QI in Action: Turning Consumer Feedback into Lasting Improvement

We spotlight a QIL project undertaken by Jessie Holberton, Tia Hay, Oliver Campos and Michael Bell around dealing with consumer feedback.

The ACHS Improvement Academy’s Quality Improvement Lead (QIL) Program supports healthcare professionals in implementing data-driven improvement initiatives within their organisations.

At Canberra Health Services, a quality improvement project aimed to improve the timely resolution of consumer complaints while strengthening how feedback was used to drive system-wide improvement.

The Challenge

In January 2024, only 66% of consumer complaints were being resolved within the organisation’s target timeframe of 35 days.

Recognising the importance of responding promptly and effectively to consumer concerns, the project team set an ambitious goal to increase the percentage of complaints resolved within 35 days from 66% to 85% and sustain this performance for at least three months by November 2024.

Canberra Health Services delivers care across the Australian Capital Territory and surrounding New South Wales region. Given its scale, resolving consumer complaints often involves multiple stakeholders, departments and processes.

To better understand the causes of delays, the project team began by analysing complaint resolution processes and interviewing stakeholders from clinical areas experiencing the longest response times. These conversations highlighted challenges in managing complaints efficiently, identifying improvement opportunities, and ensuring lessons learned from feedback were shared across the organisation.

Diagnostic tools, including cause-and-effect analysis and Pareto charting, were used to identify key drivers of delay and prioritise areas for improvement.

Testing Change Through PDSA Cycles

The project team used a series of Plan-Do-Study-Act (PDSA) cycles to test and refine interventions.

Building Understanding Through Stakeholder Engagement: The first PDSA cycle focused on gathering insights from clinical teams responsible for resolving complaints. Stakeholder interviews helped identify practical barriers and informed the development of targeted improvement strategies.

Linking Complaints to Quality Improvement: The second cycle established a process for reviewing complaint themes and subthemes within each clinical division. Rather than closing complaints once resolved, the new approach triggered quality improvement activities in response to recurring issues identified through consumer feedback.

Creating Consistent Improvement Processes: To support this work, the third cycle introduced a consumer feedback improvement activity template. This provided a structured and consistent method for documenting improvement initiatives, monitoring progress and capturing outcomes.

Empowering Staff to Resolve Concerns Early: The fourth cycle focused on strengthening staff confidence and capability in complaint resolution. In addition to formal complaint processes, frontline staff were supported to address concerns directly with consumers during episodes of care whenever appropriate.

This shift encouraged early resolution, improved communication and helped create more positive experiences for consumers and carers.

Delivering Measurable Results

The project team monitored complaint resolution performance throughout the initiative, using established key performance indicators and monthly reporting processes.

Action plans developed in response to common complaint themes were tracked and regularly reviewed. Staff confidence in complaint resolution was also measured before and after implementation.

The project successfully achieved its aim, with Canberra Health Services exceeding its target of having more than 85% of consumer complaints resolved within 35 days.

Importantly, the project also delivered broader organisational benefits. The introduction of standardised templates, improvement action plans and centralised registers enabled teams to move from an approach focused solely on resolving individual complaints to one centred on continuous quality improvement.

Embedding Improvement Across the Organisation

A key factor in the project's success was its integration into the priorities of the Partnering with Consumers Committee. Executive endorsement of the action plan helped secure organisational engagement and supported implementation across the healthcare network.

The project established systems that ensure consumer feedback generates visible improvement actions, with learnings shared more consistently across departments. By creating central registers of improvement activities, teams can now identify common themes, coordinate responses and scale successful initiatives across the organisation.

Looking Ahead

Canberra Health Services continues to build on the success of the project. Future work will focus on expanding the central register of improvement activities and making consumer feedback-driven improvements more accessible across the organisation.

Explore projects from QIL Program Graduates
You can read this full project on pg 29. in the QIL Project Summaries 2024 6th Edition.

This year's QIL program is underway, but you can register your interest for the next intake. Contact us to see if the program is right for you and how to join the waitlist at improvementacademy@achs.org.au.