Chapter XX:

Health Service Quality

Chapter Outline

Section 1: Introduction
Section 2: Operational standards
Section 3 Implementation Guidance
3.1 Organizational structure for Health Service Quality
3.1.1 Roles and responsibilities of Health Service Quality Directorate/Office
3.1.3 Health Service Quality strategic and annual plan
3.2 Clinical audit
3.3 Quality improvement projects
3.3.1 Quality improvement models
3.3.2 Implementing improvement cycle
3.3.3 Measuring change, communicating findings, documenting and recognizing achievements
3.3.4 Conclusion - Quality Improvement Project
3.4 Clinical Risk Management
3.5 Patient Focused Care
3.6 Benchmarking and experience sharing platforms
Source Documents/References
Appendices
Abbreviations
ANC - Antenatal Care
CEO - Chief Executive Director/Officer
CED - Chief Executive Director
EHAQ - Ethiopian Hospital Alliance for Quality
ER - Emergency Room
FMOH - Federal Ministry of Health
GB - Governing Board
GP - General Practitioner
HMIS - Health Management Information System
HO - Health Officer
HSQ - Health Service Quality
IPD - Inpatient Department
MPH - Master of Public Health
OPD - Out Patient Department
PDSA - Plan, Do, Study, Act
PPE - Personal Protective Equipment
QI - Quality Improvement
RHB - Regional Health Bureau
SMT - Senior Management Team
TB - Tuberculosis
TOR - Terms of Reference
WHO - World Health Organization PDSA Plan, Do, Study, Act
QI Quality Improvement
RHB Regional Health Bureau
WHO World Health Organization
Section 1 Introduction
As per the national quality and safety strategy of Ethiopia, quality is defined as comprehensive
and integrated care that is measurably safe, effective, people-centered, and uniformly delivered
in a timely manner that is affordable to the Ethiopian population and appropriately utilizes
resources and services efficiently. It encompasses seven generally accepted dimensions:

Table 1: Quality Dimensions

Quality dimensions Definitions

Avoiding injuries to patients from the care that is intended to help them; the
Safe WHO defines “patient safety” as the prevention of errors and adverse effects
to patients associated with healthcare.
The care is based on evidence-based knowledge and evidence-based
Effective
guidelines.
It must consider the people’s needs, preferences and values while delivering
health care, characterized by respect and dignity of the users. People-
People-centered
centeredness shifts the power from the health care system
and providers to patients/users of the system.
Reducing waits and sometimes harmful delays for both those who receive
Timely
and provide care.
Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Providing care that does not vary in quality because of personal
Equitable characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
Care provided to the patients is coordinated across the health care platform
Integrated and
individual providers.

Quality management in healthcare needs three core components (Juran Trilogy): Quality Planning, Quality Control and
Quality Improvement. Quality care is achieved not by one aspect. As part of the health system, information about quality
care can be drawn from integration of structure, process and outcomes. SMT and GB should ensure that health service
quality is in place and should monitor their effectiveness. All staff should participate in health service quality activities
specific to their work area.

Quality improvement (QI) is a continuous process whereby organizations iteratively test and measure changes in work
routines, set and achieve ambitious aims, shift whole system performance, and spread best practices rapidly for uptake at
a larger scale to address specific issues set to improve. The content in these operational standards is organized to include
health service quality organizations, all quality dimensions, clinical audits and regulatory accreditation concepts.
Section 2: Operational Standards

1. The hospital has an established Health Service Quality Directorate/Office.

2. The hospital has functional Health Service Quality council/committee
3. The hospital coordinates health service reform activities and integrates into the existing system.
4. The hospital has established a system to manage health care delivery related risks.
5. The hospital has functional clinical audit program
6. The hospital actively participates in collaborative learning and experience sharing platforms.
7. There is regular Hospital to health center support system
8. The hospital develops a system to insure patient preference and value.
9. The hospital regularly conducts patient satisfaction surveys.
10. The hospital has established a health literacy desk.
11. The hospital identifies priority problems in service delivery areas and implements QI projects.
12. The hospital ensures equitable service delivery.
13. The hospital establishes a system to ensure timeliness of care.
14. The hospital establishes a system to control efficiency of healthcare delivery.
 Section 3 Implementation Guidance
3.1 Organizational structure for Health Service Quality

A Health Service Quality Directorate/Office requires a clear and standard structure and framework. The structure
includes the organization's human, physical, and financial resources, such as buildings, staff, equipment, plan and
policies. These structures and serve to:

 Encourage the participation of all staff in continuous Health Service Quality processes.
 Assign responsibility for Health Service Quality processes.
 Ensure activities proceed as planned per the annual plan.
 Maximize quality, effectiveness and efficiency of services.

The hospital should establish a Health Service Quality Directorate/Office reporting to the Chief Executive
Director/Officer (CEO/CED) or relevant body based on hospital level. This unit should be led by an assigned senior
physician, general practitioner, or holder of a Master of Public Health degree or other equivalent professional. This
person will be the Health Service Quality Director/Head. The director/head should be selected using the following
criteria:

 Good clinical leadership capability

 Excellent clinical skills
 Excellent analytic and research skills
 Commitment
 Good understanding of systems thinking and systems change
 Good data-use culture
 Innovative/ creative and able to offer solutions
 Team player

Each clinical department should establish its own QI team, led by the department/case team head, to undertake HSQ
activities. Department heads are responsible for ensuring quality activities occur and reporting them to the HSQ
Directorate/Office. Each department should regularly audit its performance.

3.1.1 Roles and responsibilities of Health Service Quality Directorate/Office

As outlined above, hospitals should establish an HSQ Directorate/Office to oversee all hospital QI functions. The HSQ
Directorate/Office should comprise a director/head and Quality Officers. It should be multidisciplinary, with members
from different clinical and administrative backgrounds. The HSQ Directorate/Office head should be a member of the
hospital senior management team and accountable to the CEO/CED. The HSQ director and officers should serve full-
time in their HSQ roles.
CEO/CED. The HSQ director and Directorate/Officers should be full time in their role for HSQ activities.

HSQ Unit Roles include:

a) Develop the HSQ strategy and present to the Senior Management Team for approval,
b) Develop an HSQ strategy implementation plan and monitor execution,
c) Ensure HSQ activities relate to the hospital's vision and mission, aligned with strategic and annual plans,
d) Coordinate all HSQ activities,
e) Promote and support staff participation in HSQ activities,
f) Receive and analyze feedback from patients, staff and visitors,
g) Receive clinical audit reports and maintain records of all clinical audit activities,
h) Review selected hospital deaths as part of death audit committee,
i) Work closely with the HMIS Office to monitor performance
j) Conduct peer review in response to specific quality and safety concerns and take appropriate action and follow-up
when deficiencies are identified,
k) Build capacity of hospital staff on QI activities and findings.

This unit should collaborate closely with the Medical Director as activities are closely related.

Departmental Quality Improvement team/taskforce

Irrespective of the workload, the hospital should establish a departmental/case team level QI team/taskforce to undertake
some of the above functions. Each departmental QI team should be chaired by the department/case team director/head
that provides regular update reports to the HSQ office.

3.2 Clinical Audit and Death Audit

A. Clinical Audit
Clinical audit is defined as a quality improvement process seeking to improve patient care and outcomes through
systematic review of care against explicit criteria and implementation of change. It involves assessing structure, process,
and outcomes against agreed standards and introducing changes based on identified gaps with further monitoring to
ascertain improvements.

Hospitals should establish and implement a clinical audit program with identifiable service areas. Clinical audit involves
5 main steps:

i. Audit planning
for successful clinical audit, adequate preparation is very important. Planning involves three essential
components:
  Identifying stakeholders - those involved in the audited activity including service providers and users. Including
the unit head will be beneficial.
 Identifying the audit topic - it is necessary to decide the topic in advance. With several topics, the team should
prioritize resources efficiently.
 Planning the audit field work - the audit objective should be clearly understood by all stakeholders, required
skills and personnel identified, appropriate training and briefing conducted on roles, and a comprehensive
proposal developed with adequate resources and timetable.

ii. Develop standards/criteria for clinical care in the selected area

Standards/criteria may include:
 National or international drug treatment guidelines,
 National or international diagnostic and treatment guidelines,
 ‘Best practice evidence’ from literature reviews
 National clinical audit guideline as a reference.

iii. Assess current practice against standards

This can be done through retrospective or prospective case note review, direct observation, surveys or
interviews.

iv. Take action to address identified deficits in clinical care (Conduct QI activities)
If the audit identifies suboptimal care, reasons should be investigated using qualitative methods like those in
Table 1. Investigation should involve relevant stakeholders to address the problem comprehensively. Findings
should inform recommendations for practice change.

Table 2. Summary of qualitative study methods

METHOD ADVANTAGES DISADVANTAGES

Focus Group Discussion  Inexpensive  Groups may not represent

 < 2-hour recorded discussion  Quick the larger population

 6–10 non-random respondents  Easy to organize  Successful outcome depends heavily

 2–4 discussions for each  Identifies range of on moderator skills

significant target population beliefs  Recorders may inhibit participants.

 Moderator leads discussion

Respondents have similar
characteristics e.g. age, gender,
social status
 Discussion topics pre-defined
 Informal, relaxed, ambient
  Reveals beliefs, opinions and
motives
In-depth Interviews  Can reveal significant  May generate difficult to manage of
 One-to-one extended interview but unsought data data

 Questions are pre-  Time-consuming and expensive

determined but open-ended  Bias due to respondent pleasing
 Often covers up to 30 topics interviewer

Corrective measures will vary but may involve staff training, providing aide-memoires, developing and implementing
guidelines, or ensuring availability of appropriate drugs or diagnostics.

v. Re-assess practices against standards (Sustain improvements)

The audit should be repeated after corrective interventions to measure impact and identify if further action is needed.

Clinical audit enables participation of all clinical staff in QI activities and is an ideal mechanism for multidisciplinary
teams or department staff to improve performance collaboratively. Ideally all clinical staff should participate in at least
one clinical audit project annually and findings should be shared across the hospital. All staff should be encouraged to
identify potential audits based on observed clinical activity and outcomes. Similarly, hospital management may
recommend an audit in response to reported outcome measures. For example, a high or increasing postoperative
infection rate may prompt an audit of prophylactic antibiotic use for surgeries, to identify adherence to guidelines.

The HSQ Directorate/Office should receive all Clinical Audit Reports and maintain a record of audits undertaken.
Participation in clinical audit could be a performance measure for staff undergoing evaluation, or when assessing
department contributions to hospital strategic plans.

If possible, the hospital should appoint a clinical audit officer to support activities, including helping design protocols
and tools, data entry and analysis alongside clinical staff. If this is not feasible, hospital management should ensure
necessary equipment and supplies are available to audit staff.

The HSQ Directorate/Office should ensure clinical audits occur in the hospital. The Governing Board may include
completed audits as an indicator on the Balanced Scorecard for monitoring performance.

B. Death Audit

The death audit committee, led by the Chief Clinical Officer (CCO), should consist of members from the quality unit and
other relevant departments. The audits should be conducted regularly, with deaths being audited at the departmental
level. Additionally, it is essential to prioritize the audit of all maternal deaths, given their unique considerations and the
need for specialized care. By following these guidelines, healthcare organizations can effectively identify areas for
improvement and implement necessary changes to enhance patient safety and healthcare outcomes.

3.3. Quality Improvement Projects

Quality improvement projects in healthcare are systematic, data-driven initiatives to enhance efficiency, effectiveness,
and safety of care delivery processes, ultimately improving patient outcomes and satisfaction. They involve identifying
areas for improvement, implementing evidence-based interventions, continuously monitoring and evaluating results to
ensure sustained progress.

3.3.1 Quality improvement models

The two selected QI Models to be used in the Ethiopian healthcare are:

1. Kaizen: Engine driving improvement or entry point of all QI activities

2. Model for Improvement: Vehicle that provides structure for improvement

KAIZEN

 Focuses on improving efficiency and lowering costs.

 Key feature is big results from small changes accumulated over time.

Implementation steps
5S establishes an ideal workplace for continuous improvement. It is a philosophy and way of organizing and managing
workspace and workflow to improve work efficiency. 5S shall be conducted systematically with staff participation.
 Figure 1: Kaizen/5S

1. Sort: remove unused stuff from working area by:

• Categorizing and color code the items.
• Developing inventory list of categorized items.

• Storing “may be needed” items.

• Regularly sorting of unused items.
• Developing a culture of returning items where they belong.

2. Set in order: organize necessary items in proper order for easy service provision:
• Labeling/numbering cabinets
• Keeping items in respective areas and labeling them
• Directional arrows to services areas.
• Labeling service rooms.
• Updating equipment/stock inventories.

Note: Rules and regulations must be written and known to all staff

3. Shine: maintain high cleanness standards:

• Routine cleaning and mass cleaning campaigns
• Clean behind and under furniture/equipment
• Clean and attractive environment appreciated by clients

4. Standardize: the first three components set the stage for to develop and implement
standard operating procedures to maintain good work environment.
• Set up the sort, set and shine as a norm in all sections
• Work instructions
• Standard operating procedures (SOPs)

• Standards and regulations for administrative and technical staff

5. Sustain: train and maintain discipline of engaged staff through consistent 5S practice:
• Train and maintain staff discipline
 • Apply regular self-assessment.

THE MODEL FOR IMPROVEMENT

The model of improvement asks three fundamental questions:

• What are we trying to accomplish?
• What change can we make that will result in improvement?
• How will we know a change is an improvement?

What are we trying to accomplish?

This encourages clear aim-setting. The aim should be:
• Specific – described clearly and precisely, identifying beneficiaries and achievements
• Measurable – progress can be tracked using data
• Ambitious - may not know how to achieve initially but shouldn't limit bold targets if
aligned with customer needs/expectations and achievable
• Relevant – meaningful to others if requiring resources or support
• Time-bound – clear timeframe for achievement

“What change can we make that will result in improvement?”

This prompts thinking about changes that may help achieve the aim - change ideas. Change is required for improvement,
but not all changes result in improvement. Many techniques and tools can identify successful changes like:

• Benchmarking against better performers to identify differences

• Consulting experts to determine best practices
• Using root cause analysis tools like 5 whys and fishbone diagrams
• Applying creativity tools such as provocations and random words to think
innovatively
• Checking lists of change concepts to generate ideas
• Mapping key process steps to identify potential improvements

“How will we know the change is an improvement?”

Measurement question means finding a way to demonstrate the aim is achieved - the outcome measure. Before making
changes, the current outcome measure provides a baseline. Observing what happens to the outcome measure with
different changes then shows if there is improvement correlated to the intervention. A process measure related to the
change provides insight into how well it is being implemented.

Combined with the Plan-Do-Study-Act (PDSA) test cycle, the Model for Improvement is the foundational framework
for successful improvement activities.

Figure 2: The PDSA Cycle, a model for Quality Improvement

Plan – Do – Study – Act cycle (Deming cycle)

Step 1: Plan
• Plan the test, including data collection.
• State the test objective.
• Make predictions about what will happen and why.
• Develop a test plan. (Who? What? When? Where? What data to collect?)
Step 2: Do
• Try the test on a small scale.
• Carry out the test.
• Document problems and unexpected observations.
• Begin data analysis.

Step 3: Study
• Refine the change based on learning.
• Compare data to predictions.
• Summarize learning.
 Step 4: Act
• Refine the change, based on what was learned from the test.
• Determine modifications needed.
• Prepare next test plan.

PRINCIPLES OF IMPROVEMENT
Fundamental to the success of any improvement effort is the understanding that improvement requires change -
altering how work is done to produce visible, positive differences relative to goals with lasting impact. Not all changes
result in improvement, some just reset things. Doing more of the same does not necessarily bring change.

TYPES OF CHANGES

Reactive change: needed to maintain current performance

Fundamental change: required to create new performance systems through redesign and
fundamentally altering how the system works.

Fundamental changes that result in improvement

• Alter how work or activities are done
• Produce visible, positive difference relative to historical norms

• Have lasting impact

Improvement is characterized by being faster, easier, more efficient, effective, less expensive,
safer, cleaner, etc. The extent relates directly to the nature of implemented changes.

DRIVERS OF IMPROVEMENT IN HEALTH CARE

The drivers of Improvement are:

• Will: Desire to change current state to better state.
• Ideas: Developing ideas to improve processes and outcomes.
• Execution: Applying QI theories, tools and techniques enabling idea implementation.
 Figure 3: Drivers of quality improvement in health care

QUALITY PLANNING AND MONITORING

Successful quality improvement programs include four key elements:

1. The Problem
• In-depth understanding of the problem
• System-wide buy-in for the initiative and targeted problem
2. The Goal
• Targeted improvements based on a return on investment (ROI) and cost-benefit analyses
• Key questions when defining goals:
o How does this tie into strategic improvement objectives?

o What will have the biggest patient impact?

o What areas have largest variation?
o What will have the biggest cost impact?
3. The Aim

 Breaks up goal achievement into manageable pieces.

4. The Measures

 Measuring baselines and actuals

 Determining if and how the improvement correlates to the intervention

3.3.2 Implementing improvement cycle

Health center performance and quality need continuous improvement. The cycle involves:
 Step 6 – Monitor
action plan
Step 1 – Review
progress and performance and
expected quality
achievements

Step 5 – Prepare
Step 2 –
detailed action plan
Identify and
to implement
intervention prioritize
problems

Step 4 – Select Step 3 – Conduct root-cause analysis

interventions
addressing root-
causes
 Figure 4: Quality improvement implementation cycle

Identify the problems and prioritize

From the indicator and issue review in Step 1, list problems needing improvement. Select a
manageable number as monthly priorities. Improving all areas simultaneously may not be
possible, so the facility should choose priority areas for the timeframe before taking
improvement actions.

First priority should be problems solved with few resources, followed by more complex,
expensive ones. However, more difficult areas may need addressing first if impact is
significant. Performances related to national & regional priority areas (TB, Malaria, HIV,
Maternal and Child health) should be priority considerations.

Conduct root-cause analysis of the problem

Understanding the causes helps develop appropriate interventions. Targeting changes to

causes enables sustainable improvement versus superficial solutions. Fishbone analysis and
flowcharting are common techniques for identifying root causes.

Fishbone analysis steps

1. Place the problem to be analyzed and improved in a box at the end of a horizontal arrow
2. Categorize major cause areas (policy, process, people, environment, infrastructure) and
connect them to the backbone with diagonal arrows
3. To find secondary, tertiary, etc causes ask "why did this happen?" under each category
4. Repeat until reaching the root cause

Figure 5 illustrates a fishbone diagram analyzing causes of “Low skilled birth attendance in our area”
 Policy

Process

Absence of social health insurance

Poor delivery service quality

Lack of respect to laboring mothers

Lack of in-service training Health center

Low skilled birth attendance in our catchment
doesn’t plan for capacity building

Culture to give birth at home

Lack of transportation to bring mother to health center

Low level of awareness

Vehicle of the health center is not accessible for delivery Low economical status

Low commitment to delivery service

Environment Infrastructure

Community

Figure 5: Fishbone analysis of root causes in quality problems

Flow chart steps

1. Decide beginning and end points of the process to chart
2. Identify process steps
3. Link steps with directional arrows. May also use symbols:

Begin or End

Step

Decision

Flow Lines

Connectors

Delays
Select interventions that address the root-cause
Following root cause analysis, design an intervention addressing the root cause directly for sustainable
problem-solving versus superficial fixes. When selecting interventions, consider cost and
implementation feasibility.

Prepare detailed action plan, implement the intervention, monitor the progress and
expected achievements
Here, the team prepares an action plan to implement selected interventions and collect relevant
monitoring data using the PDSA cycle. The team should discuss implementation status and evaluate if
the intervention is leading to improvement or requires continuation, modification, or discontinuation.
The cycle then continues.

3.3.3 Measuring change, communicating findings, documenting and recognizing

achievements
Along with implementing quality improvement strategies, the care quality level needs continuous
measurement against set goals to track changes. Findings from quality measurement, after analysis,
provide advocacy tools to take further improvement actions - mobilizing resources, creating
competitiveness among providers, and increasing user awareness.

3.3.4 Conclusion - Quality Improvement Project

The above steps may result in a quality improvement project to address specific facility deficiencies
through a strategic approach. The QI project process involves: quality assessment comparing
performance to expectations/standards/goals; identifying gaps and root causes; designing and
implementing best interventions within available resources; and continuous monitoring and evaluation
of outcomes.

3.4 Clinical Risk Management

Risk is the likelihood, from low to high, of somebody or something experiencing harm from an
unwanted event or incident, multiplied by the severity of potential harm. Clinical risk management is an
approach to improving the quality and safety of care by emphasizing identifying circumstances putting
staff/patients at risk of harm and acting to control those risks.

Risk management involves assessing the environment for potential patient and staff risks, then taking
action to minimize identified risks. The risk management process seeks to answer four related
questions:

How bad?

Is there a need for

What can go
action?
wrong?

How often?

Figure 6: Risk management

Risk management proactively reduces identified risks to an acceptable level by creating a culture
founded upon assessment and prevention culture, rather than reaction and remedy. Risk assessment
examines:
Hazards – situations with potential for cause harm; and
Risks - defined as the probability a specific adverse event will occur in a timeframe or because of a
situation.

Risk assessment involves 5 steps:

Step 1 Identify hazards (what could go wrong) - Consider past incidents and near misses. Walk
around and discuss with patients and staff. Map/describe the assessed activity. A
multidisciplinary team may be needed.

Step 2 Decide who may be harmed and how (what can go wrong, who is exposed)

Step 3 Evaluate risks (severity, likelihood) and precautions needed - Use a risk matrix like Table
3.

Step 4 Record findings, proposed actions and responsible persons

Step 5 Review and update the risk assessment as needed

Table 3 Risk Assessment Matrix

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood

Low risk (green) – quick, easy measures should be implemented

immediately and further action planned when resources permit.

Moderate risk (yellow) – actions should be implemented as soon as

possible, but no later than one year.

High risk (orange) – actions should be implemented as soon as possible,

but no later than six months.
Extreme risk (red) – action should be taken immediately.

Hospitals should establish systems for regular risk assessment from healthcare provision and delivery,
ensuring steps are taken to minimize risk. Each department should regularly (quarterly) conduct risk
assessment and identify risk minimization actions. The whole team should be involved in an open,
learning environment. Areas for consideration include, but are not limited to:

Physical environment – clean, safe, hazard-free?

 Emergency exits clearly labeled and unobstructed?
 Infection prevention policies and procedures adequately implemented?
 Hazardous materials safely and securely stored?
Equipment in good working order with maintenance minimizing errors and breakdowns?
 Medication administration policies implemented to reduce errors?
 Laboratory policies ensuring correct samples from patients, accurate timely results?
 Clinical guidelines adhered to for evidence-based practice?
A ‘Safety Walk-Round’ is another Risk Management approach. A leadership/quality team visits areas
asking frontline staff about events, contributing factors, near misses, potential problems and solutions.
Issues are then prioritized for the department to develop solutions. This often embeds solutions in the
descriptions, enabling prompt care and safety improvements. It can lead to culture change as frontline
concerns are addressed through ongoing hazard observation and discussion with leadership. Safety
Walk-Rounds are a low-cost way to identify frontline staff concerns and make needed changes without
additional resources.

3.5. Patient focused care

Patient-centered care includes care quality - the compassion, dignity and respect shown. Every patient
wants to be treated as an individual and has rights to courtesy, privacy and confidentiality, and full
information about their condition, investigations and treatments. Patient-centered care involves
planning and delivering quality care in partnership between staff, patients and caregivers. Effective care
balances:
Consideration
Talking and Listening

Hospitals should adopt a Patient Rights and Responsibilities Statement readily available to patients like
posting in outpatient/inpatient areas. All staff should be aware of the Statement to treat patients
accordingly.

Patient-centered care also includes quality of hotel services like housekeeping, food services, etc. The
hospital should ensure high standards of these services within the budget by outsourcing to improve
quality and cost-efficiency.

Patient-centered care is improved by analyzing patient satisfaction. Hospital management and

Governing Board should monitor patient perspectives on care through Patient Satisfaction Surveys.
Appendices F and G contain validated Inpatient and Outpatient Satisfaction Surveys. Surveys should be
conducted quarterly with summary results reported to the Board, analyzed, and acted upon through
detailed action plans or linked to QI projects. Results can be included in the hospital’s Balanced
Scorecard. Additionally, staff attitudes and relationships with patients and caregivers should be a
component of performance evaluation. (refer Human Resource Management chapter).
Patient and public involvement in healthcare planning and implementation
Services should be tailored to population needs and expectations. Patient and public perspectives help
identify what works and doesn't in service delivery. Before involvement, important considerations are:
 What information is needed,
 Why their views are needed,
 How their views will be used, and
What patients/services will gain from this involvement.

Involvement can occur through:

Informing: where people passively receive information,
Consulting: where the users of a service are asked to give information or advice, or
Partnership: involving the public in decision-making.

The involvement level will influence who is involved and the approach. For example, informing the
public about diarrhea management may use posters at the hospital/community or lectures. Establishing
a new child clinic may involve focus groups, surveys or public meetings. Each situation requires
tailored involvement for the purpose. Using multiple approaches gives more people chances to
participate. All approaches have strengths/weaknesses and may overlap.

Health Literacy Desk

Health literacy is understanding and using health information to make informed care decisions.
Hospital health literacy desks significantly help clients learn about their health and make informed care
decisions.

Hospitals should establish a Health Literacy Desk coordinated by an assigned health education focal
point, with additional professionals as needed based on hospital tier. The unit should maintain a register
with patient details like name, address, diagnosis, information provided, contact number, etc.
Preferably, leaflets/posters should be in local languages. Audiovisual materials are also recommended.

3.6. Benchmarking and experience sharing platforms

In 2012 GC, Ethiopia launched the Ethiopian Hospital Alliance for Quality (EHAQ) clustering
hospitals nationwide. Purposes include learning, experience sharing, support, mentoring, resource
sharing and synergy towards improvement.
EHAQ hospitals are evaluated against requirements through self-then external assessment by trained
auditors authorized by the Ministry/Regional Health Bureau. The audit tools introduced in each EHAQ
cycle can be used for training, mentoring and supportive supervision. The national EHAQ audit team
supports hospitals and conducts audits and recognition. EHAQ provides a learning opportunity for
continuous healthcare quality improvement and an ideal mechanism for efficient and effective resource
management.

Additionally, as part of the health system, hospitals should support health centers technically,
materially, and with human resources to improve quality of care.
Source Documents
1. Federal Ministry of Health, Ethiopia. National quality strategy review document; 2021-2025.
2. Department of Health. (2000). An Organisation with a Memory. London, England: Her Majesty’s
Stationary Office.
3. Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring. The Definition of
Quality and Approaches to its Assessment. Vol. I.Ann Arbor, MI: Health Administration Press.
4. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). Health Management
Information System/Monitoring and Evaluation. Strategic Plan for the Ethiopian Health Sector.
Addis Ababa, Ethiopia.
5. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector. Addis Ababa,
Ethiopia.
6. Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Population. New England Journal of Medicine, 2009; 360:491-9.
7. Institute of Medicine. (1999). To Err is Human. Building a Safer Health System. Washington, DC:
National Academy Press.
8. NHS Quality Improvement Scotland. (2005). National Standards. Clinical Governance and Risk
Management: Achieving Safe, Effective, Patient-Focused Care and Services.
9. Standards Australia and Standards New Zealand. (2004). AS/NZS 4360:2004. Risk Management.
Sydney, NSW. ISBN 0 7337 5904 1.
10. World Health Organization. World Alliance for Patient Safety. (2005). WHO Draft Guidelines for
Adverse Event Reporting and Learning Systems. From information to action. . Retrieved
from:http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf.
11. World Health Organization. Patient Safety, World Alliance for Safer Healthcare.(2009).
Implementation Manual Safe Surgery Checklist 2009. Retrieved
from:http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf.
12. World Health Organization. (2009) WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves
Lives. Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.
Appendices
Appendix A Sample Risk Assessment Template

Date of Risk Assessment: dd/mm/yy

Case Team/Service Area: Example- Operating Theatres

Participants who took part in Risk Assessment: (list names and positions)

Risk Assessment Matrix:

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood
Hazard identified Consequence(negligibl Likelihood(rare, Category(green, Action to be Responsible Date for
e, minor, moderate, unlikely, possible, yellow, orange, taken person completion of
major, catastrophic) likely, almost red) action
certain)

1. Old broken equipment in Moderate Likely ORANGE Remove Head of Case Within one week
corridor and potential that equipment to Team(name) by dd/mm/yy
patients or staff may trip maintenance
and fall, or injure department
themselves on the items

2.No sharp boxes available Major Likely RED Install sharp Senior Within two days
and potential to cause boxes Nurse(name) by dd/mm/yy
needle-stick injury to staff or
patients

3.Interrupted electrical Catastrophic Possible RED Back-up CEO As soon as

supply potential for failure generator to be possible, no later
of lights, anaesthesia installed than 3 months
machine during surgical dd/mm/yy
procedure and hence
patient harm

4.Shortage of nursing staff Catastrophic Possible ORANGE Add more Case Team Head Within three
to monitor patients in nursing staff to and Head of months, i.e. by
‘recovery’ area and potential department or Human Resource dd/mm/yy
harm due to poor change skill mix Department
monitoring and clinical care of existing staff

5.Lack of pre-surgical Major Possible ORANGE Prepare pre- Senior Within two
checklist and potential for surgical checklist Surgeon(name) months, i.e. by
cancelled surgery because and train ward dd/mm/yy
patient not prepared staff in its use
adequately
Appendix B Sample Statement of Patients’ Rights and Responsibilities

Your Rights and Responsibilities as a Hospital Patient

We consider you a partner in your hospital care. When you are well-informed, participate in
treatment decisions, and communicate openly with your doctor, nurse and other hospital staff,
you help make your care as effective as possible. This hospital encourages respect for the
personal preferences and values of each individual.

While you are a patient in our hospital, your rights include the following:

1. You have the right to considerate, respectful and safe care.

2. You have the right to be well informed about your illness, possible treatments,
likely outcomes and unexpected outcomes and to discuss this information with
your doctor.
3. You have the right to know the names and roles of people treating you.
4. You have the right to consent to or refuse a treatment, as permitted by law, throughout
your hospital stay. If you refuse a recommended treatment, you will receive other
needed and available care.
5. You have the right to have an advance directive, such as a living will or health care
proxy. These documents express your choices about your future care or name someone
to decide if you cannot speak for yourself. If you have a written advance directive, you
should provide a copy to the hospital, your family, and your doctor.
6. You have the right to privacy. The hospital, your doctor and others caring for you will
protect your privacy as much as possible.
7. You have the right to expect that treatment records are confidential unless you have
given permission to release information or reporting is required or permitted by law.
When the hospital releases records to others, such as lawyers or insurers, it emphasizes
that the records are confidential.
8. You have the right to review your medical records and to have the information
explained, except when restricted by law.
9. You have the right to expect that the hospital will give you necessary health services to
the best of its ability. Treatment, referral, or transfer may be recommended. If transfer
is recommended or requested, you will be informed of risks, benefits, and alternatives.
You will not be transferred until the other institution agrees to accept you.
10. You have the right to know if this hospital has relationships with outside parties that
may influence your treatment and care. These relationships may be with educational
institutions, other health care providers, or insurers.
11. You have the right to consent or decline to take part in research affecting your care.
If you choose not to take part, you will receive the most effective care the hospital
otherwise provides.
 12. You have the right to be told of realistic care alternatives when hospital care is no
longer appropriate.
13. You have the right to know about hospital rules that affect you and your treatment
and about charges and payment methods. You have the right to know about hospital
resources, such as social and religious services, or ethics committees, that can help
you resolve problems and questions about your hospital stay and care.
14. You have the right to have an autopsy done by a physician who is not affiliated with
this hospital and/or to have it done at an unaffiliated institution. Any person
authorized to give consent for an autopsy will receive this information before signing
the consent or giving consent by telephone.
15. You have the right to be free from all forms of abuse or harassment.

You have responsibilities as a patient.

1. You are responsible for providing information about your health, including past
illnesses, hospital stays, and use of medicine. You are responsible for asking questions
when you do not understand information or instructions. If you believe you can’t follow
through with your treatment, you are responsible for telling your doctor.

2. This hospital works to provide care efficiently and fairly to all patients and the
community. You and your visitors are responsible for being considerate of the needs
of other patients, staff, and the hospital.

3. You are responsible for providing information for insurance and for working with
the hospital to arrange payment, when needed.

4. Your health depends not just on your hospital care but, in the long term, on the
decisions you make in your daily life. You are responsible for recognizing the effect of
life-style on your personal health.

5. A hospital serves many purposes. Hospitals work to improve people’s health; treat people
with injury and disease; educate doctors, health professionals, patients, and community
members; and improve understanding of health and disease. In carrying out these
activities, this institution works to respect your values and dignity.

You have the right to be free from restraints of any form (physical or chemical) and/or seclusion
that are not medically necessary.
A restraint can only be used if needed to improve your well-being and when less restrictive
interventions have been determined to be ineffective. A restraint may be used to ensure your
safety and/or that of others.

There must be an order for restraints, and that order should never be written as standing or as
needed. This order must:

 be followed by consultation with the treating physician as soon as possible if not

ordered by the treating physician
 be in accordance with a written modification to the plan of care
 be implemented in the least restrictive manner possible
 be in accordance with safe and appropriate restraining techniques
 end at the earliest possible time

Your condition must be continually assessed, monitored and revaluated.

Staff involved must have ongoing restraint education and training.

Seclusion is the involuntary confinement of a person where the person is physically prevented
from leaving. A physician or other Licensed Medical Practitioner (LMP) must see and evaluate
the need for the restraint or seclusion within one hour after its initiation.

Time limits exist for which orders for restraint or seclusion are valid, depending upon your
age. After the order expires, the physician or LMP must see and assess you before issuing a
new order.

A restraint and seclusion may not be used simultaneously, except in certain situations.

For more information about your rights regarding restraint or seclusion, please contact
………………. (Hospital state the contact person and details here).

Complaints and Grievances

We would like to resolve any concern you might have as soon as possible. Please first discuss it
with the staff looking after you; you may also request to speak to the nurse in charge, assistant
manager or manager. If you are not satisfied with the results, you may contact the ……
(Hospital to specify here).
Appendix C Sample Patient Satisfaction Survey Tools

Outpatient Assessment of Health Care (O-PAHC) Survey

Survey No. Health Facility Name:

Age Ethiopian Date (DD/MM/YYYY):

Male 1 Female 2
Morning/Afternoon Department:

Strongly
Strongly Disagree Disagree Agree Agree
1. During this visit, nurses treated me with
1  2  3  4 
courtesy and respect.
2. During this visit, nurses listened carefully to me. 1  2  3  4 
3. During this visit, nurses explained things in a
1  2  3  4 
way I could understand.
4. During this visit, doctors/health officers treated
1  2  3  4 
me with courtesy and respect.
5. During this visit, doctors/health officers listened
1  2  3  4 
carefully to me.
6. During visit, doctors/health officers explained
1  2  3  4 
things in a way I could understand.
7. I could distinguish between doctors/health
1  Yes 2 No
officers and nurses.
8. The outpatient department was clean. 1 2  3  4
9. The bathrooms/latrines were clean (leave blank
1 2  3  4
if not applicable).
10. I was prescribed new medication at this visit. 1 Yes 2 No, Skip Q11, 12, & 13
11 The staff told me what the medication was for. 1  Yes 2  No
12 The staff described the medications possible
1  Yes 2  No
side effects in a way I could understand.
13 All the medications I needed were available at
1  Yes 2 No
the drug dispensary here.
14 Someone discussed with me what symptoms to
1  Yes 2  No
look out for after I left the health facility.
15. It was easy for me to find my way around the
1  Yes 2 No
facility.

16. On a scale of 0-10 (0 being the worst facility, 

10 being the best facility), how would you rate this 0 1 2 3 4 5 6 7 8 9 10
health facility?
Worst…....................................................................................Best
17. I would recommend this outpatient 1 2 3 4
department/clinic to my friends and family. Definitely no Probably no Probably yes Definitely yes
18. I had to pay for this outpatient visit. 1 Yes 2  No, Skip Q19
19. I consider this outpatient visit too expensive. 1  Yes 2 No
Inpatient Assessment of Health Care (I-PAHC) Survey

Survey # Health Facility Name Department Ward:

Ethiopian Date (DD/MM/YYYY): Age:

Male 1 Female 2

Never Sometimes Usually Always

1. During this health facility stay, how often did nurses treat you
1 2 3  4
with courtesy and respect?
2. During this health facility stay, how often did nurses listen
1 2 3  4
carefully to you?
3. During this health facility stay, how often did nurses explain
1 2 3  4
things in a way you could understand?
4. During this health facility stay, how often did doctors/health
1 2 3  4
officers treat you with courtesy and respect?
5. During this health facility stay, how often did doctors/health
1 2 3  4
officers listen carefully to you?
6. During this health facility stay, how often did doctors/health
1 2 3  4
officers explain things in a way you could understand?
7. I could distinguish between doctors/health officers and nurses. 1 2 3  4
8. During this health facility stay, how often was the room you
1 2 3  4
were sleeping in kept clean?
9. During this health facility stay, how often was the area around
1 2 3  4
you quiet at night?
10. During this health facility stay, how often did you have
1 2 3  4
enough personal privacy?
11. During this health facility stay, did you experience any pain? 1  Yes 2 No, Skip 12 & 13
12. During this health facility stay, how often was your pain well
controlled? 1 2 3  4
13. During this health facility stay, how often did staff do
1 2 3  4
everything they could to help you with your pain?
14. During this health facility stay, were you given any
1  Yes 2  No, Skip 15 & 16
medication that you had not taken before?
15. Before giving you any new medication, how often did staff
1 2 3  4
tell you what the medicine was for?
16. Before giving you any new medication, how often did staff
1 2 3  4
describe possible side effects in a way you could understand?
17. Did anyone discuss with you what symptoms to look out for
1  Yes 2 No
after you left the health facility?
18. Was it easy to find your way around the health facility? 1 Yes 2 No


0 1 2 3 4 5 6 7 8 9
19. On a scale of 0-10 (0 being the worst facility, 10 being the 10
best facility), how would you rate this health facility? Worst facility
..............................................................Best
facility
1 2 3 4
20. Would you recommend this health facility to your friends and
Definitely Probably Probably Definitely
family?
no no yes yes
21. Did you have to pay for this health facility stay? 1Yes 2  No, Skip Q22

22. Do you consider this health facility stay too expensive? 1 Yes 2  No
Appendix D Sample Complaints Management Procedure

Introduction

Any hospital complaint management process tries to answer the following questions:

 How easy is it for patients to make complaints?

 Are patients’ complaints analyzed systematically?
 Do changes occur to the way patients are cared for and treated as a result?
 How are staff trained and supported in patient (customer) care? Communication
skills? Confidentiality issues? Complaints handling?
 Is there recognized customer care practice e.g. codes of conduct?
It is important that all hospitals have an effective complaint management process (referred to as
‘the complaints system’ in this guide) in place for identifying, receiving, handling and
responding appropriately to complaints and comments patients/service users or persons acting on
their behalf make in relation to a service/s or care received.

Even hospitals in high income countries do receive complaints from their service users and
complaints are a fact of hospitals’ business- from minor staff behavioral issues to serious
accusations of incompetence or misconduct.

Patient/client feedback comes in three forms: compliments, comments and complaints. All three
are worth recording as they act as pointers to what’s going right or wrong within your hospital.

Everybody hears and remembers compliments-although they sometimes seem rarer than
comments and complaints! However, even the negative comments worth your attention too as
they can be useful early warnings of dissatisfaction or a weakness in the hospital delivery service
system. Ignoring a negative comment may lead to a full-blown complaint and take up much of
your time and energy.

It is important to remember that whoever receives a complaint is the patient’s or client’s first
point of contact. You will win points both for yourself and the hospital if you seem genuinely
concerned and interested in helping to resolve the matter

This guide is designed to help all hospital staff deal with complaints as quickly and effectively
as possible. It is split into two parts: Section I is for front line staff and contains general tips for
all hospital staff dealing with complaints; Section II deals with general advice for those
responsible for hospital policies and procedures. We hope this guide will help you in handling
complaints from the unhappy patients/clients/service users.
Section I: Dos and don’ts in handling complaints What is a
complaint?

A complaint is a clear expression of dissatisfaction with a given hospital service and it may be:

 A verbal comment serious enough to demand a direct response

 A letter from a client/patient
 A letter on behalf of a patient/client
The must dos at hospital level

For the purposes of assessing, preventing or reducing the impact of unsafe or inappropriate
hospital care, the hospital must:

 Bring the complaints system to the attention of service users and persons acting on
their behalf in a suitable manner and format(including notice/leaflets);
 Provide support to service users and persons acting on their behalf on how to bring
a complaint or make a comment, where such assistance is necessary;
 Ensure that any complaint made is fully investigated and ,so far as reasonably
practicable, resolved to the satisfaction of the service user and person acting on
their behalf and;
 Take appropriate steps to coordinate a response to a complaint where that complaint
relates to care or treatment provided to a service user, and share or notify the
appropriate regulatory body where patient safety has been compromised through
professional misconduct/incompetence/negligence.

Top tips for those handling hospital complaints Listening to a

complaint

The most important thing is to make sure the complainant feel you’re really listening, if you can
take the time and space to listen properly first time around when a client/patient/family
member/friend complaints to you in person or by phone. It will save a lot of extra time and
trouble later on! Here are some useful tips to bear in mind:
 Stay calm
 Take the client/patient/complainant to a private , seated area or take their call in a
quiet zone
 Thank the client or complainant for bringing the matter to your attention
 Ask them to tell you the full story from the beginning, just listen and keep listening-
don’t interrupt or argue
  Empathize-but it is generally better to avoid phrases such as “I know how you
feel”(you can’t)
 Pick up on key words, e.g., ‘You must have been very worried about x (etc.…)”
 Take notes- and check that the complainant agrees with what you’ve written
 Summarize for the complainant what has been said to make sure you
haven’t misunderstood or missed anything.

Say sorry and mean it

Once you’ve listened carefully, express regret that the complainant is dissatisfied. This is often
all the complainant needs, but it must sound genuine. So…
 Be sincere- the person you’re talking to will detect and resent an automatic response
 Remember, an expression of regret will make the complainant feel heard and
understood. It doesn’t mean you are admitting liability-it simply means you are
acknowledging the upset and are ‘sorry that something has happened’, not ‘ sorry it
was caused by anyone’s fault’
 Try not to make apologies on behalf of someone else-or let someone else apologize
for you. The complainant may feel put off and could end up unhappier than before!
 Get the complainant on your side by saying things like, ‘How can we solve the problem?’

Explain quickly and clearly

A prompt and thorough explanation can work wonders too. Here are some key points that might
help, most of which apply to written explanations too:

 Focus on the key issues the complainant is concerned about- and ask in what order
they’d like you to cover them
 Use clear language and explain any health jargon
 Encourage the complainant to ask questions throughout
 Check they have understood, e.g., ‘I’m not sure I’ve put that clearly. Did that
make sense?’
 Ask the complainant if your explanation has answered their concerns
 Reassure them that the matter will be dealt with promptly and that you’ll keep
them informed of progress
 To identity the specific issues of a complaint, it may be helpful to ask
the client/patient/relative to put something in writing
 Never blame other members of staff.
What to do next?

Refer any clinical problems to the hospital medical director or equivalent for university hospitals
as soon as possible

 Ask the complainant what they’d like you to do at this stage and if possible do it
 If the complaint is now satisfied, record the complaint and how you resolved it and send
a copy to the CG&QI Unit.

What if the complainant isn’t satisfied?

 If the complainant isn’t satisfied, ask if they wish to take the complaint further
and explain the ‘Hospital’s Complaints Procedure’. Give them a copy of the
hospital’s complaints’ leaflet
 Agree a plan within the hospital of what action will be taken by whom and by when
 Look at the root causes of the problem and see if there are any changes you could
make to stop it happening again, e.g.:
- Bringing a policy on what to say when a patient’s appointment has been cancelled
- Putting up a notice in the waiting areas inviting patients and visitors to make
comments on a new change in service, etc.
- Displaying information sheets or TV programs on standard treatments or procedures.
 Tell the complainant which member of the hospital service/case team is going to
deal with the complaint and by when.

How to respond in writing

First send out an immediate, brief letter of acknowledgment (see appendix G for a sample
acknowledgement letter) when you receive a written complaint from a complainant. This should
inform the complaint who is going to deal with the complaint and by when.

Remember to respond within 24 hours on receipt of a written complaint and within 28 days to
provide a full response in writing after a full investigation has been carried out.
Appendix E: A sample hospital’s acknowledgement letter to a complaint

[Complainant name]
[Address 1]
[Address 2]
[Address 3]
[

[Date]

Dear [Salutation]

RE:

Thank you for the information you have shared with us about < service name> that we received
on <date>.

The first step is for <name and position of hospital staff> to look at what you have told us. We
will then write to you within <insert date/working days> to inform you about how we will
respond to this information.

A leaflet is enclosed that gives you information about what the Hospital’s Complaint Procedure.

<Additional closing information if appropriate>

Yours sincerely

<Name>
<Job Title>

Encl: Hospital’s Complaint Procedure

Appendix F Hospital’s Complaint Procedure

Most issues can be resolved without you having to make a formal complaint. Try having an
informal chat with your doctor or a member of staff first.

A formal complaint takes time and minor issues are resolved quicker if you just speak to a
person on site. For example, if you are worried about something during your hospital outpatient
appointment talk to one of the nurses or the team leader.

The Federal Ministry of Health calls this informal process 'local resolution' and urges
everyone to see if things can be solved there and then before they escalate to a real problem.

However, if despite everything this doesn’t solve your problem, or even if it does but you would
still like to make a formal complaint, you should follow the ‘Hospital’s Complaints Procedure’
as described below.

Giving feedback and comments

Not all issues have to end up with a complaint. Sometimes it is enough to give feedback or leave
a comment. All hospitals do welcome feedback as it will help improve the quality of their
services.

You can give feedback about the hospital service or staff in person or in writing and the hospital
may respond to your comments.

Stage one: Thinking of making a complaint

If you don't feel like you can solve issues informally then you should make a formal complaint
to the hospital directly. If you cannot make a complaint yourself, then you can ask someone else
to do it for you.

Every hospital has a complaints procedure. To find out about it, ask a member of staff, look
on the hospital’s noticeboards or website, or contact the “Clinical Governance and Quality
Improvement Unit” for more information. Each hospital has this unit.

What to consider before making a complaint

If you decide to make a complaint it's important to consider what you want to happen.
For example:
 Are you content with an apology?
 Do you want action to be taken against a member of staff?
 Do you want a change to the system?
Whatever action you're seeking, make this clear. Before you make your complaint, make a
note of:

 The relevant events;

  Dates
 Times
 Names and conversations, and include all necessary details.
Your notes will also help you to remember all the details in the future. Processing a complaint
can take a while, and you might be asked to verify some information at a later stage.

Whether you decide to complain orally or in writing, try to make your explanations as short and
clear as possible. Focus on the main issues, and leave out irrelevant details.

If you can, talk through what you want to say with someone else, or ask them to read
what you've written before you send it.

If you complain in writing, keep a copy of everything you give to the hospital, and make a
note of when you sent it.

Who can help you make a complaint?

Making a complaint can be daunting, but help is available. Ask a hospital staff to show you
where the “Clinical Governance and Quality Improvement Unit” is and they will offer
confidential advice, support and information on health-related matters to patients, their families
and their carers.

What happens if you are not happy with the hospital response or reply to your written complaint?

If you have already complained to the Case Team Leader/Department Leader/Service Head of
the hospital and you are still unhappy with their response, then contact the hospital manager
(address to be included here). You should provide as much information as possible to allow
your CEO to investigate your complaint, such as:
 Your name and contact details
 A clear description of your complaint and any relevant times and dates
 Details of any relevant hospital staff or services
 Any relevant correspondence, if
applicable When should I complain?

As soon as possible. Complaints should normally be made within 12 months of the date of the
event that you're complaining about, or as soon as the matter first came to your attention.
The time limit can sometimes be extended (so long as it's still possible to investigate the
complaint). An extension might be possible, for instance in situations where it would have been
difficult for you to complain earlier, for example, when you were grieving or undergoing
trauma.

If you made your complaint to the hospital manager you will receive the findings of the
investigation together with an appropriate apology and the changes or learning that have taken
place as a result of the investigation.
Stage two: I am not happy with the outcome of my complaint

If you are unhappy with the outcome of your complaint you can refer the matter to the
Health Service Ombudsman, who is independent of the healthcare system and the
address is:

………
………

Include the following details in your complaint:

 Your name, address and telephone number
 Name and contact details of anyone helping you with the complaint
 Name and contact details of the hospital you wish to complain about
 The factual details of your complaint (listing the main events and when they
happened)
 Why you think your previous complaint wasn’t resolved to your satisfaction,
and how this has caused you injustice
 Details of the complaints you've already made to the hospital and the outcome
of their investigations
 Copies of any relevant documents (it's usually helpful to number these and provide
a list) Keep copies of everything you post, and make a note of when you send it. The
Health Service Ombudsman’s decision is final but this does not take away your human
rights to pursue a civil law suit.

How long will it take to complete an enquiry?

We will aim to complete our enquiry within 20 working days. If we are not able to do
this, we will keep you informed of what is happening.

Contact details
Our contact details are –

<Hospital’s contact details>