Objective This paper explores how hospital complaints managers react to recommendations for systemic quality reforms by health complaints commissions in response to complaints by patients in Queensland and New South Wales. Methods Semi-structured qualitative interviews were conducted with complaints managers in 17 hospitals. Interview transcripts were then thematically analysed and data on responses to health complaint commissions was organised in relation to Valerie Braithwaite's typology of motivational postures. Results Respondents supported involvement by an independent authority where patients had serious complaints about the services they received in hospital, but wanted more negotiation with commissions on service improvement recommendations. Conclusions Hospital complaints managers mostly responded as virtuous or rational actors to the symbolic power of complaints commissions. This may be context dependent because Australian health commissions operate within a pro-reform context as a result of recent publicity around health system failures. What is known about the topic? Little is known about regulatory relationships between complaints commissions and hospitals. There has been no Australian research considering how complaints managers respond to commission recommendations for quality improvements and reforms to hospital services. What does the paper add? The paper uses a novel theoretical framework based on regulatory theory to understand and describe the reactions of complaints managers to commission recommendations. What are the implications for practitioners? Commissions should seek commentary from complaints managers through open dialogue before making final recommendations. This will ease the progress of reforms and make recommendations more acceptable and 'genuine' in the specific context of the hospital.