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Patient Experience Strategy

2011– 15

Patient Experience Strategy 2011 – 2015 Page 1 of 33

Patient Experience Strategy 2011 – 2015

Jan Atkinson Assistant Director of Public Involvement and Information Governance Barbara Carr Assistant Director of Nursing, Quality and Patient Experience ‘Patient Experience must be a key arbiter of all NHS Services’ The NHS Operating Framework 2011/12

October 2011


Purpose To assist all staff, patients and their carers on the Trust’s plans to improve the patient experience. Our core purpose is to provide the highest quality of care delivered with compassion, putting patients at the heart of everything we do. CONTENTS: Section 1 Patient Experience 1.1 What is ‘Patient Experience?’ 1.2 Chief Executive Statement 1.3 Non Executive Director Statement 1.4 Executive Summary Section 2 Principles 2.1 Key Principles 2.2 Trust Board 2.3 Director of Nursing and Patient Safety 2.4 Executive Directors, Managers, Senior Clinical Managers, Ward Matrons, Clinical Directors 2.5 Individuals 2.6 Quality Standards Steering Group (QSSG) Section 3 Strategy 3.1 The Patient Experience Strategy Section 4 Measuring 4.1 Measuring Patient Experience 4.2 Audit and Clinical Effectiveness (ACE) Committee 4.3 The Healthcare Quality Improvement Partnership (HQIP) 4.4 NHS National Patient Survey Programme 4.5 Local Survey Programme 4.6 Patient Reported Outcome Measures (PROMS) 4.7 Survey data capture methods Section 5 Improving 5.1 How do we improve patient experience? 5.2 External, public and private organisations 5.3 Customer service training 5.4 Patient experience dashboard 5.5 Use of patient stories 5.6 Communication and first impressions 5.7 Patient Charter 5.8 ‘You said – we did’ 5.9 Patient environment 5.10 Dignity and respect 5.11 Patient Experience and Quality Standards (PEQS) 5.12 Eliminating Mixed Sex Accommodation (EMSA) 5.13 Use of volunteers 5.14 Patient and public involvement in research 5.15 Equality and diversity 5.16 Staff commitment 5.17 Rounding 5.18 Compliments / complaints 5.19 When things go wrong Section 6 Monitoring 6.1 Measurement of the Patient Experience Strategy


Section 1 Patient Experience 1.1 What is ‘Patient Experience’?

• Receiving excellent treatment, meeting the patients and their family’s emotional needs, as well as the physical treatment of their journey.

• Having the right information at the right time, given by the right person, to make the right choice.

• Feeling safe in a clean, comfortable environment.

• Being listened to and talked to; being treated with dignity and respect.

• Being kept safe from harm.

1.2 Chief Executive Statement Our aim is that every patient, client, carer and relative must receive a first class experience from all of our staff and the services we provide. Quality must be based on their perspective, not ours. We have many examples of where our patients have a good experience and our aim is to provide this every time. As well as working in the service we are all or will be, at some time, on the receiving end of health services. In many ways health services are like any other service; customers expect and deserve good service and to be satisfied with their experience so they will recommend the service to friends and family. However, it is also unlike other services too; we often see people at their most vulnerable and when their senses are heightened because of the situation they find themselves in. This makes it all the more important that we make every effort to make their experience of using our services the very best we can, even in what can be difficult, sensitive or traumatic circumstances. At its’ most simple it is about thinking about what we would want for ourselves or our families. While we have achieved a lot in this area there is still much to do. This strategy provides the journey we will take and I am delighted we are on this journey together. Alan Foster Chief Executive

1.3 Non Executive Director Statement

Patient Experience, along with Patient Safety, is a top priority for our Trust and I am delighted, as the non executive lead on patient experience to support this strategy. Rita Taylor Senior Independent Non Executive Director


1.4 Executive Summary

Our Values

1.4.1 Healthcare is a people business, we therefore place great emphasis on; patients, public and staff who are all key to what we do. This is recognised in our People First values and new employee Compact, both of which are developed in partnership with our staff.

Our People First values expect that we will:

• Be responsive to the needs of our patients as individuals

• Be responsive to the needs of our stakeholders

• Treat all people with compassion, care, courtesy and respect

• Respect each person’s right to privacy, dignity and individuality

• Take time to be helpful

• Respond quickly and effectively

• Always give clear, concise explanations

• Practice good listening skills

• Develop and maintain an appropriate environment

• Look the part

• Deal effectively with difficult situations

• Perform as a team

Fundamentally, Putting Patients First is what we stand for and believe in.

1.4.2 Achieving the highest standard in patient experience is a priority for North Tees and Hartlepool NHS Foundation Trust and for the Board of Directors.

We need to innovate and improve on finding new ways of working with our patients to capture patient experience to make the improvements that need to happen.


1.4.3 Improving patient experience includes all staff, regardless of profession; it is everybody’s business to improve the patient journey. Patient experience should be of a standard that all staff would expect to receive for themselves or their own family members.

1.4.4 The implementation of this strategy will improve patient and carers experience thus encouraging patients to make a positive decision to choose North Tees and Hartlepool NHS Foundation Trust as their Trust of choice.

Section 2 Principles

2.1 Key Principles

• Patient Experience is effectively used to make a difference: Public Involvement offers genuine opportunities to influence policy, service design and delivery from an early stage, based on respect for and valuing patient and carers views.

• Choosing the right methods/for the right occasion: A varied range of methods is available to match people’s different preferences and abilities to engage.

• Providing appropriate and accessible information: There is open and transparent access to relevant information to enable informed choice.

• Ensuring involvement is a positive and enhancing experience: Involvement includes active development of the skills, knowledge and confidence of participants.

• Staff/volunteers are resourced and trained to effectively engage: Appropriate training, guidance and support are provided to enable professional staff to effectively engage with patients.

• The performance of the patient experience is monitored and evaluated: Mechanisms are in place to ensure that the experience of engagement is evaluated and results made available to participants in an accessible and appropriate format.

2.2 Board of Directors

• The Board of Directors is responsible for the strategic direction of the hospital and will ratify this strategy.

• The Board of Directors is also responsible for receiving and considering assurance that the strategy is being implemented.


2.3 Director of Nursing and Patient Safety

• The Director of Nursing and Patient Safety is accountable to the Board of Directors for leading on the implementation of this strategy.

2.4 Executive Directors, Managers, Senior Clinical Managers, Ward Matrons, Clinical Directors

• Senior staff in the organisation are responsible for ensuring that patient experiences within their areas of responsibility is of a high standard. They will receive quarterly reports ensuring high standards are maintained in embedding the principles of the Patient Experience Strategy.

2.5 Individuals

• All staff, students, volunteers are responsible for ensuring that their behaviour and communications with each other, patients and their carers contribute to the success of the patient experience.

2.6 Quality Standards Steering Group (QSSG)

• The QSSG will monitor the implementation of the Patient Experience Strategy and report progress quarterly to the Patient Safety and Quality Standards Committee.

Section 3 Strategy

3.1 The Patient Experience Strategy

This strategy links to and is complementary to:

• Patient and Public Involvement Strategy

• Communications Strategy

• High Impact Actions ( incorporating Essence of Care)

• End of Life Care Pathway

• Equality Schemes

• PALS and Patient Relations

• CQUIN

• Clinical Effectiveness

• RESPECT


Section 4 Measuring

4.1 Measuring Patient Experience

Patient experience is closely related to and influences clinical effectiveness and safety. Poor patient experience can be needlessly wasteful and costly to the organisation.

The Care Quality Commission (CQC) monitor Trusts on a yearly basis which includes Outcome 1: Respecting and involving people who use services. The expected outcome of this is ‘What should people who use services experience?’

People who use services:

• Understand the care, treatment and support choices available to them.

• Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support.

• Have their privacy, dignity and independence respected.

• Have their views and experiences taken into account in the way the service is provided and delivered.

The Clinical Effectiveness (CE) Strategy describes the local framework in place to support:

• Clinical Effectiveness – the implementation of evidence based clinical practice

• Clinical Audit – measuring local compliance with best practice recommendations

• Patient Surveys – feedback from patients on the quality of healthcare they received The CE Strategy describes in detail how the above activities are prioritised and how progress is reported and monitored. It also sets guidance around acceptable methodologies for conducting such activities.

• NICE (National Institute for Clinical Excellence) quality standards for patient experience their development and involvement – how progress will be monitored.

Approved patient survey activity must also be registered with the Clinical Effectiveness Unit. Patient Surveys must be conducted using methodologies that respect the patient confidentiality and anonymity, whilst ensuring they are allowed to provide feedback on their experience in a non-threatening environment. Typically patients should be asked to comment at a suitable point after completion of their episode of care when they are able to reflect openly and transparently, away from the direct healthcare environment. The preferred methodology should be the independent retrospective survey (either a postal questionnaire sent to the patient’s current place of residence or an electronic questionnaire made accessible to patients) aiming to allow patients the opportunity to answer questions in their own time and minimise bias. Professionals should ensure patients are not subject to formal satisfaction questionnaires at times when they may feel compromised or vulnerable (e.g. patients being questioned whilst still in hospital, or over the telephone with little time for reflection or possible reluctance to raise any negative issues they had experienced).


4.2 Audit and Clinical Effectiveness (ACE) Committee

The Trust ACE Committee oversees the development of the local clinical audit forward programme and monitors progress where areas of deficiency have been identified as a result of clinical audit. The ACE Committee includes public representation from Stockton LINk, Hartlepool LINk and the Hospital User Group (HUG) in line with HQIP recommendations.

4.3 The Healthcare Quality Improvement Partnership (HQIP) The Healthcare Quality Improvement Partnership (HQIP) was established in 2008 in order to provide improved co-ordination of the national clinical audit programme and to encourage patient and public engagement in clinical audit. NHS Trusts must now be able to demonstrate effective engagement with the public when agreeing priorities for local clinical audit and overseeing action plans as a result of deficiencies highlighted by individual audits.

4.4 NHS National Patient Survey Programme

The Trust takes part in the National Patient Survey Programme which provides a way of measuring patient experience within our organisation, comparing our results over time, as well as assessing our performance with other NHS Trusts regionally and nationally. Our results also contribute to ongoing monitoring by the Care Quality Commission. We have a well established feedback strategy in place where results are shared widely with key stakeholders, both within and outside our trust, including board members, senior managers, clinical staff at all levels and our patients and the public through the media. Action plans are developed by key staff ensuring they are meaningful, achievable and timely and they are presented to the Audit and Clinical Effectiveness Committee (ACE) for approval and sign off.

4.5 Local Survey Programme

Local surveys offer a way of understanding issues highlighted in national surveys in far greater detail and can help identify why there may be changes in satisfaction ratings and what causes these trends. Local surveys offer staff more real time results and help bring about more specific service improvements. Local survey programmes are developed each year to reflect priority areas highlighted by the NHS National Patient Survey Programme, NICE guidance and National Service Frameworks. Departmental survey examples are outlined in Appendix 1.

4.6 PROMS – Patient Reported Outcome Measures

All patients who have a hip or knee replacement, varicose vein or groin hernia surgery are invited to complete a PROMS questionnaire. PROMS enable us to assess the impact of interventions on people’s health status by asking patients about their health and quality of life


before and after surgery. It is anticipated that the scope of PROMS will be extended to other elective procedures in the future.

4.7 Survey data capture methods 4.7.1 There is not a single right way to collect information and report on

patients’ experience of care. Instead, we have a number of sources of information and approaches to measurement, dividing broadly into qualitative and quantitative methodologies. Both are useful at every level of the healthcare system but for different purposes.

4.7.2 The importance of engaging local leaders and clinicians in the effort to

improve patients’ experience calls for measurement strategies underpinned by a number of principles. Methods of collecting and reporting patients’ feedback should be tied as closely as possible to clinical services so that clinicians identify with the results. (SLM 4.12)

4.7.3 For a day to day management and improvement purposes, middle

managers and clinical teams should monitor quality of care as often they monitor budgets. For this, they need relevant, accurate, timely, frequent information form their own patients that they can use to compare their own services with others. In practical terms, this means access to ‘near real time’ feedbacks, based on standard questions, with demographic information that allows for assessment of population mix.

4.7.4 At the level of organisations, and in the health system more widely,

commissioners, planners and policy makers should make use of the data collected to support management and improvement of front line services, and should avoid demanding fresh collections of data for their own purposes.

4.7.5 Prior to the implementation of Service Line Management (SLM), the

directorates of orthopaedics, surgery and obstetrics and gynaecology have undertaken patient experience projects. The projects consist of patient and staff interviews and focus groups and a patient satisfaction survey. The findings are analysed and displayed in poster format and presented, in the form of a mirror session, to the directorate meeting, the staff on each site and the Trust Directors Group. At each mirror session the issues are discussed and solutions sought. The project is concluded with an action planning session where solutions are prioritised and an action plan is produced. The completed project is presented to the Board of Directors.

Patient Experience Case Study from Obs & Gynae Project Mrs X underwent shared care during her pregnancy. She saw the

consultant on two occasions and, although she had to wait a long time to see him, she was satisfied with the visits. She experienced good continuity of care from her community midwife with a mixture of home visits and appointments in clinic.

The process of Mrs X’s delivery went smoothly and she was very

impressed with the organisation of her planned operation and was confident that the staff knew what they were doing. After her delivery she did feel tired and pestered by the number of different staff


attending to her and her baby undertaking different checks. Although the ward was very busy she was kept informed and felt satisfied with the care she received although she was aware that there was a shortage of staff.

Section 5 Improving

5.1 How do we improve patient experience?

5.2 External Public and Private Organisations: LINks (Local Involvement Networks - soon to be HealthWatch), HUG (Healthcare User Group). We need to ensure we capitalise and use the information gathered from their visits and surveys and show we are listening to the views of our patients by showing progression and implementation of their recommendations. We have many members from these organisations attending Trust meetings to ensure patient views are heard. These attendances and invitations to attend these meetings has greatly improved in the last 12 months and we must ensure sustainability and encouragement is given to our lay members.

5.3 Customer Service Training for Front Line Staff In January 2011 the Trust introduced customer service sessions on Conflict Resolution Training. This is a reminder to staff about the importance of customer care. Staff are asked about their positive and negative experiences of customer service and then relate these back to their experiences within the NHS. This is an interactive session and staff are asked to contribute examples of how they can give excellent customer care. This is now running on induction programmes too.

The objective of the session are:

• Define good customer service

• Identify our range of customers

• Give examples of good and poor customer service

• Identify how we feel when we receive good / poor customer service

• Identify ideas on how each of us can give excellent customer service

A strategy is being developed to roll-out customer care training within

5.4 Developing a Patient Experience Dashboard: Using the dashboard as an integrated patient experience measurement tool using an overall patient experience score to drive improvement.

5.5 Use patient stories: Statistics tell us the process and systems experience of the individual - stories tell us the individual’s experience of the system. Listening to patients and families stories about their experience is valuable and has a motivating effect – staff support is critical as this makes a positive difference.

Time to reflect EAR -

Effective Affective Reflective


“If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter and that is what must never be forgotten when policies are being made and implemented”. Robert Frances QC.

5.6 Communication and First Impressions

First impressions influence a patient’s trust and how confident they are feeling in our hospital surroundings – including verbal and non-verbal communications, how staff are dressed, information they have received pre and post their visit, letters, phone calls, etc.

Patients and carers place a high level of importance on their communication with health professionals. They want, deserve and expect to be listened to, addressing both their emotional and physical needs.

5.7 Patient Charters

The directorate of Trauma and Orthopaedics reviewed its complaint and PALS (Patient Advice and Liaison Service) issues through the Trust’s CLIP (Complaints, Litigation, Incidents and PALS) report and identified that there was a number of issues raised by patients with regard to the attitude of staff and how they were treated and spoken to. It was agreed that work needed to be done in this area. In conjunction with the Training and Development Department, workshops were initiated with staff to develop a ‘Customer Charter’ around the do’s and don’ts of patient interaction with staff. The directorate have created a poster for each of the clinical areas to remind staff how they are expected to conduct themselves when in contact with patients.

This charter is to be further developed for other directorates.

5.8 ‘You said – we did’

In response to key stakeholders the Trust want to develop a culture of ‘you said – we did’ by listening to and responding to patient/relative feedback.

The following are examples of changes made so far:

Communications

Following many complaints from patients regarding the introduction of an 0845 telephone number for contacting main switchboard this was reverted to the 01642 617617 number.

Critical Care

Normal morning visiting time is from 10.00am. Having listened to visitors comments (mostly verbal from matron rounds) that they could not always get to see their relatives because staff were busy attending to them, we responded by changing the visiting hours.


Visiting hours are now 11.30 – 13.30 and 16.00 – 20.00 this is also across both sites so if patients are transferred they have the same visiting times. If a patient is very sick then ‘open visiting’ is allowed.

Surgery As part of the SLM Patient Experience it was highlighted that some patients were not always aware of nursing staff responsible for their care on a shift by shift basis. They felt as though results and treatment plans were not discussed in a timely manner. We now include patients as part of the bedside handover, formally introduce patients to staff responsible for their care each shift change. Daily “Matron Rounding” provides an opportunity to give updated information regarding progress and treatment Patients awaiting surgical intervention historically were admitted morning of surgery, as part of the SLM patient experience feed back; we now have patients with staggered admission times this avoids long waits within the hospital setting when procedures are planned for later in the day. Endoscopy Patients stated that the wait prior to procedures was too long and so admission times were reviewed and further staggered. North Tees specific – some patients had stated that they had difficulty finding the unit so as a result direction maps are included with appointment letters. Hartlepool specific – patients were brought to a second waiting area after admission but due to limited space relatives could not accompany them. Patients requested a relatives/friends area be available for them to wait. The patient flow has been altered to allow this to happen wherever possible. Pharmacy Inpatients felt that Pharmacy staff were distant and unknown. We have devised a script for inpatient staff and a handout card for patients. Outpatients felt that the Pharmacy reception area was not managed well. We now have a story board to let patients know the prescription journey and reception staff manage the waiting are better. Radiology Patients informed us that Medical Physics on the Hartlepool site always looked closed, we are installing a window into the door to make it appear a more welcoming area and to look open. Patients informed us that some staff uniforms looked grubby and old. We have audited our staff uniforms and new uniforms have been issued to ensure our staff always look professional, clean and tidy.


Patients told us they sat for long periods without any one asking if they needed to be seen. We have installed a system whereby staff will ask patients to report back to the reception area if they have sat longer than ten minutes waiting to be seen. A Patient told us she was lost in the department and staff walked past her, without question, even though she was in a restricted area. Staff have been reminded to always offer assistance to patients who look out of place and are probably lost. Customer care training is being offered to all staff dealing with patients and members of the public. Pathology Patients accessed the path lab into non public areas. We have since brought in a visitors security system and key locks with electronic entry areas, no visitors can now access any areas of path lab on either site, unless they ask for admittance or ring for entry. Orthopaedics Patients commented on how difficult the orange juice pots were to open. Normally these were left for the patient to decide whether they wanted them or not. Now the patients are asked if they want the juice and if so the pots are opened and the juice poured into a glass for them. Visiting times have been altered slightly to allow patients to: a) finish their meals before their relatives visit. b) complete their physiotherapy before their relatives visit. Medicine Discharge Lounge process poor – LINks identified through audit process that long waits for patients in relation to discharge medication. RPIW was carried out and as a result reduced timescales by approx 1.5 hours this was an average reduction of 45 minutes. The patient journey was improved by a team approach including all professionals involved in the patient episode. Cold food: Identified through LINks and in patient surveys. Hostess services have been introduced along with same day ordering and improved choice of menu. Trial of microwave kitchen meals to reduce waste and improve timeliness. TIA – poor communication between referral and review on weekends. Process relocated the TIA to stroke ward so patients have familiarity with stroke experienced staff and reduced wait to see the physician as they are already on the ward. Ward communication between staff and the users: Large proportion of the medical directorate have now achieved placing episodes of care notes within the patient bed space. This has increased the patient awareness of medical management and intentions, discharge planning etc.


Complaints: Ward posters are now displayed informing users they can speak to ward matrons as first line instead of making a formal complaint. This has resulted in a reduction in the number of formal complaints as issues are dealt with locally. Meals: As a result of discussions with families who have expressed concerns around meal consumptions, the involving of carers and relatives assist patients with their meals has been introduced. Families and carers have open access to the wards to assist with meals.

5.9 Patient Environment – Cleanliness, Food

Patients expect and have the right to a clean ward. A hospital or department that appears dirty or untidy might be perceived by the patient that their care would also be poor.

We will ensure that:

The patient environment is conducive to patient care, is clean, safe and well maintained.

We achieve a PEAT (Patient Environment Action Team) score of four or above when it is assessed against the NPSA (National Patient Safety Agency) standards.

Our food is healthy and nutritious and that it is served at or above the required temperature.

5.10 Dignity and Respect

Privacy, dignity and respect are key aspects affecting patient’s experience.

‘Care and Compassion?’ this report by the Health Service Ombudsman on ten investigations into NHS care of older people (15 February 2011) give a stark contrast between the reality of the care and compassion these patients received and the principles and values of the NHS and its’ beliefs.

Our tested patient experience must show that the standard of care for or patients is delivered with care, compassion and dignity.

5.11 Patient Experience and Quality Standards (PEQS)

This tool was developed in November 2008 for monthly ward visits by the Director of Nursing and a senior nursing team to measure quality across three key domains, namely:

• The patient environment • Nursing care and documentation • Patient experience


Each of these domains attracts a score and ultimately, produces a quality score for each ward. Scoring is undertaken through a review of evidence and by talking to patients to find out their views about dignity and respect, communication, reputation and potential actions to further improve patient experience.

Feedback is given to ward managers at the time of the review to ensure that good work is recognised and support is offered where improvement is required. This verbal feedback is followed up in writing and this approach has been appreciated and welcomed by ward staff and patients alike.

5.12 Eliminating Mixed Sex Accommodation (EMSA)

5.12.1 Introduction

The NHS Operating Framework for 2011/12 requires all providers of NHS funded care to confirm status of compliance with the national definition to eliminate mixed sex accommodation except where it is in the overall best interests of the patients, or reflects their patient choice. Those organisations that either do not make a declaration or declare they are not compliant will face penalties.

A supplementary letter from the Chief Nursing Officer and Deputy NHS Chief Executive in February reiterated the requirement for Boards to make a declaration of compliance with regard to Eliminating Mixed Sex Accommodation (EMSA) no later than 1st April 2011.

The huge variation in ward designs has prompted a more specific definition of a “breach” of EMSA compliance which therefore confines central reporting to sleeping accommodation. However, mixing in bathrooms or toilets is still unacceptable, as is requiring patients to pass through opposite-sex areas to reach their own facilities.

Further and more far reaching guidance is likely to emerge around day case and Endoscopy service provision in addition to clinic and outpatient provision.

5.12.2 Status of Compliance

Current Status: The Trust has worked throughout the recent two years to ensure compliance with emerging and more radical EMSA guidance and latterly has undertaken a number of initiatives to manage sustainability, such as:

• Introduction of a patients’ status, at a glance, electronic board monitoring – providing real time monitoring and alert system.

• Consistent written and verbal Information to manage patient expectations.

• Privacy and dignity screens installed in the Coronary Care Unit.

• Endoscopy Unit at UHNT have worked with estates to improve patient experience and now become a compliant unit


• Emergency Assessment Units on both hospital sites are now fully compliant, by using rigorous monitoring and asserting staff responsibility requirements, at no cost.

• Improved toilet and bathing facilities.

• Improved signage for ward facilities.

The Trust has a robust system of reporting and complies with statutory returns with regard to status of potential breaches of sleeping accommodation via the Unify2 system.

The Trust has a plan for continued compliance during 2011-12 supported by an EMSA Policy and a strong governance framework, whereby alert and audit underpin practice. This includes:

• Generation of weekly reporting and monitoring via Senior Clinical Leaders (SCLs)

• SCLs report to monthly monitoring group for variance analysis, root cause analysis, lessons learnt and compliance status.

• Quarterly EMSA local patient satisfaction audits report to High Impact Actions Committee.

The live bed management system operating within the Trust has the added advantage of an alert system to staff on booking a bed, enabling policy philosophy to be embedded in practice.

Discussions and agreements with commissioners during early planning and implementation have been sufficiently detailed to cover the majority of predictable situations, and to ensure that episodes of mixing are not wrongly classified as “justified” for non-clinical reasons. Such discussions have continued to feature in Integrated Strategic Operational Planning (ISOP) negotiations.

5.12.3 External Assurance

A PCT / Peer Review visit in the recent year signified assurance with utilisation of allocated investment monies and in EMSA compliance plans.

In addition, early verbal feedback from a Department of Health visit on 10 March 2011, by Dr Liz Jones (Policy Lead) signified not only a positive impression with regard to electronic board monitoring and practical application and behaviours but also a commitment to cite the Trust as an exemplar of best practice and a beacon site for sharing such practice.

5.12.4 Future Plans

Future plans to address sustainability include inclusion in Audit North programme and Audit Committee considerations, involvement of Overview and Scrutiny Committee and local HealthWatch and involvement of patient groups to improve patient perception.

5.12.5 Declaration of Compliance A statement of declaration has been compiled to reflect the compliance position:


The Declaration will be published on the Trust website from 1 April 2011.

5.13 Use of Volunteers (Voluntary Patient Helpers)

We have recently (May 2011) undertaken a recruitment drive for volunteers to assist us with ‘real time’ collection of data on patient experience. Initially we will use face to face collection of data in paper format, with a view to using electronic capture encouraging patients to use these devices with the assistance of our volunteers.

5.13.1 ‘Can I help you?’

Part of the volunteer role will be to take time to talk to patients to assist with any issues/concerns they have whilst in hospital. They will escort patients around the hospital, help patients at meal times and generally assist matrons on the wards with patient flow where necessary.

5.13.2 Clinical Support services will be looking for volunteers to continue with their ‘Secret Shopper’ programme, three monthly rolling programmes to different areas will be undertaken on a regular basis and actions taken from the results.

5.14 Patient and Public Involvement in Research

The Department of Health and the National Institute of Health Research (NIHR) promote patient and public awareness of all aspects of research including the setting of research priorities and helping to assess proposals. Presently, within the Trust, all research proposals are subject to peer review, the process being managed by the Research and Development Office. It is planned to extend this review process and we will set up a Patient and Public Research Advisory Group made up of members of the Healthcare User Group (HUG) and the two Trust based branches of the NHS Retirement Fellowship (NHSRF). This new group – to be set up during 2011 – will be supported by the Trust’s Research and Development Office and will play an important role in the approval process of new research projects. It is also envisaged that involvement with other aspects of the research process will be developed.

5.15 Equality and Diversity

We will embed with staff the need to routinely use Equality Impact Assessments to assess services and policy. If inequality is caused by age, gender, disability, race, religion, or sexual orientation we will identify and address.

We need to ensure staff understand equality and diversity to ensure that practice and services are equal and fair to all.


5.16 Staff Committed and Feel Enabled to Improve Patient Experience

We need to value and praise our staff and give them a sense of ownership, and enthuse staff to see the need and benefits to improve patient experience.

5.17 Rounding by Senior Nurses / Midwives

Rounding incorporates specific actions into nursing rounds conducted at a specific time of day by both the Senior Clinical Leader and the senior nurse in charge of the ward/department. The aim of this is to improve patient safety, patient experience and effectiveness of care. We aim for this to occur in all clinical areas within the Trust.

The Senior Clinical Leader/Midwife will conduct an unannounced ward round within a designated clinical area each week.

The senior nurse/midwife in charge of the area will conduct a daily ward round during afternoon visiting. During the round they will communicate with all patients and relatives. This will include asking:

• Have you been treated with dignity and respect?

• Has nursing / medical communication been good?

• Do you understand your treatment plan?

• Would you recommend this hospital to others?

• What single thing could we do to improve patient stay.

• Do you get enough help when eating?

• Have you received enough pain relief during your stay?

• Is there anything we need to do to help you plan your discharge home?

They will then complete a report giving numbers of issues identified and numbers of issues locally resolved. Relevant issues will also be documented within individual patient’s contemporaneous records.

5.18 Compliments/Complaints

For year ending March 2011 the Trust received 2,941 compliments and a total of 341 complaints of which:

• 98% were acknowledged within three days

• 92% responded to within 25 working days

• 8% over the 25 days

• 5.19 When things go wrong

When patients make the effort to complain more work needs to be done to learn from complaints and PALS issues to identify themes and


evidence a change in practice, all contributing to Patient Safety and experience.

The real focus required is to support measurable improvements in service quality.

The King’s Fund Point of Care Programme is designed on the basis of the Institute of Medicine’s six dimensions of ‘Patient – Centred – Care’ which are:

1 Compassion, empathy and responsiveness to needs, values and expressed preferences

2 Co-ordination and integration

3 Information, communication and education

4 Physical comfort

5 Emotional support, relieving fear and anxiety

6 Involvement of family and friends

(Source: Institute of Medicine 2001)

6 Monitoring 6.1 Measurement of the Patient Experience Strategy

This Patient Experience Strategy will be delivered by the Senior Clinical Leader on behalf of the Trust.

The measurement of this strategy will be via the Senior Clinical Leader’s Quality report to the Director of Nursing which in turn is received by the Trust Board.

Variance from this strategy will result in directorate action planning. Review and evaluation of the strategy will be via Quality Standards Steering Group (QSSG) and Integrated Professional Nursing and Midwifery Board (IPNMB) on a quarterly basis. All mandated national patient surveys will be reported in summary format to the ACE committee; this committee will monitor receipt of action plans from appropriate areas of the Trust and report any outstanding shortfalls to the Ps and Qs committee. All local patient surveys will be reported to relevant areas of the Trust affected by the results. The Trust Survey Lead will monitor that such surveys have been received by appropriate staff and have been actioned appropriately. Any variances will be reported to the Clinical Effectiveness Manager, who will escalate to the relevant Clinical Audit Lead, and ultimately to the ACE committee if no local resolution has been made.


Glossary of terms used in this strategy

ACE Audit & Clinical Effectiveness

ARU Assisted Reproduction Unit

CE Clinical Effectiveness

CHD Coronary Heart Disease

CLIP Complaints, Litigation, Incidents and PALS

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

DoH Department of Health

EAR Effective Affective Reflective

EMSA Eliminating Mixed Sex Accommodation

HFEA Human Fertilisation & Embryonic Authority

HQUIP Health Quality Improvement Partnership

HUG Healthcare User Group

IC&P Infection Control and Prevention

IPNMB Integrated Professional Nursing and Midwifery Board

ISOP Integrated Strategic Operational Planning

LINk Local Involvement Networks

LSA Local Supervising Authority

MDT Multi Disciplinary Team

MIDAS Monitoring, Intrusion Detection, Administration System

MRSA Methicillin Resistant Staphylococcus Aureus

NCAT National Cancer Action Team

NHS National Health Service

NICE National Institute for Clinical Excellence

NIHR National Institute of Health Research

NMC Nursing & Midwifery Council

NPSA National Patient Safety Association

PALS Patient Advice and Liaison Service

PCT Primary Care Trust

PEAT Patient Environment Action Team

PEQS Patient Experience and Quality Standards

PROMS Patient Reported Outcome Measures

QARC Quality Assurance Reference Centre

QSSG Quality Standards Steering Group

RESPECT Responsive Equipped Safe and secure Person centred Evidence based Care and compassion Timely


SCL Senior Clinical Leaders

SLM Service Level Management

TIA Transient Ischemic Attack

UGI Upper Gastrointesnital


NORTH TEES & HARTLEPOOL NHS FOUNDATION TRUST APPENDIX 1 - Patient Experience Strategy – Local Survey Programme Directorate Type of Survey Data – method

used Frequency Carried out by Mandatory

Yes/No Monitoring/evaluations and feedback method

High Impact Actions Patient Questionnaire

Questionnaire 50/quarter Rapid Response Team Stockton

Yes Business support team provide quarterly feedback

Community Services Clinical Directorate Falls team Patient

Questionnaire

Questionnaire Every patient who has an intervention from the falls team

Falls Team Stockton

Yes Surveys collated by falls team admin

Information sharing session for stroke patients and their carers

Questionnaire 8 weekly Community Stroke Team, Stockton

No Collated and actioned as appropriate

Satisfaction with service

Face to face review and 6 week telephone contact

On-going Drop-in Stroke Centre Stockton independent living centre. Tithebarn House

No Collated and actioned as appropriate

PASCOM (podiatric surgery only)

Questionnaire Telephone

1st part Pre surgery 6 month review

Specialist podiatrists consultants

No Input data into PASCOM system Reports

Catering survey

Questionnaire Ad hoc Catering Yes Feedback to Nutritional Advisory Trust Group


Directorate Type of Survey Data – method used

Frequency Carried out by Mandatory


Community Services Clinical Directorate (Continued)

Weight management on patient experience in adult and paediatric settings

Questionnaire Ad hoc when sessions are done

Dietician/ Nutritionist and Dietetic Assistants

No Reports done and evaluation forms completed

Joint survey with Children’s Centres for Health Visiting.

Questionnaire Quarterly. Children’s Centres

Yes Sure Start Children’s Centre reports.

PROMS

Questionnaire Pre and Post treatment

Musculoskeletal Service

Yes PROMS returned to the business team for collation and feedback.

Smoking Cessation

Face to face questionnaire 254 respondents

Snapshot survey carried out from end Nov 2010 to mid Jan 2011 Annual Survey

Coordinators within Stop Smoking Drop In sessions

Recommended

Report produced Summary of results for both PCT areas Action Plan produced

Smoking Cessation Follow up of non returners at four weeks post quit date Follow up to ascertain quit status of all four week quitters again at six months. Follow up to ascertain quit status of all six month quitters again at one year

Telephone – two calls No response – one letter Telephone – one call one letter

Ongoing Stop Smoking Advisers

Yes Quit status reported to the Dept Health, Commissioners and Performance Managers At each follow up people are asked whether they were satisfied with the service and whether they want a flyer in order to reattend. Compliments and complaints are recorded and forwarded for MIDAS entry


Directorate Type of Survey Data – method



Community Services Clinical Directorate (Continued)

Coronary Heart Disease: Patient Satisfaction Survey following Heart failure rehabilitation programme – this has just commenced 9th February 2011

Questionnaire eight weeks – for each patient at completion of the eight week programme

CHD team member lead of Rehab programme

No We are asking for them to be returned to audit department.

Diabetes: Patient experience survey

Questionnaire Yearly Diabetes teams at North Tees and Hartlepool

No Data collection by audit clerk

Young Persons questionnaire

Questionnaire Quarterly School Nursing No Business support team provide quarterly feedback.

Surgery/ Outpatients

Patient experience (Service Line Management) Patient satisfaction survey

Patient questionnaire

Ongoing patient satisfaction

Ward staff

No

Feedback weekly via graph report displayed in public area on the ‘knowing how we are doing’ Productive Ward board and staff meetings

Patient Thank you cards

Comments card

Ongoing

Ward staff

No

Feedback to ward staff

PROM’s Varicose veins Hernias

Questionnaire Ongoing Ward Staff Yes National feedback, monthly returns and compliance with % return via clinical effectiveness and cascaded





Surgery/ Outpatients (Continued)

PEQS – Patient experience

Face to face

Monthly

Ward matrons/ SCL matron

Yes

Feedback given to each ward and department on the day of the QRP. Formal feedback received from Director of Nursing & Patient Safety to ward matrons/SCL matron.

Matron rounds

Face to face Monthly Ward matrons/ SCL matrons

Yes Discussed in staff meetings.

High Impact Actions Patient Interviews

Face to face

Monthly

Ward staff

Yes

High Impact Actions benchmarking, Action plan development/updates shared with wards and departments and cascaded to all staff.

Productive Ward Patient experience

Face to face

Six monthly

Ward staff

No

Productive ward meetings – feedback to ward staff.

Patient experience – CLIP reports

Telephone, face to face and written complaints

Quarterly Patient safety co-ordinator

Yes Directorate feedback, cascaded

PALS – Patient experience

Face to face, written patient experience

Ongoing Ward staff, ward matrons, SCL matron, patient safety co-ordinator

No Feedback of issues at SCL to cascade to all staff. Patient feedback via ward matron/ SCL/PAL’s.





Trust local breast cancer survey linked to peer review

Questionnaire

3 yearly Clinical effectiveness

Yes

Action any points and includes in annual work programme in accordance with Peer Review cancer standards

National patient cancer survey

Questionnaire

Commenced 2010

Clinical effectiveness

Yes Action any points and includes in annual work programme in accordance with Peer Review cancer standards

Urological cancer survey peer review

Questionnaire

Commenced 2010

Clinical effectiveness

Yes Action any points and includes in annual work programme in accordance with Peer Review cancer standards

Surgery/ Outpatients (Continued)

UGI Cancer patient experience survey

Questionnaire Ongoing

UGI MDT Yes

Collated by survey lead. Fed back annually to UGI MDT which actions any points and includes in annual work programme in accordance with Peer Review cancer standards

Medical Directorate

Quality Review Panel

Questionnaire and Face to Face

Monthly Senior Nursing Team

No Corporate Dashboard and Discussion with Senior Teams

National Patient Survey

Questionnaire Yearly Audit Teams Yes Feedback from Audit Team (National Survey)

Senior Matrons Ward Matrons Ward Rounds

Face to Face with patients and relatives

Monthly Senior Clinical Leaders Ward Matrons

No Evaluation through feedback from patients / relatives





Nursing & Clinical Governance

National Patient Survey

Questionnaire Yearly Audit Teams Yes Feedback from Audit Team (National Survey)

Senior Matrons Ward Matrons Ward Rounds

Face to Face with patients and relatives

Monthly Senior Clinical Leaders Ward Matrons

No Evaluation through feedback from patients / relatives

Patient Safety Walkabouts

Direct observation

Twice Monthly Associate Medical Directors, Director of Nursing, Medical Director, Ass Director of Nursing

No Immediate feedback to ward staff.

Patient/ parent experience - Neonates

Questionnaire Yearly Ward Staff

No Local Action plans

Paediatrics and Neonates

Patient/ parent experience - Paeds

Questionnaire Quarterly Hospital Play specialists

No

Local Action Plans

Maternity

CQC Maternity Survey

Questionnaire

2 yearly

CQC

Yes

Results reviewed and actions planned accordingly, Patient Safety and Quality Standards Group

Matrons walk rounds

Face to face discussions on rounds

Monthly

Head of Midwifery

No

Results reviewed and actions planned accordingly, Obstetric Managers meetings, feedback Directorate meeting and executive feedback.


Directorate

Type of Survey Data – method used



Ward/Area Managers Roundings


Weekly

Ward / Area Managers

No

Results reviewed and actions planned accordingly, Obstetric Managers meeting

Patient Safety Roundings


Monthly

Patient Safety Coordinator

No

Results reviewed and actions planned accordingly, Obstetric Managers meeting

Maternity (Continued)

Annual review of Supervisors of Midwives

Face to face discussions at time of annual visit by peer Supervisor of Midwives and User represent- atives.

Annually

LSA Midwifery Officer

Yes

NMC, LSA meetings, Trust Supervisor of Midwives Group and Patient Safety & Quality Standards group. Action plan produced from annual visit report.

Patient Experience

Recorded interviews and set open questions.

Ad hoc

Internally

No

Action plans developed from findings by Directorate groups and presented to Executive team.

Trust Thank you cards

Completion of cards

Ongoing

Internally

No

Areas each cascade details at ward /area meetings.

NHS Choices intranet site

Details entered onto intranet site voluntarily.

Ongoing

NHS Choices

Yes Trust on website

Information into departmental CLIP reports.

PALS / Informal complaints

Face to face or completion of cards.

Ongoing

PALS / Departmental staff

No

Information into departmental CLIP reports and trend analysis undertaken.





PEQS

Face to face discussions

Monthly

Senior clinical Nurses etc

Yes

Feedback to Area managers and Matrons, action plans from findings.

Maternity (Continued)

Maternity MRSA

Postal Survey

Dependant on numbers

IC&P team and Clinical Effectiveness

No

1st survey just underway now - Infection control group and then directorate groups.

Gynaecology

National In-patient Survey

Questionnaire

Annually

Clinical Effectiveness

Yes

Results reviewed and actions planned accordingly. Patient Safety and Quality Standards Group

National Out-patient Survey

Questionnaire

Annually

Clinical Effectiveness

Yes

Results reviewed and actions planned accordingly, Patient Safety and Quality Standards Group

Endometrial ablation feedback

Questionnaire covering efficacy and outcomes

Ongoing to women who have had endometrial ablation

Internal

No

Action plans developed from finding by directorate group.

Patient Experience

Recorded interviews and set open questions.

Ad Hoc

Internally

No

Action plans developed from findings by Directorate groups and presented to Executive team.

Trust Thank you cards

Completion of cards

Ongoing

Internally

No

Areas each cascade details at ward /area meetings.

NHS Choices intranet site

Details entered onto intranet site voluntarily

Ongoing

NHS Choices

Yes Trust on website

Information into departmental CLIP reports.





PALS / Informal complaints

Face to face or completion of cards.

Ongoing

PALS / Departmental staff

No

Information into departmental CLIP reports and trend analysis undertaken.

Gynaecology (continued)

PEQS

Face to face discussions

Monthly

Senior clinical Nurses etc

Yes

Feedback to Area managers and Matrons, action plans from findings.

Colposcopy

Patient Experience

Questionnaire

Annually

QARC

Yes

Results reviewed and actions planned accordingly, QARC, Colposcopy Group and O&G Patient Safety and Governance group

EPAC

Patient Experience

Questionnaire

2 yearly

Internally

No

Results reviewed and actions planned accordingly, O&G Patient Safety & Governance and also Directorate meeting

ARU

Patient Experience

Questionnaire

Ongoing

ARU team

Yes

Results reviewed and actions planned accordingly, ARU team and HFEA during assessments.

Day Case Unit and Theatres

Day Case Patient Survey

Questionnaire Bi yearly Clinical Effectiveness

No Presentation to staff. Action plan.

Post operative telephone assessment

Telephone Daily Ward staff No Daily through verbal feedback

Theatre recovery discharge score

Theatreman Daily Trained theatre staff

Yes Monthly reports to Matrons Displayed on anaesthetics dashboard

Theatre recovery temperature score (compliance with NICE guidance 65)

Theatreman Daily Trained theatre staff

Yes Monthly reports to Matrons Displayed on anaesthetics dashboard





Elective Access (Colorectal)

Patient Satisfaction

Questionnaire Two yearly Clinical Effectiveness (National Patient Survey – Cancer)

Yes Monitored by NCAT publication sent to Cancer Networks and forwarded to Trusts, then down to individual MDTs

Infection & Prevention Control

MRSA patient experience

Questionnaire Ongoing throughout year

Infection control team and survey lead.

No but part of CQUIN

Feedback at directorate senior nurse meetings and link worker meetings with action plans requested if any major issues identified

Patient Advice and Liaison Service

Evaluation of PALS Service

Questionnaire Last one carried out Quarter 4 2009

Sent by PALS Officers evaluated by Clinical Effectiveness

No Clinical Effectiveness Evaluation Survey Results

PALS Volunteer Be-friender visits to wards

Face to face (UHH)

Twice a week PALS Officer & PALS Volunteer

No Compliments recorded by PALS, where appropriate any concerns acted on asap and escalated where necessary

Orthopaedic Directorate

Patient Satisfaction Survey – (Service Line Management)

Questionnaire/face to face/ comment cards

New survey being planned

Ward staff No Feedback to patients as ward notice board displays, Directorate and Staff meetings

Thank you cards

Comments from patients Face to face at times

Ongoing Ward staff Ward clerks

No Feedback to patients as ward notice board displays. Monthly returns to clinical effectiveness.





Orthopaedic Directorate (continued)

Patient Environment Quality Standards (PEQS)

Face to face Monthly (alternate sites)

Senior clinical matrons Ward matrons Director & Asst Director of Nursing

Yes Feedback to individual ward/area at the time of the visit. Formal feedback from DoH by letter to Ward Matron, Senior Clinical Lead, Assistant Director and Clinical Director.

Matron Rounds and Senior Clinical matron rounds

Face to Face with patients and their relatives

At least Monthly Senior clinical matrons Ward matrons

Yes Evaluation on feedback from patients and relatives. Action plan if required

National In Patient Survey

Questionnaire

Yearly Clinical Effectiveness

Yes Feedback results to directorate by survey lead to Directorate and staff meetings

High Impact Actions interviews

Comments from patients Face to face

Ongoing Ward staff Yes Feedback to High Impact Action group for benchmarking. Action plan as required. Staff meetings

Patient Experience via PALS and Patient Relations

Letters/ Telephone / Face to face

Ongoing Senior clinical lead, Ward/dept matrons, Asst Director, Clinical Director, Appropriate nursing/medical teams

Yes Feedback to individual ward/area at the time of the compliment or concern raised. Formal feedback to individual or area. Senior staff meeting. Directorate meeting. Appropriate specialty meeting Clinical governance forum.

NHS Choice website Comments from patients

Ongoing NHS Choices

Yes Feedback from patients and relatives delivered to relevant dept. Action plan if required





Orthopaedic Directorate (continued)

How did we do? Questions asked at the patients discharge

Questionnaire

Every patient discharge

Ward staff Ward clerks

Yes Feedback results to Matron or nurse in charge, address any issues raised before patient is discharged

Customer Awareness training for staff

Group work Ongoing Ward staff Yes Customer Charter developed to remind staff how they are expected to conduct themselves when in contact with patients

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