This article explores how complaint investigations undertaken by health ombudsman contribute to the improvement of the healthcare system. Using a qualitative case-study approach, semi-structured interviews were conducted with participants form the Scottish Public Services Ombudsman (SPSO) and three health boards within its jurisdiction. Health board participants were frustrated by complaints process used by the SPSO, in particular the lack of communication during an SPSO investigation especially when there were differences in clinical judgment. Using Braithwaite’s typologies of motivational postures and Hertogh’s models of administrative control it was found that a sense of capitulation was the primary determinant in ensuring health board compliance with SPSO recommendations and that the relationship between SPSO and health boards was predominantly coercive in nature. For the SPSO to be more effective in contributing to system improvement requires it to review its role and means of conducting complaint investigations.

本文探讨了卫生监察员进行的投诉调查如何有助于改善医疗保健系统。采用定性案例研究方法，对苏格兰公共服务监察员 (SPSO) 及其管辖范围内的三个卫生委员会的参与者进行了半结构化访谈。卫生委员会参与者对 SPSO 使用的投诉流程感到沮丧，特别是 SPSO 调查期间缺乏沟通，尤其是在临床判断存在差异时。使用 Braithwaite 的激励姿态类型学和 Hertogh 的行政控制模型发现，投降感是确保卫生委员会遵守 SPSO 建议的主要决定因素，并且 SPSO 和卫生委员会之间的关系本质上主要是强制性的。为了更有效地促进系统改进，SPSO 需要审查其进行投诉调查的作用和方式。