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PALS OPERATIONAL POLICY

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Policy Name Version Number

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Complaints PALS Operational Policy V.3 July 2013

Secondry Intranet Location

Trust wide

Current Author Joanne O’Neill Author’s Job Title Complaints Manager Department Complaints Department Ratifying Committee Quality & Risk Ratified Date July 2012 Review Date July 2013 Owner Gwyneth Wilson Owner’s Job Title Director of Patient Experience and Lead for

Nursing and Non Medical Professionals

It is the responsibility of the staff member accessing this document to ensure that they are always reading the most up to date version, - This will always be the version on the intranet

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

PALS Operational Policy Version3- July 2012 of 13

Related Policies Complaints Handling Policy and Procedure Patient Travel Expenses Reimbursement Policy and Procedure Being Open Policy

Stakeholders

Board of Directors Chief Executive Complaints and PALS Team Clinical and Managerial Teams Patient Experience Committee Risk Management and Patient Safety Departments

Version Date Author Author’s Job Title Changes

V1

18/6/09 Karl Perryman

Head of Complaints and Legal Services

V2

11/8/11 Joanne O’Neill

Complaints Manager

Minor updates

V3 16/7/12 Joanne O’Neill

Complaints Manager

Minor updates

Short Description Policy to support the work undertaken by the PALS team.

Key words PALS, Signposting, Concerns, Suggestions and Complaints




CONTENTS PAGE

1 INTRODUCTION

4

2 PURPOSE

4

3 DEFINITIONS

4

4 RESPONSIBILITIES

5

5 PALS AVAILABILITY

6

6 RESPONSE TIME OF CALLERS

6

7 REFERRAL TO THE PALS SERVICE

7

8 CONFIDENTIALITY

7

9 SAFETY OF PALS STAFF

7

10 PROVISION OF INFORMATION

7

11 MONITORING OF COMPLIANCE

8

12 EQUALITY IMPACT ASSESMSENT

8

13 REFERENCES

8

MONITORING COMPLIANCE TABLE

10

EQUALITY IMPACT ASSESSMENT

11

APPENDICIES

Appendix A 13




1 INTRODUCTION

1.1 The Patient Advise and Liaison Service (PALS) was launched nationally in April 2002 to ensure patients have more say in their own treatment and more influence over the way the NHS works. The purpose of this document is to provide information about the PALS philosophy and its operational policy.

1.2 Currently, The Queen Elizabeth Hospital King’s Lynn Foundation Trust has one PALS officer and one PALS Travel Desk Officer based in the hospitals front foyer and one Complaints/PALS officer who divides time between complaint handling responding to PALS enquiries.

2 PURPOSE

2.1 The purpose of PALS is to:

• Provide a confidential service to help make patients and visitors experiences within the NHS are as problem free as possible.

• Ensure patients, their families, and carers are better informed and that their voice is heard.

• Resolve individual concerns and information requests as quickly as possible.

• Provide information and feedback into health services, which will lead to quality improvements, based on patient experience and needs.

• Ensure that the service is available to all, regardless of age, race, religion, ability, gender, sexual orientation, social and political views, economic status and information literacy.

• Work with other organisations within the health community, including community PALS services and voluntary and statutory organisations, to provide as seamless service as possible for patients.

2.2 PALS are not a referral service intended to replace the problem solving skills of

staff throughout the hospital. It is a supplementary and complimentary service intended to act as a safety net for patients who feel their concerns have not been answered, or who have not been able to talk to staff directly about their worries. The PALS team will, at all times, ensure that their clients concerns are heard within a confidential environment.

3 DEFINITIONS

3.1 The Patient Advise and Liaison Service (PALS), are in place to ensure that the NHS listens to patients, their relatives, carers and friends and answers their questions and resolves their concerns as quickly as possible.



4 RESPONSIBILITIES

4.1 Complaint Manager

The Complaint Managers role is to manage the PALS on a day to day basis and ensure that PALS staff are available at all times to support patients, carers and visitors concerns.

4.2 PALS Officer

The role of the PALS Officer is to:

• Maintain a visible presence in the hospital, accessible to patients, visitors and staff.

• Listen to the client who is accessing the service and confirm what their concerns or queries are.

• Advise the client of options on how to proceed. This may include sign posting to the relevant service, information giving, explaining the complaints procedure or organising meeting with the appropriate staff.

• Provide support to the client in meetings with clinical and/or administrative staff, when required.

• Support training and education through attendance at User Group meetings and involvement in a range of appropriate steering groups.

• Provide as seamless a service as possible for clients, by networking with:

• The NHS Norfolk & Waveney PALS

• Local voluntary and charitable organisations

• Statutory organisations

• Self-help groups

• Network with the above mentioned organisations to provide the material for the database of information, which will enable PALS to make the service available to all, regardless of age, race, ability, gender, sexual orientation, social and political views, economic status and information literacy.

• Accurately log all enquiries, concerns and information requests on the Trust’s Datix information management system.

• Provide quarterly reports on the PALS activity for inclusion in to the CLIP report. Offering statistical and trend analysis.

• Listen to patient’s views and suggestions for improving services.



• As Patient’s champion, refer patient suggestions and concerns to the Patient Experience Committee (PEC) and Board of Directors.

• Act as a catalyst for change in improving the overall patient experience for visitors, patients and families.

• Promote the PALS to all members of the community including hard to reach groups such as the travelling community and migrant workers.

4.3 The role of the PALS Travel Desk Officer is to:

• Action claims for travel costs in accordance with the Healthcare Travel Costs Scheme (HTCS) and the Trust’s Patient’s Travel Expenses Reimbursement Policy and Procedures.

• Act as a ‘front of house’ information and sign posting service.

• Assist with the routine work of the PALS officer during prolonged periods of absence.

The PALS Travel Desk Services will be available at the Hospital front foyer between 08.30hrs and 16.30hrs daily.

5 PALS AVAILABILITY

5.1 Normal working hours will be from 08.30hrs until 17.00hrs Monday to Thursday and 08.30hrs until 16.30hrs on Fridays. Service cover will be provided outside normal working hours by provision of an answer phone on the PALS office telephone number and dedicated email facility. It is not anticipated that the PALS office will be manned during bank holidays. To maintain continuity of service, the PALS Team will provide cover for each other during absence.

6 RESPONSE TIMES OF CALLERS

6.1 Communications from potential clients/callers will be acknowledged within an agreed time frame, which is as follows:

• Messages or staff referrals will be responded to within one working day of receipt.

• Clients will be seen in person within one working day of contact, or at the earliest possible time convenient to the caller and a member of the PALS team.

• When the original contact is made in person, wherever possible the PALS officer will try to see them immediately, or alternatively an appointment will be made either on the same day or at the earliest possible time.

• Wherever possible, contacts requiring information will be dealt with immediately.

Written correspondence from clients should be acknowledged, preferably in writing, within 3 working days.



7 REFERRAL TO THE PALS SERVICE

7.1 There is no formal referral system; patients, members of the public and staff are informed of the service through banners, posters and websites indicating how to contact the PALS team.

8 CONFIDENTIALITY

8.1 PALS will ensure that clients’ concerns are dealt with in strictest confidence, in the following manner and with reference to the Caldicott Guardian, where necessary:

• Where the client is not the patient who is the subject of concern, the patient’s consent will be obtained prior to discussion with any other party, unless the concerns expressed are of a general nature, which does not impinge on the patient’s confidentiality.

• Where the patient’s condition is such that he or she is unable to give such consent, the PALS officer is to ensure that the requirements of the Mental Capacity Act 2005 and the Code of Practice Amendments 2007 are fully met before proceeding with the enquiry.

9 SAFETY OF PALS STAFF

9.1 The safety of PALS staff will be ensured through the following measures:

• The PALS staff will have a personal alarm available to him/her at all times.

• During office hours and whilst in the hospital, the PALS staff are to remain contactable via their pagers at all times.

• When meeting clients, whether in the PALS office or elsewhere in the hospital, PALS staff will ensure that they place themselves so that their egress is not compromised.

• If the client(s) become abusive or aggressive, the PALS staff member will make a reasonable attempt to calm the situation without risking their personal safety unnecessarily. If this fails, the PALS staff member will terminate the interview and, if appropriate, call for assistance from the Trust’s Security Manager, the Porters or the Police in accordance with the Trust’s Security Policy and the Zero Tolerance Policy, which is well publicised throughout the Trust.

• Should PALS staff be aware before the interview that there is potential for the client(s) to exhibit unacceptable conduct, suitable provision must be made to ensure the safety of both the client(s) and staff.

10 PROVISION OF INFORMATION

10.1 PALS will provide information regarding relevant services available both within

and outside the Hospital. This will include:



• In house information leaflets relating to medical conditions, clinical procedures and after care.

• Voluntary organisations and self-help groups, e.g. Red Cross, Community Transport and Local Information Support Team.

• Relevant contact names and telephone numbers for care and support in the community, e.g. NHS Direct and Social Services.

• Independent advocacy services e.g. Independent Complaints Advocacy Service (ICAS).

• Health information on the internet and intranet.

10.2 Information will be provided either verbally, in printed form, or by signposting to other agencies. The format and delivery of information will be appropriate to the client’s needs.

10.3 Provision will be made for clients with learning disabilities, visual or hearing impairment and those for whom English is not a first language.

11 MONITORING OF COMPLIANCE

11.1 Monitoring of compliance will be achieved quarterly by the Quality and Risk Committee via the CLIP Report.

11.2 In order to monitor the users’ experience, an audit will be completed annually. In order to produce this audit a sample of users of the PALS will be sent a questionnaire concerning their experience of the service. The questionnaire will follow the template at Appendix A and may be amended by the Complaints Manager at any time.

11.3 Compliance with roles and responsibilities is monitored at appraisal, following review of the individual’s knowledge and skills framework (KSF) together with the job description.

12 EQUALITY IMPACT ASSESSMENT

12.1 This policy has been subject to an Equality Impact Assessment and is not considered to have a discriminatory impact on any individual or groups. A translated version of this policy will be provided upon receipt of request.

13 REFERENCES

13.1 This policy has been developed in line with the requirements of the NHSLA Risk Management Standards 2012-13, Standard 2, Criteria 3,5,6 and 10.

• Data Protection Act 1998

• Department of Health: Supporting the implementation of the PALS and Liaison Services.

Pals.nhs.uk



Appendix


MONITORING COMPLIANCE Key elements (Minimum Requirements)

Process for Monitoring (e.g. audit)

By Whom (Individual / group /committee)

Frequency of monitoring

Responsible individual / group / committee (plus timescales(for Review of Results Development

of Action Plan Monitoring of action plan and implementation

Responsibilities

Annual Appraisal Specialty Reviews Annual Complaints Report Performance Reviews

Complaints Manager

Annually Overall appraisal rates monitored by Performance & Standards Committee

Divisional Board

Divisional Board

Process for listening and responding to concerns/complaints of patient, their relatives and carers

PALS Questionnaire/Survey Complaints Manager

Annually Performance & Standards Committee

Director of Patient Experience & Lead for Nursing & Non-Medical Professionals

Process for ensuring that patients, their relatives and carers are not treated differently as a result of raising a concern

PALS Questionnaire/Survey Complaints Manager

Annually Divisional Board Director of Patient Experience & Lead for Nursing & Non-Medical Professionals

Process by which the organisation aims to improve as a result of concerns

CLIP Specialty Review

Complaints Manager

Quarterly Quality & Risk Committee

Director of Patient Experience & Lead for Nursing & Non-Medical Professionals

Process by which the organisation monitors the changes that have been made as a result of concerns being raised

CLIP Complaints Manager

Quarterly Director of Patient Safety

Quality & Risk Committee


EQUALITY IMPACT ASSESSMENT Equality Impact Assessment Tool (To be completed and attached to any policy document when submitted to the appropriate committee for ratification.)

STAGE 1 - SCREENING Name & Job Title of Assessor: Joanne O’Neill – Complaints Manager Date of Review: July 2012 Policy or Function to be assessed:

Yes/No Comments

1. Does the policy, function, service or project affect one group more or less favourably than another on the basis of:

• Race & Ethnic background No

• Gender including transgender No

• Disability:- This will include consideration in terms of impact to persons with learning disabilities, autism or on individuals who may have a cognitive impairment or lack capacity to make decisions about their care

No

• Religion or belief No

• Sexual orientation No

• Age No

2. Does the public have a perception/concern regarding the potential for discrimination?

No

If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact Assessment. Signature of Assessor:Complaints Manager Date: 16 July 2012 Signature of Line Manager: Director of Patient Experience & Lead for Nursing & Non-Medical Professionals Date: 17 July 2012


STAGE 2 – EQUALITY IMPACT ASSESSMENT If you have indicated that there is a negative impact on any group, is that impact:

Yes/No Comments

1. Legal/Lawful under current equality legislation?

N/A

2. Can the negative impact be avoided? N/A

3. Are there alternatives to achieving the policy/guidance without the impact?

N/A

4. Have you consulted with relevant stakeholders of potentially affected groups?

N/A

5. Is action required to address the issues?

N/A

It is essential that this Assessment is discussed by your management team and remains readily available for inspection. A copy including completed action plan, if appropriate, should also be forwarded to the Equality & Diversity Lead, c/o Human Resources Department


APPENDIX A

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