.g. Father, daughter, next of kin)


10



B18 Relationship to patient (if other) Free text field for other type of relationship to patient

B19 Consent Required

This optional field allow complaints officers to keep track on consent details.


B20 Consent Requested Date This optional field allow complaints officers to keep track on consent details.

B21 Consent Obtained Date (*)

Date consent form is received by NHS organisation.

Once consent has been received, the complaint will change from ‘enquiry’ to ‘formal’

4.3 Details of the “Complained Against”:These fields are for local use only and would be not be available to the ISD analysts.

Field Ref. No

Field Name Definition

B22 Location (s) (*) The location of where the complaints relates to.

B23 How many staff has been complained about? Number of staff complained about.

B24 Staff ID ID number of member of staff being complained about

B25 Title

B26 Forename (s)

B27 Surname

B28 Profession Job title

B29 Telephone Number (s) / e-mail address

4.4 Details of the Complaint(Mix between mandatory and non-mandatory fields):

No. Field Definition

C1 How many issues have been raised? This will be a derived field from what is completed in the above section.

C2 Issues Raised – Top level categories are: Staff Waiting Times For Delays In/ At Environment & Domestic Issues Operational & Procedural Issues Treatment Transport Other

Details will be recorded on Principal Issue, along with details of other issues if applicable. The ISD system will allow you to record as many issues as necessary. However, ISD will only extract the first 3 issues for analysis purposes.


11


C3

Staff Group

Consultants/ Doctors Dental

Nursing, Midwifery, Health Visiting, District Nurses

Allied Health Professionals (AHPs)

Scientific / Technical Ambulance Ancillary Staff Estates NHS Board administrative

staff/members (exc. FHS administrative)

Hospital/CHP/PCO administrative staff/members

GP Pharmacists (Hospital) Other (Free text box)

Please see the Appendix for a complete list of the staff groups

C4

Service Area A&E Hospital acute services Care of the Elderly Rehabilitation Psychiatric / Learning Disability

Services Maternity Services Ambulance Services Community Hospital Services Community Health services - not

elsewhere specified Purchasing NHS24 SNBTS Administration Unscheduled Health Care (Out of

Hours) NHS24 SNBTS (Donor) Other Special Health Board Salaried GPs Family Health Services (General

Medical Practitioners (GPs), General Dental Practitioners, Opticians, Community Pharmacists)

Other (free text box)

Please see the Appendix for a complete list of the Service Areas

C5Patient Admission Type (if applicable)

Inpatient Daycase Outpatient Ward Attender Day Patient Maternity Accident and Emergency

(A&E) Minor Injuries Unit Care Delivered in the

Community Not applicable (this would be for

Ambulance / Purchasing / Admin etc)

Inpatient: is a patient who can be categorised into any one of the following groups:

a) A patient who occupies an available staffed bed in a hospital and:

EITHER - remains overnight whatever the original intention (except haemodialysis patients).OR - at admission, is expected to remain overnight but is discharged earlier (except haemodialysis patients). Discharges include transfers-out and deaths.

OR - is a mother who delivers in hospital and whose admission and discharge is between successive bed counts.


12


OR - is admitted as an emergency or urgent case, regardless of length of stay. (See Emergency admission)

b) Patient admitted as an emergency or urgent case that dies, whether or not a bed was occupied. (See Urgent admission) c) A patient admitted as an emergency or urgent case who undergoes a major operative intervention without occupying a bed in the operative specialty. d) A psychiatric patient admitted under Section 18 of the Mental Health Act (Scotland) 1984 who is on leave of absence from the hospital under Section 27 of the Act. Such patients must, for legal reasons, be regarded as inpatients for the duration of their absence which may be for up to 6 months (Refer to the Mental Health Act (Scotland) 1984). Note During the first 28 days a patient will be regarded as a 'patient on pass' for statistical purposes (i.e. SMR04 returns). Such patients will be discharged from SMR04 and ISD(S) 1 when their period of absence exceeds 28 days. If the patient returns for readmission after 28 days while still under Section 27 of the Mental Health Act, a new SMR04 will be generated

Day case: Is a patient who makes a planned attendance to a specialty for clinical care, sees a doctor or dentist or nurse (as the consultant’s representative) and requires the use of a bed or trolley in lieu of a bed. The patient is not expected to, and does not, remain overnightOutpatient: Is a patient who attends a consultant or other medical clinic or has an arranged meeting with a consultant or a senior member of his team outwith a clinic session.Ward Attender (medical): is a patient from outwith the hospital or an inpatient from another specialty who attends a ward on an individual basis, by appointment or casually, and is seen by a junior doctor with or without a nurse present.Day patient: Is a patient who attends a day hospital on a regular basis.Maternity: Is a patient admitted to a maternity unitAccident & Emergency: Is a patient admitted to Accident & Emergency unit

Minor Injuries Unit: Is a patient admitted to Minor injuries unit

Community: Is a patient receiving care from Community Health ServiceOther: When a patient does not fall in one of the categories listed above

C6 Specialty (If applicable) Please see the Appendix for a complete list of Specialties.

4.5 Outcome of the Complaint (Mandatory and non mandatory fields):

Field Ref No Field Name Definition

D1

The response date of when the NHS Organisation has fully responded to all aspects regarding the complaint to the complainant (*)

This is the date that the NHS Organisation responds to the complainant with the outcome decision of the investigation into their complaint.ISD will be using this field together with the date that the formal complaint was received to calculate the time taken to resolve the complaint.


13


D2 Has the response been sent within 20 working days?

This field will be calculated by ISD. The calculation involves subtracting the date responded to from the date the complaint was received. ISD will remove any Public Holidays and weekends that occur between these dates.

D3 Reason why complaint has taken longer than 20 days to resolve (*)

If the complaint has taken more than 20 working days to resolve, this field records main reasons as to why this has happened.

A drop down menu of reasons will be provided. See table 17 in the appendix for details

D4Has an extension been agreed with the Complainant, beyond 40 working days?

Where it appears that the 20 days target will not be met, the person making the complaint must be informed of the reason for the delay with an indication of when a response can be expected. The investigation should not normally be extended by more than a further 20 working days. Where it may be necessary to ask the complainant to agree that the investigation be extended beyond 40 working days, a full explanation should be given in writing, again including the reason for the delay with an indication of when a final response can be expected

D5If yes to the above, what was the date of the letter detailing this extension?

Date the letter was sent to the complainant requesting the extension with a revised completion date

D6 What was the reason for the delay?

Reasons as to why the complaint has taken longer than 40 days.

D7

Outcome: Fully Upheld Partially Upheld Not Upheld Transferred to another unit Consent not received Irresolvable - funding Irresolvable – complainant’s expectations too high Complaint Withdrawn Conciliation Irresolvable – other Unreasonable complaint

This field records the final outcome of the complaint.

Fully upheld: Complaint is accepted

Partially upheld: Complaint is partly accepted

Not upheld: Complaint is not accepted

Transferred to another unit: Complaint is transferred to another Health Board, Division, Service or national support organisation

Consent not received: Consent form not received from patient.

Irresolvable – funding: Complaint is irresolvable due to funding difficulties

Irresolvable – complainant’s expectations too high:

Complaint withdrawn: Complaint not taken forward.

Conciliation: Form of mediation (non financial) whereby disputes may be settled

Irresolvable – other: Other reasons not listed for a complaint to be irresolvable.

Unreasonable complaint: Exaggerated number of complaints from the same individual or an unreasonable complaint.



14


D8 Outcome – Summary of Response

Free text field to describe any actions or proposed actions that the NHS Organisations have committed to do, as a result of this complaint. These actions will be detailed in the final response letter sent to the complainant.

D9Action Date Immediate actions following from investigation of complaint:

This field will show the date where immediate action following the complaint has been implemented.

D10

Action Type Immediate actions following from investigation of complaint:

Drop down menu contains list of actions or proposed actions that the NHS Organisation has committed to do, as a result of this complaint.See table 8 in the appendix for details.

D11 Service Improvement / longer term plans

Tick box to indicate if a service improvement has been made following the complaint. ISD will only provide the number of service improvements.


15


APPENDICES

1. Complaint Category Tables The main changes to the categories are within the ‘Service Area’. This category is no longer split by patient admission type. Instead, there is now a new category for the Patient Admission Type. Please see the lists below for more information.

Table 1. ISSUES RAISED Code/ Description

Code Description

Staff

A01 Attitude and Behaviour

01 Conduct02 Alleged assault03 Staff attitude04 Physical intervention05 Lack of support06 Threatening behaviour07 Confrontational08 Abruptness09 Treatment to patient (not clinical treatment)10 Inappropriate comments11 Verbal abuse12 Rudeness13 Rushed – not time to see patient14 Staff disposition15 Poor staff morale16 Insensitive to patient needs17 Rough handling of patient18 Member of staff has not apologised to patient19 No assistance from staff in feeding a patient20 Staff calling patient by an inappropriate name21 Other (free text)22 Not listening

A02 Complaint Handling

01 Formal02 Informal03 Acknowledgement not been issued04 Not happy with the outcome of the complaint05 Length of time taken to resolve06 No information has been sent to the complainant08 All points raised in the complaint have not been

answered in the response letter09 Other (free text)

A03 Shortage/ availability

01 Shortage of staff02 Recruitment03 Other (free text)


16


A04 Communication (written)

01 Letter wording 02 E-mail03 Press releases04 Fax05 Patient has been sent no communication06 Misunderstanding07 Lack of explanation 08 Test results have not been communicated to the

patient09 Other (free text)

Staff

A05 Communication (oral)

01 Telephone02 Face to face03 Misunderstanding04 Lack of a clear explanation05 Patient not being verbally told things06 Staff not reply to patient verbal question07 Next of kin has not been informed that the patient

has been taken to hospital08 Test results have not been communicated to the

patient09 Other (free text)

A07 Competence

01 Staff not trained properly02 Negligent03 Inefficient04 Lost test results 05 Administrating incorrect treatment06 Not observing patients 07 Not involved in the patients care plan08 Staff unaware of patient’s diagnosis09 Other (free text)

Waiting Times For

B11. Date of Admission / Attendance

01 Cancellation of admission02 Unacceptable time to wait for the appointment03 Admission date continues to be rescheduled04 Too short notice given for date of admission 05 Date for admission exceeds the published maximum

waiting time06 Date for admission can not be given to the patient07 Other (free text)08 Waiting for Referral

B12. Date for appointment

01 Cancellation of appointment02 Unacceptable time to wait for the appointment03 Appointment date continues to be rescheduled04 Too short notice given for the appointment05 Date for appointment exceeds the published

maximum waiting time06 Other (free text)

B13. Test Results

01 Waiting too long for test results02 Test results lost or mislaid03 Test results unclear04 Other (free text)

Delays In/At

C21. Admissions / Transfers / Discharge procedure

01 Delays in internal transfer (ward to ward)02 Delays in external transfer (hospital to hospital)03 Delay in admission04 Delay in discharge05 Delay in transportation (ward to ward) 06 Delay in transportation (hospital to hospital)


17


07 Other (free text)

C22. Outpatient and other clinics

01 Waiting too long in reception to see the Consultant / Doctor / Nurse

02 Overbooking at clinic03 Lengthy Consultations04 Other (free text)

Code / Description

Code Description

Environment /Domestic

D29. Premises

01 Access to premises02 Bad geographical location03 Signage04 Disabled access05 Entry system06 Security07 Condition of premises08 Maintenance09 Noise pollution10 Accommodation11 Lack of water12 Water too hot13 Water too cold14 Water is dirty15 Poor lighting16 Poor ventilation17 Lack of toilets18 Toilets in bad state of repair19 Lack of Health and Safety20 Smoking21 Drop off and pick up points22 Lack of car parking spaces23 Ticket machine not working / availability24 Disabled parking25 Queues for parking26 Parking fees27 Décor28 No accommodation for relatives29 Repairs30 Other (free text)

D30. Aids/ appliances / equipment

01 Furnishings02 Electrical equipment broken 03 Computers broken04 Telephones not working06 Lack of dustbins 07 Condition of items08 Availability of items09 Access to items10 Broken mirrors12 Lighters14 Sports equipment15 Utility Equipment17 Availability of cards to use the patient line18 Lack of electronic wheelchairs19 Other (free text)


18


D32. Catering

20 Lack of suitable aids for eating or drinking01 Hotel services03 Food too cold04 Availability of food

Environment / Domestic (Cont)

05 Do not cater for special diets06 Poor service of food07 Poor choice on menus08 Food hygiene10 Take aways11 Poor food quality12 Poor food quantity13 Presentation of food14 Lack of supplies in hospital canteen / shops15 Other (free text)

D33. Cleanliness / Laundry

01 Condition of bedding02 Dirty toilets / bathroom / shower03 Cleanliness of ward04 Staff not washing hands05 Bins not being emptied06 Not cleaning equipment before use on another

patient07 Staff not changing scrubs whilst moving from the

theatre to the wards08 Clinical equipment not being clean09 Cleanliness of outpatient areas10 Dirty kitchen11 Other (Free Text)

D34. Patient Privacy / dignity

D35. Patient Property / expenses

01 Too many visitors02 Visitors not being allowed03 Visitors too noisy04 Other patients behaviour05 Breach of Confidentiality06 Facility time07 Human rights08 Patient rights09 On ward activities10 No curtains11 Open doors13 Other01 Reimbursements02 Travel expenses03 Stolen property04 Patient funds05 Lost property06 Patient property been damaged08 Other

D36. Patient Status

01 Racial discrimination02 Age discrimination03 Sexual discrimination04 Religious discrimination06 Sectarianism

Environment /

07 Patient has been removed from practice / ward/ hospital

08 Child protection


19


Domestic

09 Disability discrimination10 Language discrimination11 Other (free text)12 Homophobic discrimination

D37. Personal records

01 Personal details have been heard by other patients / visitors

02 Availability of records03 Records have been lost04 Gaining access to records05 Accuracy of records06 Inappropriate comments on records

07 Test results / X-Rays / scan results going missing / lost

08 Unauthorised use of medical information for research / publication purposes

09 Advice given to staff by a patient or relative has not been written in the records

10 Patient dispute what is in his/her medical record

11 Patient wants extra notes added to his/her medical records


D38. Bed shortages

01 Availability of beds02 Lack of single rooms04 Other (free text)

D39. Mixed Accommodation

01 Mix of male and female patients02 Children in adult wards03 Other (free text)

D40. Hospital Acquired Infection

01 MRSA02 C.difficile03 MSSA04 Other (free text)

Procedural Issues

E41. Failure to follow agreed procedures

01 Failure to follow agreed procedure


E42. Policy & Commercial decisions of NHS Board

01 Costs and funding issues02 Hospital closures03 Ward closures04 Downgrading of services05 Out of hours services06 Staff cuts07 Treatment not available08 Drug not available09 Other (free text)

E43. NHS Board Purchasing

01 Services provision02 Purchasing problems04 Supply of drugs / medicines05 When a NHS Board uses a service not approved of by

a patient/relative (e.g. Contact to a taxi firm)06 Other (free text)

E44. Mortuary / post mortem arrangements

01 Arrangements after patients death02 Delayed release of the body04 Where a relative feels the experience of visiting the

mortuary could have been better


20


05 Next of kin given incorrect information on a proposed post-mortem

07Other (free text)

Treatment

F51. Clinical Treatment

01 Therapies02 Wrong diagnosis03 Wrong medicine given04 Problems with medication05 Wrong treatment given06 Treatment against will07 Lack of pain management08 Falls from bed / trolley09 Length of time having to be seen in different

departments10 Waiting to see doctor / nurse once been admitted11 Error in performing a procedure on patient12 Lengthy Consultation13 Patient being restrained or controlled14 Samples go missing15 Co-ordination of clinical treatment16 Medications not given on discharge17 Error with prescription18 Staff not observing patient19 Waiting for fitting20 Waiting for medication21 Waiting for scans22 Treatment postponed23 Treatment cancelled24 Poor aftercare25 Poor nursing care26 Invasive procedure carried out27 Lack of continuity28 Waiting for test to be carried out29 Treatment didn’t have expected outcome30 Test results lost or mislaid31 Test results unclear32 Other (free text)

****NEW CODES ADDED AS AT 3RD June 2009 ****

33 Disagreement with treatment / care plan 34 Poor medical treatment

****NEW CODES ADDED AS AT 7th December 2011 ****

35 Detox problems36 Addiction problems

F52. Consent to treatment

01 Consent to treatment not given02 Patient has not understood what giving consent

meant03 Patient has not sufficient information to give

informed consent to a procedure04 Other (free text)

Transport G61. Transport

01 Transport arrangement including ambulances02 Transport charges03 Wrong type of transport provided04 Transport problems – internal


21


05 Waiting for transport06 Transport being cancelled07 Transport not turning up08 Transport problems - external09 Other (free text)

Other H71. Other 01 Free Text

Table 1: Staff Group

Code / Description

Code Description

Staff Group

J01. Consultants / Doctors

01 Consultant (Medical)02 Consultant (Surgical)03 Doctor04 Junior Doctor05 Locum06 Registrar07 Other (free text)08 Consultant (Psychiatrist) **NEW**

J02. Nurses

01 Children’s nurse02 Community nurse03 District nurse04 Health visitor05 Learning disabilities nurse06 Mental Health Nurse07 Midwife08 Nurse09 Nursing assistant 10 Other (free text)11 Nurse Specialist ** NEW CODE AS AT 3rd JUNE 2009

**

J03.Allied Health Professionals

01 Art therapist02 Audiologist and hearing therapist03 Cardiac physiologist04 Cardiographer05 Counsellor06 Dietician07 Donor carer08 Drama therapist09 Health education and promotion officer10 Health Informatics staff11 Health support worker12 Healthcare assistant13 Hospital play specialist14 Industrial and occupational therapists15 Medical illustrator / clinical photographer16 Medical physicist17 Music therapist18 Physiotherapists19 Speech and language therapists20 Other21 Radiographers22 Podiatrists


22


23 Cardiology Technician ** NEW CODE AS AT 3RD JUNE 2009 **


23


Staff Group

J04. Scientific / Technical

01 Anatomical pathology technician02 Biomedical scientist03 Clinical Biochemist04 Clinical cytogeneticist05 Clinical embryologist06 Clinical engineer07 Clinical immunologist08 Clinical microbiologist09 Clinical scientist in histocompatability and

immunogenetics10 Critical care technologist11 Cytoscreener12 Gastroenterology technician13 Lab assistant14 Molecular geneticist15 Neurophysiology technician16 Orthopaedic Technician17 Physiological scientist18 Respiratory physiology technician19 Other (free text)

J05. Ambulance

01 Ambulance technician02 Ambulance care assistant03 Emergency medical dispatcher04 Paramedics05 Patient Transport06 Other (free text)

J06. Ancillary Staff / Estates

01 Car Parking Attendants02 Catering staff03 Chaplain04 Cleaners05 Drivers06 Estates and facilities management07 Gardener08 Grounds men/women09 Hotel services staff10 Housekeeper11 Laundry staff12 Painter / decorator

Staff Group

13 Porters / messengers14 Receptionists15 Security personnel16 Storekeeper17 Other (free text)

J07. NHS Board / hospital administrative staff / members (exc. FHS administrative)

01 Administration02 Communications/public relations (pr)

manager03 Complaints staff04 Computing staff05 Finance manager06 General manager07 Human Resources / personnel manager08 Information management staff09 Library services staff10 Management11 Medical records staff12 Secretarial staff


24


13 Sterile services managers14 Ward clerk15 Other

J08. GP

01 General Practitioner02 Practice manager03 Other04 Salaried GP

J09. Pharmacists01 Community pharmacist02 Hospital pharmacist03 Pharmacy technician04 Other

J10. Dental

01 Dental Hygienist02 Dental Nurse03 Dental technician04 Dental therapist05 General Dental Practitioners06 Orthodontist07 Other08 Salaried Dentist

J11. Opticians

01 Optometrist / ophthalmic optician02 Orthoptist03 Optical Services04 Other

J12. Other 01 Free textJ13. Social care 01 Social worker

02 Carer03 Other

Table 2: Service Area Code /

DescriptionCode Description

Service Area

ACCIDENT Accident & EmergencyACUTE Hospital Acute Services

ELDERLY Care of the ElderlyREHABILITATI

ON RehabilitationMENTAL Psychiatric / Learning Disability Services

MATERNITY Maternity ServicesAMBULANCE Ambulance Services

COMHOSPITAL Community Hospital Services COMHEALTH Community Health Services – not elsewhere specifiedCONTINUING Continuing carePURCHASING Purchasing

NHS24 NHS 24SNBTS SNBTSADMIN Administration

UNSCHEDULED Unscheduled Health Care

SHB Special Health BoardsGP Salaried GPs / DentistsFHS Family Health Services (deleted on 30/09/2013)

PRISON Prison ServicesSOCIAL Adult Social Care


25


OTHER Other (free text box)

Table 3: Patient Admission Type

Code / Description Code Description

Patient Admission Type

INPATIENT InpatientDAYCASE Daycase

OUTPATIENT OutpatientWARD Ward attender

DAYPATIENT Day patientMATERNITY MaternityACCIDENT Accident & EmergencyINJURIES Minor Injuries Unit

COMMUNITY Community EMERGENCY Primary care Emergency Centre **new**

OTHER Other

Table 4: Specialty


Specialty

C2 Accident and EmergencyZ26 AddictionsZ20 AdministrationG22 Adolescent PsychiatryAW AllergyR7 Ambulance men / Women – Accident & EmergencyC3 AnaestheticsC51 Audiological MedicineR8 Audiological ScienceR82 AudiometryZ8 BiochemistryJ2 Blood Transfusion

H1A Breast Screening ServiceC41 Cardiac SurgeryA2 CardiologyC4 Cardiothoracic SurgeryJ3 Chemical Pathology

Z12 Child ProtectionG2 Child & Adult PsychiatryZ12 Child ProtectionG21 Child PsychiatryR1 Chiropody / PodiatryZ19 CleanlinessA3 Clinical GeneticsAV Clinical NeurophysiologyH2 Clinical OncologyA5 Clinical Pharmacology & TherapeuticsR2 Clinical PsychologyH1 Clinical Radiology


26


Z9 Colo-rectalAFA Community Child HealthD1 Community Dental PracticeT41 Community Mental Handicap NursingT21 Community MidwiferyZ27 Community Nursing- Care at HomeZ28 Community Nursing – Care HomesZ29 Community Nursing – Day CareZ1 Community NursingT5 Community Nursing (District Nursing)

G1A Community PsychiatryT31 Community Psychiatric NursingZ2 Continence Service

Z21 Corporate CommunicationsZ14 Day Surgery UnitZ24 Dental Emergency – Out of HoursRC Dental HygieneDB Dental & Maxillofacial RadiologyD7 Dental Public HealthRD Dental Surgery AssistanceRS Dental TherapyA7 Dermatology

A82 DiabetesR3 DieteticsZ22 DREAMS (Dep’t of Rehabilitation Elderly and Mobility Services)C5 Ear, Nose & Throat

RK1 ElectroencephalographyRK2 ElectrocardiographyZ13 Emergency ReceivingA81 EndocrinologyA8 Endocrinology & Diabetes

Z10 EndoscopyZ6 EstatesF1B Family Planning ServiceG3 Forensic PsychiatryA9 GastroenterologyD2 General Dental PracticeA1 General MedicineT1 General NursingE1 General PracticeG1 General PsychiatryC1 General SurgeryC11 General Surgery (excludes vascular)AA Genito-Urinary MedicineAB Geriatric MedicineE11 GP ObstetricsE12 GP (Other than Obstetrics)F2 GynaecologyJ4 Haematology

Specialty(Cont)

J1 HistopathologyZ17 Health RecordsT6 Health Visiting

R81 Hearing AidsAC HomeopathyZ7 Hotel Services


27


J5 ImmunologyR41 Industrial TherapistsA6 Infectious DiseasesCC Intensive Care MedicineG5 Learning Disability (Mental Handicap)Z11 LymphodemaZ23 Medical Emergency – Out of HoursJ6 Medical Microbiology & VirologyAD Medical OncologyAT Medical OphthalmologyRM Medical PhotographyR9 Medical PhysicsT4 Mental Handicap NursingT3 Mental Health NursingJ61 MicrobiologyT2 MidwiferyAH NeurologyC6 NeurosurgeryH3 Nuclear MedicineT8 Nursery Nursing

Z25 Nurse SpecialistF3 ObstetricsF1 Obstetrics & Gynaecology

F31 Obstetrics AntenatalF32 Obstetrics PostnatalAK Occupational MedicineR4 Occupational TherapyC7 OphthalmologyC13 Oral and Maxillofacial SurgeryD4 Oral MedicineDA Oral MicrobiologyD9 Oral PathologyD3 Oral SurgeryD5 OrthodonticsZ15 OutpatientsZ16 Out of HoursZ18 ParkingA21 Paediatric CardiologyD8 Paediatric DentistryCA Paediatric SurgeryAF Paediatrics

C31 Pain ManagementAM Palliative MedicineRA PharmacyRE Physiological MeasurementRB PhysiologyR5 PhysiotherapyC9 Plastic SurgeryP1 Prison ServicesRF Prosthetics / OrthoticsG4 Psychiatry of Old AgeG6 PsychotherapyAN Public Health MedicineAP Rehabilitation MedicineAG Renal Medicine


28


AQ Respiratory MedicineD6 Restorative DentistryZ4 Retinal ScreeningAR RheumatologyT7 Sick Children’s NursingT11 School NursingZ3 Sexual Health

Z27 Social care – Care at HomeZ28 Social care – Care HomesZ29 Social care – Day CareDE Special Care DentistryR6 Speech & Language TherapyDC Surgical DentistryR11 Surgical PodiatryZ5 TheatresRL Therapeutic Radiography

C42 Thoracic SurgeryC8 Trauma & Orthopaedic Surgery

RK3 UltrasonicsCB UrologyC12 Vascular SurgeryJ62 VirologyF1A Well Woman Service

Table 5: Received Method


Received Method

LETTER Complaint was received by letterEMAIL Complaint was received by e-mailFAX Complaint was received by fax

SUGGESTION Complaint was received by on a suggestion form / cardWEBSITE Complaint was received via a websitePHONE Complaint was received by telephonePERSON Complaint was received in person

PRISFORM Complaint was received on Prison Complaint formOTHER Complaint was received by another method not listed

above

Table 6: Health Sector


Health Sector

HB Complaint relates to a Health BoardSHB Complaint relates to a Special Health Board

ACUTE Complaint relates to Acute Hospital ServicesCOMMUNITY Complaint relates to Community Health Services


29


MENTAL Complaint relates to Mental Health ServicesFAMILY Complaint relates to Family Health Services

NATIONAL Complaint relates to National and Support OrganisationsELDERLY Complaint relates to Care of the Elderly

DISABILITIES Complaint relates to Learning DisabilitiesPRISONER Complaint relates to Prison Services

REHAB Complaint relates to treatment received in RehabilitationRESPITE Complaint relates to treatment received in Respite careSOCIAL Complaint relates to Adult Social careOTHER Complaint relates to treatment received outside of

Scotland

Table 7: Outcome Of Complaint


Outcome of Complaint

FULLY Fully UpheldPARTIALLY Partially Upheld

DENIED Not UpheldTRANSFERRED Transferred to another unit

CONSENT Consent not receivedFUNDING Irresolvable – funding

EXPECTATION Irresolvable – complainant’s expectations too highUNREASONAB

LE Unreasonable complaintCONCILIATION Conciliation / mediationWITHDRAWN Complaint Withdrawn

CONCL Not yet determinedOTHER Irresolvable – Other

Table 8: Actions Taken


Action Type

ACCESS Improvements made to service access e.g. booking arrangements, signage, appointment times, patient pathway/journey

ACTION PLAN Action plan instigated e.g. Lead Manager identified to coordinate improvements, service review instigated, service improvements identified

COMMUNICATION

Improvements in communication staff-staff or staff-patient e.g. early engagement and resolution with complainant, meeting with complainant to address reasons for complaint, provide clinical reasons etc., discussions with staff inviting suggestions for improvements, fixed agenda at Board level to team level meetings, arrangements for involving patients e.g. lay involvement in meetings, surveys, patient stories, comments cards, social media

CONDUCT Conduct issues addressed e.g. complaints and future conduct discussed with staff, values and behaviours agreed with staff and integrated into staff culture

EDUCATION Staff education and/or training identified e.g. learning and training opportunities identified, staff training and development implemented e.g. elearning modules, roll out of training programme


30


NO ACTION REQUIRED

No action required e.g. consent not given, irresolvable, due to funding or expectations of complainant too high, not upheld, transferred to another Board/organisation, withdrawn

POLICY Policy or procedure reviewRISK Risks issues identified and added to local risk register

SYSTEM Changes to system e.g. booking system, complaints reporting, recall arrangements, referral, discharge

SHARE Share lessons with staff / patient / public e.g. learning points identified by Service/Senior Managers and shared with teams, demonstrate lessons learned and share on notice boards, posters and dashboards etc., meeting with complainant to share actions plans/service improvements

WAITING Review of waiting times

Table 9: Who submitted the complaint?


Who submitted the complaint

PATIENT Patient or former patientKIN Next of Kin

PARTNER PartnerPARENT ParentCHILD Child

SIBLING SiblingRELATIVE Other relative

CARER CarerFRIEND Friend

NEIGHBOUR NeighbourMINISTER Minister

GP General Practitioner (GP)MEDIA Media

COUNCILLOR Local CouncillorPARLIAMENT MP / MSPSOLICITOR Solicitor

CAB Member of CAB (PASS worker)ADVOCATE Advocate

VISITOR Visitor to the NHSPUBLIC Member of the public

VETERAN Person who has worked in the Armed ForcesOTHER Other

Table 10: Risk Rating


Risk Rating LOW LowLEDIUM Medium


31


HIGH High

Table 11: Complaint Type


Complaint Type

SUGGESTION SuggestionENQUIRY Enquiry

INFORMAL Informal ComplaintFORMAL Formal Complaint

Table 12: Has the Diversity Form been sent?

Code / Description Code Description Has the Equality and Diversity form been sent out?

Y Yes

N No

Table 13: Has the complaint reference number been put on the Equality and Diversity form?

Code / Description Code DescriptionHas the complaint reference number been put on the Equality and Diversity form?

Y Yes

N No

Table 14: Are PASS involved in the complaint?

Code / Description Code DescriptionAre PASS involved in the complaint

Y YesN No

Table 15: Relationship to patient

Code / Description Code DescriptionKIN Next of Kin


32


Relationship to patient

PARTNER PartnerPARENT ParentCHILD Child

SIBLING SiblingRELATIVE Other relative

CARER CarerFRIEND Friend

NEIGHBOUR NeighbourMINISTER Minister

GP General Practitioner (GP)MEDIA Media

COUNCILLOR Local CouncillorPARLIAMENT MP / MSPSOLICITOR Solicitor

PASS PASS workerADVOCATE Advocate

OTHER Other

Table 16: Is consent required?

Code / Description Code DescriptionIs consent required?

Y YesN No

Table 17: Reason why complaint has taken longer than 20 days to resolve? Non mandatory


Reason why complaint has taken longer than 20 days to resolve

CONSULTANT Delayed Response: Consultant/Medical Staff

NURSE Delayed Response: Nursing StaffSTAFF Delayed Response: Other Staff

OFFICER Delayed Response: Complaints OfficerREPLY Delay in drafting reply: Investigating Manager

HOLIDAY Staff on Annual LeaveNOTES Medical Notes: Availability

CLO Draft reply delayed at CLOCOMPLEX Complex nature of investigationCONSENT Delay in obtaining consent

OWNERSHIP Difficulty in establishing who should actionADR Alternative Dispute Resolution (mediation / conciliation)

OTHER Other

Table 18: Has a service improvement been made or is there longer-term plan to be put in place?

Code / Description Code DescriptionY Yes


33

NHS Complaints Information Services DivisionNational Services ScotlandService Improvement / Longer term plan

N No


34

Specialty

Service Area

Staff Group

Patient Admin Type

Issue Raised

Environmental / Domestic

D33. Cleanliness / laundry

01. Bedding

J06. Ancillary Staff

12. Laundry Staff

ACUTE: Hospital Acute Services INPATIENT: Inpatient

C8: Trauma and Orthopaedics Surgery


2. Example On How Codes Will Be UsedA patient who was an admitted as an inpatient to Orthopaedics made a complaint about dirty bedding in the ward after he had his operation. By using the drop down menus on each header, this would be coded as follows:

The code D3301 will be the main issue code. The other codes, for example, J0612 for the staff group, gives additional information about the complaint.

The next sections in this document will contain information on the following:

The fields that are required to be submitted to ISD How the validation and extraction of the data to ISD will be done. Step by step guide on how to input data into the ISD Complaints system

(this will be for the NHS Boards who will use this)


35