Occupations and Terms of Reference › Complaints and patient experience officer
Universal terms of reference · POS-035 · version 1.0 · status: draft · next review 2027-10-27
Complaints and patient experience officer
To make sure patients and families can raise concerns easily, that complaints are answered fairly and on time, and that the experience of care improves.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You handle complaints and feedback. You log and investigate complaints, answer people on time, track themes, and make sure learning is shared to improve the patient experience.
Reports to: Quality manager.
Leads or supervises: No direct reports.
What you do on a typical day
- Log and acknowledge complaints within the set time.
- Investigate complaints with the service team.
- Write clear, empathetic responses.
- Analyse themes and report them.
- Support staff through difficult complaints.
Working conditions and demands
- Complaints can be emotional.
- Must be impartial and respectful to all sides.
- Handles confidential patient information.
What good looks like
- Complaints answered within policy timeframe.
- Patients feel heard.
- Learning reaches teams.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Quality means the patient's experience as well as the clinical result; both are measured.
- Problems are reported early and without blame, and learned from.
- Standards are followed the same way on every shift and at every site.
- Every staff member can raise a concern without fear of reprisal.
- Improvement work is planned, measured and kept going until it is embedded.
- Data is used to improve care, and is protected while it is used.
- Where a standard cannot be met, the gap is recorded and escalated the same day.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-035 |
| ISCO-08 | 2421 (skill level 4) |
| ESCO | to map |
| Department | Quality and safety |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-024. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Quality manager | Complaints themes and actions. |
| Patient advocate | Patient voice and support. |
| Chief quality and safety officer | Serious complaints. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Complaints process | Logs and investigates complaints within policy timeframe. | Timeframe met for 95% or more | Monthly | C-01 | T-08 | POL-WHISTLE | 2 |
| Responses | Writes clear, timely responses to complainants. | Responses sent on time; quality checked | Monthly | C-02 | T-08 | POL-EQUAL | 2 |
| Themes and learning | Reports complaints themes and tracks improvement actions. | Themes report issued quarterly | Quarterly | C-03 | T-08 | – | 2 |
| Speaking up | Makes sure complaints are never a reason for reprisal and that people know how to raise concerns. | Patient information on raising concerns is current | Annually | C-01 | T-08 | POL-WHISTLE · POL-EQUAL | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Response wording within policy | Serious complaints about safety (quality manager and CQO) |
| Investigation approach for routine complaints | Complaints that involve potential harm to patients (quality manager and CQO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in health, social care or a related field | Yes | Lifetime |
| Q-02 | Complaints handling qualification | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Complaints, patient experience or patient advocacy in a health setting | 3 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | – |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-01 · C-02 · C-03 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Complaints handling process | Logs complaints | Investigates complaints | Designs the complaints system | Complaints audit | Every 12 months | T-08 |
| C-02 | Empathetic written and spoken communication | Writes clear responses | Handles difficult conversations | Designs communication standards | Communication review | Every 12 months | T-08 |
| C-03 | Turning feedback into improvement | Records themes | Reports themes | Leads improvement from feedback | Improvement review | Every 12 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Complaints answered within timeframe | 95% or more | complaints log | Monthly |
| PI-02 | Complaints themes reported | 100% | themes report | Quarterly |
| PI-03 | Complaints reopened | set by facility | complaints log | Quarterly |
| PI-04 | Patient feedback on handling | set by facility | survey | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Complaints and patient experience officer | 3 years (recommended) | Q-01 | C-01 practitioner, C-02 practitioner | T-08 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |