southampton university hospitals nhs trust … · • opd snapshot patient experience survey...

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

3-Monthly Patient Experience Report: November 2009

Report to: Trust Board – 24

th November 2009

Report from: Julia Barton, Associate Director of Nursing/Judy Gillow, Director of

Nursing/DIPC Sponsoring Executive: Judy Gillow, Director of Nursing/DIPC Aim of Report: 1) To brief board members on performance against patient experience

targets (PIF and Patient Experience Strategy) 2) To highlight areas of progress and challenges, and identify the actions

taken and planned work streams to address these. 3) To provide a summary of patient feedback for months August,

September and October 2009. Review History to Date: - Second Quarterly Patient Experience Report

- TEC 18

th November 2009

Principle Objectives: To be the hospital of first choice for patients and to be in the UK Top

Quartile for Quality indicators. PO1c - Care exceeds patients expectations PO1d - Patient experience and customer satisfaction

Recommendations: Trust Board members are asked to:

1. Note that complaints targets are now compliant. 2. Note the achievements made so far during phase 2 of the same sex

accommodation programme and that the current compliance level stands at 65%. Acknowledge an apparent slow down of progress linked to capacity during September and October.

3. Note that targets for Privacy & Dignity are compliant with CQUIN

requirements and that Trusts internal target has been increased.

4. Note the consistently good performance for nurses and doctors giving patients “understandable answers”.

5. Note that the CQUIN target for “Staff talking in front of patients” is

non-compliant. Note the recommended actions to address this and that the trust’s internal target has been increased to bring it in line with CQUIN targets.

6. Support the actions to increase the return rate for monthly Picker

patient surveys.

7. Note the penultimate draft of the “Your Stay in Hospital” booklet aimed to address the pre hospital information target.

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1.0 Summary of Performance over Reporting Period

2.0 Our Goals: A Reminder

Patients tell us that a good experience is made up of the components below. Our Patient Improvement Framework targets reflect these goals and the feedback we receive from patients on aspects of care they would like to see improved.

• To be treated with honesty, compassion, respect and dignity

• To have the right information at the right time to enable the right choices

• To have consistent high quality care (safe, effective and personal)

• To be cared for in a clean, comfortable environment, which provides privacy and dignity and supports and promotes recovery and well being.

• To be cared for by professional, competent and reassuring staff

• To be listened to and communicated with effectively 3.0 Summary of Patient Improvement Framework Performance Months 5,6&7 2009/10

Table 1 details the Trust’s performance against agreed priorities for patient experience in 2009/10. Targets 2 & 3 have been increased by 5% and 10% respectively. This brings them in line with the SWEST Quality Contract CQUIN Targets for 2009/10.

Table 1: Summary of Trust PIF Performance August to October 2009

No

PIF Priority Target % or Status RAG

1. Same Sex Accommodation

99% Compliance (Facilities) by 31.3.10 Partly Met 65%

A

2. Privacy & Dignity Target reset this Q and raised from 90% to 95% (Patients surveyed report being treated with Privacy and Dignity)

Partly Met Average

M. 1-7 = 90.1%

A

3. Staff Talking in front of patients

Target reset from 80% to 90% this Q. (CQUIN for SWEST target)

Partly Met Average

M. 1-7 = 81.4%

A

4. Printed information prior to admission

80% of patients receive printed information about the hospital prior to admission 80% receive printed information about their condition prior to admission

Not Met 53% 69%

Average M. 1-7

R

5. Information on wards 80% of patients given the right amount of information via their ward/department.

Fully Met 80%

Average M. 1-7

G

6. Number of complaints Total of no more than 60 per month trust wide.

Partly Met Average 64 per

month this Q

A

Areas of Good Performance:

• Complaints: 3 day acknowledge risen to 100% and closure in response times risen significantly.

• Privacy & Dignity Target increased but sustained good performance. P&D DVD now completed. P&D Leaflets being distributed. Revised P&D Policy in draft form.

Areas of Slow Progress:

• Total number of Picker Responses: Reduced over this Q due to volunteers leave period. New performance management approach to individual ward responses being implemented.

• Patient information - “Your Stay in Hospital” booklet is in final draft form. This is a major initiative, which has been specifically developed to provide much improved information for patients. Vacancy for “Head of Patient Partnerships and Information” post due to be advertised in next Q.

• Improvement Initiatives & Planned Developments:

• OPD snapshot patient experience survey undertaken in July.

• Patient Property review and new policy out for consultation.

• New Patient Communications Group established and due to meet Nov 09.

• Review and revisions to Vulnerable Adults groups and establishment of a Trust Vulnerable Adults Steering Group

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4.0 Summary of Divisions PIF Targets and Work Programmes for Patient Experience

Each division has completed a detailed work plan for the priority areas of the PIF, and according to divisional and care group priorities. For the first time, a summary of all divisions’ programmes is included. Division 4’s plans are still in draft and being refined. An update against divisional PIF action plans will be provided in the next Q Patient Experience report for which divisions will RAG rate progress made against each of the PIF work streams. Progress is currently monitored in detail via Divisional & Care Group Management Teams. A new process for monitoring is also being developed for use in monthly divisional performance reviews.

Division PIF Patient Experience Targets Summary of Actions

Effective OPD Pathways

• 98% OPD appointments correct 1st time

• Maximum 6 week wait from GP referral for 1st

appointment

• 90% of all pts on 18/52 pathways leave clinic or receive confirmation in 24 hours of dates for diagnostic tests & follow-up.

• All F/up appointments and diagnostic tests delivered with clinically specified timeframes

• Patients who do not follow typical pathways (10%) will be escalated to the Business Unit and Practice Manager to ensure appointments are booked.

• Maximise use of clinical OPD facilities

• Redesign OP booking Service

• Define templates for OPD services

• Deliver a clinically triaged booking system

• Look into system of home working

• review consultant diary management & leave policy

• Workforce redesign – business unit/practice management model.

• Review audit of OPD clinical patient experiences

• Reconfiguration of OPD timetable to reflect theatre schedules and consultant job plans.

Division 1

Excellent Communication

• All staff understand and work to agreed customer care standards – zero tolerance to staff attitude complaints.

• All written information will be accurate, timely, understandable relevant and delivered to patients.

• timely and positive management/resolution of complaints.

• Implement use of patient stories

• Develop telephone answering standards

• Rolling review of all written information – identification of top 5 items by volume and care group.

• Standard setting for all divisional written information (in line with trust standards)

• Better IT involvement.

• System for local resolution of complaints at senior level.

Single Sex Accommodation

• SSA facilities and accommodation achieved in AMU, Endoscopy and C7

• Develop metrics (quantitative and qualitative

• Work with estates on SSA work plan for AMU

• Develop estates solution for C7 and Endoscopy

• Use patient surveys and user groups to achieve Trust targets.

Communication with Patients

• Develop mystery shopper model • Partnership with patient user groups

• Involve all management teams and consultants with monthly mystery shopper model. (Sept 09 – using volunteers to telephone all A&C staff)

• Plan of questions to include drs talking in front of patients

• Reduce numbers of complaints with communication issues (Sept 09 – trend analysis by CGMTs for presentation at DMY CG meetings.)

• Use GTT approach Improve Privacy & Dignity for/by:

• C3 Ward & Cancer Care

• RCN Dignity Campaign Launch

• Bariatric Patients

• Cancer care SI improvement project, one stop clinics and enter/exit of rooms.

• MDT protocol for Bariatric Patients

• Link into trust wide strategy

• Equipment – review of funding and storage

• Partnership working with community.

Division 2

Improving pre assessment/OPD Processes

• Review of OPD processes booking/letters & telephone communication

• Patients will not leave OPD without “next step”

• Central model for medicine and Sp. medicine.

• Focus on cancer strategy and OPD move to SGH.

• Spot check audit as measure.

4

Improving Patient Information

• Produce patient information for top 10 in each care group.

• Produce patient information for top 5 conditions for each care group

• Use of listening clinics

• Identify areas where pt information needed via patient audit/questionnaire

• Identify lead

• Divisional PI group to ensure all PI is written in line with trust PI policy.

• Poster advertising clinics (Sept 09 – format changes in light of poor attendance at first clinic.)

• Expand listening clinics to cancer care Age and gender specific accommodation provision

• Dedicated women’s hospital

• Single sex theatre lists

• Single sex facilities in GDU

• Follow up EBP project to ensure compliance

• All theatre lists to be single sex

• Planning to use gender specific day surgery facilities

• Discuss criteria for transsexual patients

• Consider fathers needs

• Partner accommodation Effective communication with all patient groups

• Ensure all PI is reviewed in line with Trust guidelines

• Ensure PI is disseminated to patients prior during and following admission

• Disability awareness

• Appropriate use of language/interpreter services

• User involvement in development of services

• User involvement in developing strategies form complaints and SUIs.

• Review patient information in key areas and submit to PI group.

• Complaint liaison patient for strategies if appropriate

• Instigate maternity customer care training

• Themes negative user feedback to be used for CC training

• Theme of week

• MCAs to encourage feedback prior to discharge

• Develop PPI guidelines

• Neonates exit questionnaire for all parents – audit and feed back to staff twice a year.

• Link to ADNS re: use of Picker Survey. Privacy & Dignity

• Implement same sex strategies

• Individual treatment rooms and use of privacy screens

• Respect for ethnicity

• Disability awareness

• Learning form patient feedback

• Improvements in attitudes of staff.

• Day surgery individual assessment rooms

• Quiet room for pts and staff with ethnic needs on gynae.

• Completed survey of patients with disability – awaiting results (gynae)

• Discuss patient feedback at staff meetings

• Staff to attend communication training (gynae)

• Matty focus on induction area

• Use of “Do not Disturb” signs in 3 bedded bays & transitional care ward.

• Implementation of disability pathway

• Screen babies in neonates

Division 3

Improving pre assessment and OPD Processes

• Ongoing review of gynae lean workshops

• Learning form and adopting Experience Based Design project findings

• RCA of DNAs and “Was not Brought”.

• Use of innovative communication (email and SMS)

• Discharge planning to improve patient pathways.

• Review electronic signs for patient flows

• Ensure adequate signposting in all areas

• Discharge lounge facility to be provided on H level for gynae and obs patients

• Review of matty prenatal diagnostics

• RTTC on Burley and Labour wards to improve and streamline processes

• Review access and referral in antenatal pathways

• Extra consultants to be employed for neonates OP service

• 2 parent information websites to be available for parents in neonates.

Division 4

Same Sex Accommodation Critical Care:

• % of patients/relatives via satisfaction surveys who are agreeable with P&D care/facilities.

• % of patients who do not state concerns re: SSA

• Zone Compliance

• Signage Audit Cardio thoracic

• No mixed sex bays excluding CCU and CHDU

• % of patients complaints that mention P&D as a specific concern

• Picker survey feedback

• RTTC satisfaction Surveys

• Divisional and Care Group Assurance Frameworks completed for each priority.

• Care group plans for approval at Divisional Board WB 23/11/09

Overall Divisional Priorities Set: Same Sex Accommodation/P&D

• SSA in all wards (100%)

• SSA Bathroom Facilities (100%)

• % of Patients treated with Dignity & Respect (100%)

Communication with Patients & Relatives

• % staff not talking in front of patients (100%)

5

Communication with Patients & Relatives

• Number of complaints

• % of patients and relatives whose surveys demonstrate good communication

• Results of Q documentation audit showing good communication with patients/relatives

Improving Pre Assessment & OP Processes

• Anaesthetic Provision

• Anaesthetic audit within pre assessment pathway

• % of patients who have access to one stop clinics (CV&T)

• % of patient complaints that mention OP and pre assessment as a specific concern (CV&T)

• Reduction in pre operative LoS (CV&T).


• Discharge pamphlet to patients (C Care & CV&T))

• Web Design (CC)

• Pre operative information for all patients (CV&T)

• Reduction in number of complaints (by 25%)

• Information to patients Improving POA and OPD Processes

• % Reduction in DNAs

• % Reduction in cancellations Improving Patient Information

• Understandable answers from nurses and doctors (100%)

Same Sex Accommodation • Develop P&D initiatives in OPD Gym & hydro (CS)

• Develop SSA plans for Interventional Radiology Unit when new location agreed

• Ensure P*D in all radiology in-patient waiting areas where possible.

Communication • Relocation of phlebotomy patients to OP clinic to improve management & communication

• Establish dedicated pathology call centre

• DVD for haemophilia patients

• Health promotion viewing facilities within path OP areas – review feasibility.

• Adapt cancer care dietetics leaflet for older patients.

• Review nutritional support discharge arrangements for tube feeds.

• Circulate “Healthy Eating Essentials” leaflet to all ward areas and OP clinics

• Support training of ward hostess role

• Refresh business case of pharmacy patients medicines help line.

• Therapies call patients to make appointments

• Respond to all complaints within agreed timescales.

• Implement a radiology “choose & book” service

• Centralise radiology reception staff where possible.

• Refresh radiology front line staff customer care skills.

• Work with GPs on access to radiology results

• Develop written information for patients access to level B MRI scanner.

Division 5

Privacy & Dignity

• Upgrade mortuary service for bariatric capacity

• Upgrade to changing rooms in hydro pool.

• Improve public access & appearance to C level pharmacy dispensing area

• Work with Div 2 to relocate vascular OPD screening.

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Admission, Discharge and OPD

• Implement phlebotomy in pre assessment and PAH

• Create anticoagulation one stop clinic.

• Work with surgical team to support Head and Neck one stop clinic with biopsy support.

• therapies steering group with commissioners on location of services and post procedure follow up appointments

• Ensure stroke therapist on duty 7/7

• Embed lean project on TTOs and develop solutions for getting TTOs to wards faster.

• Achieve 2 week wait for diagnostics (Radiology)


• Undertake phlebotomy and haemophilia patient satisfaction surveys.

• Target older patients as largest users of pharmacy services and most at risk.

• Reduce confusion from generic and brand names.

• Improve ward based pharmacy information for discharge and written information leaflets for high risk drugs.

5.0 Patient Experience Requirements of PCT Commissioning Contract & CQUIN Targets

SOLENT & SWEST Quality Contracts (Schedule 3 (4A)): Patient Experience KPIS `

Contract No.

Broad Subject Current Information Compliance Status

Q1 Complaints KPIs Compliant

Q11 Safeguarding Vulnerable Adults Process for capturing training under development.

Q14 National In Patient Survey Action Plan Compliant

Q16 Patient Experience Strategy & Customer Care training

Capturing Customer Care Training for induction but still developing systems to capture other customer care training.

Q17 Q In Depth Review of Pt Experience by Division

Compliant

Q18 Using real time patient feedback (Vulnerable Adults included)

Vulnerable adults feedback system under development

Q19 Same Sex Accommodation Compliant

Q20 Learning Disabilities Subject to cross-organisational improvement plan.

Q21 Essence of Care Compliant

Q22 Patient Communication Compliant

Q24 Involvement of Patients and Carers in Discharge Planning

Compliant

The key areas for development of information systems for patient experience relate to the capture of training attendance for customer care, MH and learning disabilities and also the capture of patient feedback from vulnerable groups. Plans are in place to resolve.

SOLENT CQUIN for Patient Experience

• Maternity Services – patient satisfaction survey

• Stroke Services – patient satisfactory survey Maternity services are currently undertaking comprehensive surveys and patient interviews to determine user representation (see Appendix B). However much of this is labour intensive. Stroke services are not currently capturing specific patient feedback about their services. Plans are underway to explore the use of Picker Frequent Feedback technology to assist in capturing patient feedback for both of these areas, as established Picker questionnaires exist for both. Cost implications will need to be considered prior to proceeding with this option.

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SWEST CQUIN for Patient Experience • % of Doctors not talking in front of patients – Need to achieve rolling average of 90%

performance.

Performance this Q: 81.4 achieved between months 1 & 7. See actions detailed in Communication section of this report. It is vital that we improve in this area or we may risk being “fined.”

• % of patients who feel they were always treated with dignity and respect. Need to achieve rolling average of 90% performance.

Performance this Q: 90.41 achieved between months 1 & 7.

6.0 The Patient Experience Strategy Steering Group/Sub Groups

The Patient Experience Strategy was refreshed in December 2008. A diagram representing the key themes of the Strategy in found in Appendix A. The group and its sub groups has developed and monitored the delivery of the following improvement initiatives over the last Q:

1) Review implications and learning from patient experience surveys in: � Out Patients � Discharge Lounge � PICU � Cancer Services

2) Oversee delivery of Same Sex working group and programme 3) Consider learning and implications form Experience Based Design pilot in Div 3 4) Monthly review of Picker Frequent Feedback results and development of strategy to increase responses. 5) Sanction review of consent profromas to ensure patient friendly documentation. 6) New Interpreters’ Policy developed. 7) Oversee work of subgroups including:

Essence of Care Group 1) Review of revised DoH Benchmarks for Essence of Care and new pain benchmark. 2) Developing new Div/CG assurance process for action plans including RAG of actions

from previous audits. 3) Review results and actions of bowel and bladder audit. 4) Contribute to trust wide documentation audit. 5) Ensure water jugs dried – added to ward hostess job description. 6) Contribute to review of appearance policy 7) New property policy under development.

Patient & Public Involvement/Patient Information Groups

1) Review of OPD appointment letters in progress 2) Corporate identity guidelines and implications for patient information. 3) Notice board presentation approach developed. 4) Proactive approach to NHS choices. 5) Update Picker PDA questions.

This Q a review of all the groups covering aspects of the Vulnerable Adults agenda has been completed. A new Trust Wide Vulnerable Adults Steering group is due to be established in November 2009. This group will oversee the workings and strategies of the 4 subgroups (Mental Health and Learning Disabilities Groups; Safeguarding Adults Group and Dementia Group) and streamline reporting to CSCSG.

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7.0 Quarterly Performance Overview

Feedback Headlines: “What are patients saying about our services?”

Annual In Patient Survey 2008 Results received May 09

An update on the action plan is due to be completed shortly. It would appear progress is being made in most areas but further concentrated efforts are needed with hospital noise, patient communications, patient information, pain control and storage for property, for improvements to be reflected in the monthly frequent feedback survey.

Picker Frequent Feedback Monthly In Patient Survey

The total number of survey responses for the Q1 and Q1 are as follows: April: 254 May:187 June: 135 July: 108 Aug: 81 Sept: 57 and Oct: 80 Despite considerable efforts from the volunteers service in October to increase the number of surveys completed, returns remain below 100 per month. This has significant implications for delivery of the quality contract and for individual ward patient experience reports. November’s Patient Experience Steering group have reviewed the trends and agreed a new approach to increasing survey numbers. This includes

• All wards and departments to aim for 20 returns per month

• Care groups have requested development of monthly league tables and RAG ratings to help them monitor returns.

• Weekly monitoring of returns via security office log by ADNS.

• Use of medial and nursing students who will be trained by volunteers

• Use of other staff members not in uniform who work in a clinical area.

• Continued focus on recruiting volunteers to assist in monthly Picker Surveys

It is crucial that in increasing the Picker survey returns, objectivity is not compromised. It is established that patients provide more favourable feedback when surveys are completed by staff in uniform who work in the care area.

Out Patient Department Survey

SUHT’s National OPD survey data collection is completed and the final report is awaited. A total of 8 volunteers were able to capture patient experiences in 10 different OPD clinics on 1

st July 2009. A paper based survey questionnaire

was developed using 22 questions and some biographical questions, similar to those included in the national annual OPD survey. Consultation with the matrons covering the OPD areas to be surveyed led to some refinements and improvements. A total of 90 surveys were completed The survey reveals that the patients who attended SUHT’s OPDs on the day of this snapshot survey on the whole had positive experiences. 82% rated their care as good, very good or excellent and 87% felt that they were treated with dignity and respect. Reported positive experiences were in relation to:

• Scheduling of appointments

• Clear directions to the OPDs

• Helpful, good mannered receptionists

• High quality of care from nursing and other health care professional staff

The survey highlights areas for potential improvement as:

• Difficulty in finding a place to park

• Patients actually having their appointment with the person they were expecting

• The relatively low % of patients who commenced their appointment on time

• The inadequacy of communications and information about the length of their wait and the reason for this

9

• The ability to discuss fears and anxieties with their attending doctor

• The low percentage of patients who received introductions from the staff they came into contact with.

Results have been shared with Care Groups who will feed into their PIF plans for improving OPD patient experiences. It is key that divisions ensure staff are taking appropriate actions on the basis of this feedback.

Comment Cards & Your Say Email

A total of 79 pieces of patient feedback have been received from “feedback forms” and via the “your say” email address (cf 148 in Q1). 39 of these provided positive praise (cf 53 in Q1) Top 3 themes for other feedback was: delays and waits (15), attitude of staff (5) and suggestions for improvement (4). NB: Q1 covered 4 months not 3.

NHS Choices Website

A total of 7 patients left feedback for SGH via the NHS Choices web site during August and September. This brings the total pieces of feedback for SGH to 53 since 2007. 6 of these items of feedback were negative and 1 positive. the negative feedback related to a consultant’s attitude and treatment, cleanliness, poor communication and general comments including disorganised care and treatment. 2 Patients left feedback for PAH hospital in September 09 – both were positive. All posts are provided with a personal response from the PALS team and fed back directly to departments when these are named. Patients leaving negative feedback are asked to contact the PALS team to discuss their experiences further.

PALS The top PALS themes are:

• Communications – use of answer machines

• Appointments - rescheduling and long waits • Dissatisfaction with clinical treatment • Delays and or cancellations for in patient treatment.

• Admission, discharge and transfer issues • Queries about what is written in medical notes

• Difficulty in obtaining information form medical staff • Doctors conflicting info

• Attitude – mainly of medical staff.

These represent similar trends to previous quarters.

Complaints Please see section on complaints in Key Performance Data section of this report. A total of 193 complaints have been received over Aug, Sept and Oct (average 64 per month). The % of complaints closed in target time has improved from 71% to 92.9%. The 3-day acknowledgement target has increased from 97% to 100%. The top 4 complaint themes for this Q were:

1) All aspects of Clinical Treatment (92)

• Inappropriate medical treatment (36)

• Adverse outcome/reaction (10)

• Inappropriate nursing treatment (9)

• Missed diagnosis (4)

• Timeliness of treatment (4) 2) Communication – written and oral to patients (29) 3) Appointment delays and cancellations (out patient) (19) 4) Attitude of Staff (16) 5) Admission, discharge and transfer arrangements (12) 6) Appointment delays & cancellations (in patient) (8)

It is important that divisions and care groups review their local trends with staff groups and identify/refine improvement plans.

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8.0 Impact of the Releasing Time to Care Programme on Patient Experience

The Releasing Time to Care programme requires clinical staff to focus on both patient and staff experiences. At the point of implementation, staff are required to undertake local patient surveys. This measure is repeated following completion of core modules. The results below suggest the programme is having a positive impact on patients and staff alike.

Wards on programme (32) Pre % Post %

Overall patient satisfaction as excellent or very good 97 100

Overall staff satisfaction as excellent or very good 83 90

Feel able to give safe reliable care to my patients (yes and mostly)

83 87

The programme also demonstrates the positive benefits on patient experience through the release of direct patient care time, through the reduction of time spent in motion and the number of interruptions.

All wards Pre % Post %

Direct Care = 40 57

% time in motion = 18 11

Interruption/hour = 16 11

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8.0 Key Performance Data and Summary reports

SAME SEX ACCOMMODATION Headlines: Progress with delivery phase 2 of the Same Sex Accommodation programme has continued. DoH DSSA Case Study at SUHT under development and presentation at 1 national and 1 regional SSA sharing events. Progress this period

• Delivering Same Sex Accommodation Road show held during September. The drop in centre was staffed by matrons. Patients were provided with packs with information about Privacy and Dignity and were encouraged to share their experiences via a video diary.

• New privacy and dignity leaflets have been printed and are in the process of being distributed to wards and departments.

• A SUHT Privacy and Dignity DVD has been completed and will be used with staff, patients and public.

• Sliding signs delivered and erection in clinical areas nearly completed.

• AMU redesign plans for “Green Bay” signed off by AMU staff, and Capital Programme leads for SSA.

• Provisional plans for WNC agreed and good engagement form divisional and Care Group team to finalise this and complete work before year end. C Neuro now has a compliant operational solution in place.

Outcomes this period Facilities compliance has increased from 59 to 65% this Q. Overall, the number of patients in mixed accommodation has not seen a significant increase or decrease this Q, although some care groups show significant decreases again and others slight rises. There has been a small dip in patient experience data. Both of these trends are attributable to operational and capacity issues experienced throughout Sept and Oct. Key Risks: A further peak in H1N1 (swine flu) cases has been experienced in Sept and Oct, with more patients spending longer in hospital and needed level 2 and 3 critical care. Current bed capacity issues have meant the trust has been on red alert status for most of September and October. timing of decanting. Next Steps Continue implementing operational and capital development plans for WNC, et al for Phase 2 of the programme to reach 99% compliance by year end. C7 – meeting to agree solution planned. G level Cohort bays - plan being signed off Continue development of AMU plans and agree timescales for works. Gain final approval for new P&D Policy incorporating SSA. Develop online database for individual breach recording. Links to the PCT SSA Audit, the SSA Detailed Action Plan and SSA A 3 plan are provided.

No. of Patients in Mixed Sex Bays 2009/10 Q1 and 2

0

500

1000

1500

2000

2500

3000

May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09

Month

No

. o

f P

ati

en

ts b

y B

ay

Surgery

Trauma &

Ortho

Medicine

Cancer Care

Neurology

Cardiothoracic

Total

G:\CGOVDEV\SHARE\Z - KEY TRUST COMMITTEES - do not amend please\Patient Experience Steering Group\2009\November\Enc Gi - Same Sex A3 plan Sep 2009.xls

G:\CGOVDEV\SHARE\Z - KEY TRUST COMMIT

G:\CGOVDEV\SHARE\Z - KEY TRUST COMMIT

Same Sex Accommodation Compliance Trajectory

67

5 0

1728

316

67

97

0

20

40

60

80

100

120

Jan-

09

Feb-

09

Mar-

09

Apr-

09

May-

09

Jun-

09

Jul-09 Aug-

09

Sep-

09

Oct-

09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar-

10

Month

Percen

tag

e C

om

pli

an

ce

Red

Amber

Green

Source: Estates Audit

65%

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Source Monthly In Patient Survey

Privacy & Dignity Headlines: The Trust has sustained a rolling average of 90.4% of patients reporting they were always treated with dignity and respect across months 1 to 7 of 2009/10. This Q, the P&D Target has been raised to from 90 to 95%

Progress this period:

• Position Maintained.

• This performance meets the SWEST Quality Contract CQUIN target to achieve a rolling average of 90% by Q4 of 2009/10.

Outcomes this period

• Completion of SUHT P&D DVD

• Distribution of P&D Leaflets (regional) in progress.

• Review of patient gowns started – meeting to negotiate with linen provider in Nov 09.

• 27 Trust HCSWs supported to attend a regional P&D Conference.

Key Risks Operational and Capacity pressures resulting in increasing patient moves and loss of continuity for care delivery. Next Steps

• Completion of review of P&D/SSA Policy and re-launch.

• Revised RCN P&D Campaign to be planned and launched before year end.

• Review of P&D issues especially when discussing condition and treatments as part of Communications Group ward round audit.

• Final decision on patient gowns and roll out of new gowns.

Source Monthly In Patient Survey

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Communication Headlines: The targets for the 3 indicators relating to Patient Communication have been increased from 80 to 90% this Q, which results in an amber position. Progress this period All indicators demonstrate a dip in performance in September and October, with September’s result being the poorest since August 2008, when 30% of patients surveyed reported that staff had talked in front of them. The “Talk in front of” KPI is also a SWEST CQUIN with the target set at a rolling average of 90% by Q4. Current rolling average for months 1 to 7 is 81.4. The dip in performance may be partly attributable to the fall in overall monthly survey responses over the summer period and the Trust’s capacity and operational pressures in September and October. Outcomes this period

• Communications and Customer Care Group re-established with relevant membership. First meeting due to take place in November 2009.

Key Risks Failure to meet CQUIN target for communication for SWEST Quality Contract by Q4 will result in a non-payment situation. Next Steps

• Development of Care Group/Divisional Performance league tables to drive up numbers of responses received.

• Use of personnel other than volunteers to increase number of monthly in patients survey responses to minimum of 20 per ward/dept.

• Presentation of data about staff talking in front of patients at December Core Brief with key questions to all staff about the actions they are going to take to improve this position.

Source Monthly In Patient Survey: No Responses.

Talk in front of Patients: Trust

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09

Talk in front of Patients

Target of 90%

Understandable Nurses: Trust

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Understandable Nurses

Target of 90%

Understandable Doctors: Trust

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Understandable Doctors

Target of 90%

Source Monthly In Patient Survey: Yes Always and Yes Sometimes Responses.

14

Patient Information Headlines: Numbers of patients receiving pre hospital information remains under target this Q. The elective responses received to the Pre Hospital information were 32, 18 and 23 for Aug, Sep and Oct respectively, whereas responses from elective patients in the previous Q ranged from 38 to 94. This may go some way to accounting for the swing in results. Progress this period: New “Your Stay in Hospital” booklet now in final draft form and requiring only final minor changes. Booklet has been out to consultation to PPI and staff groups and been proof read by patients. Link to booklet included below and copies will be available with this report.

H:\Patient Information\YOUR STAY IN HOSPITAL cover V4.pdf

H:\Patient Information\YOUR STAY IN HOSPITAL INSIDE PAGES V5.pdf


• Review of information and feedback via NHS Choices with view to uploading additional Trust information onto this website.

• Draft approach to display of information on clinical notice boards developed and approved.

• Update on printing costs for patient information.

• Review of patient information leaflets to incorporate FT logo undertaken & in readiness when approval date granted.

• New Trust Corporate Identity guidelines agreed and now distributed.

Key Risks Patient Partnerships and Information post vacant. Next Steps

• Continue work on reproducing all core patient information leaflets.

• Update Patient Information Policy & Guidelines re: corporate identity guidance.

• Recruit to Patient Partnerships and Information post.

• Distribution of P&D Leaflets.

• Assessment of Cancer Services Information Centre for MacMillan Patient Information Quality Mark due to be pilot in November 09 and will result in Beacon Status if passed.

• Complete work stream to develop better quality site maps and pilot these with patients and public.

.

Source Monthly In Patient Survey: Yes Responses.

Before Admission Printed Info about Hospital? Trust

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


Printed info about Hosp.

Target of 80%

Source Monthly In Patient Survey: Yes Responses

Before Admission Printed Info about condition? Trust

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Target of 80%

Printed info condition"

Info about condition given on ward: Trust

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Info given on ward

Target of 80%

Source Monthly In Patient Survey: “The Right Amount” Responses. (not enough 18.8%)

15

COMPLAINTS Headlines: Number of complaints received per month has risen slightly compared to the previous Q but remains either just over or under target each month. There has been an exceptional improvement in the meeting of the 3 day target (100% achieved) and response closure time targets 80 to 100% achieved) which has been sustained throughout October. This represents a significant increase from since the previous Q. The number of attitudinal complaints received shows minimal movement.

Progress this period

• Central complaints team have performed consistently well this Q and since working to special measures from end of Aug 09.

• Complaints review now completed and due to be disseminated by end of November.

• Agreed Complaints KPIs and departmental service standards.


• Sustained delivery of all complaints targets and the central and divisional teams have responded to the urgent need to improve performance since the previous Q.

• New staff member recruited and has commenced in central team.

• Improved line management and appraisals with central team.

• New process to complaints raised by PCTs and GPs implemented in partnership with PCT colleagues form NHS Hants and NHS Soton.

Key Risks Continued failure to meet complaints targets affecting reputation patient and PCT. Next Steps

• Divisional/Corporate action planning in response to the report recommendations

• Update of Complaints Policy to be agreed.

• Process for Remedy to be agreed and incorporated into 2010/11 planning cycles.

• Closer monitoring of numbers of cases reporting “not satisfied “ at first attempt and being referred to ombudsman.

• Agree next steps form Complaints Review report and develop divisional, care group and central plans to implement these.

Complaints Acknowledged Within 3 Working Days

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


Acknowledged within 3 working days Target

Monthly Complaints Received

0

10

20

30

40

50

60

70

80

90

Ap

r-08

May-0

8

Jun-0

8

Jul-0

8

Aug-0

8

Sep-0

8

Oc

t-08

Nov-0

8

Dec-0

8

Jan-0

9

Feb-0

9

Ma

r-09

Ap

r-09

May-0

9

Jun-0

9

Jul-0

9

Aug-0

9

Sep-0

9

Oc

t-09

Month

Nu

mb

er o

f C

om

pla

ints

Number of attitude of staff style complaints reported between April

09 - October 09

0

5

10

15

20

25

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct

-08

Month reported

Nu

mb

er r

epo

rted

Reported numbers of attitude

of staff style complaintTarget

Source: Safeguard

Complaints response times

0

20

40

60

80

100

08/9 Q2 08/9 Q3 08/9 Q4 09/10

Q1

Jul Aug 28-Aug 11th

Sept

18th

Sept

25th

Sept

4th Oct

Quarter/Month/Week

% r

esp

on

ded

to

in

targ

et

tim

e

16

9.0 Conclusion

o The report demonstrates areas of progress over the previous Q and includes additional information relating to themes emerging from patient feedback.

o The Divisional PIF targets and actions relate directly to the priority areas identified in numerous sources of patient feedback.

o The improvement in complaints performance is significant and the tremendous efforts made by divisional, care group and central complaints teams as well as individual clinicians must be recognised.

o Further progress with reform of Patient Complaints/Support Services will be the focus of the next Q.

o Divisions need to review their complaint themes and the information sent to patients prior to admission as a priority.

o Divisions need to further engage with clinicians, nurses and other health care staff re: the practice of talking in front of patients and develop urgent plans to eradicate this practice.

Appendix A: Patient Experience Strategy Key Themes

17

Appendix B: Summary of Patient Experience Feedback Maternity Services.

satisfaction of antenatal care

VERY SATISFIED

51%

NOT AT ALL

SASTISFIED

1%

NOT VERY

SATISFIED

8%NO RESPONSE

3%

SATISFIED

37%

satisfaction of overall maternity care

VERY

SATISFIED

51%SATISFIED

30%

NOT VERY

SATISFIED

9%

NO RESPONSE

4%

MIXED

4%NOT AT ALL

SATISFIED

2%

southampton university hospitals nhs trust … · • opd snapshot patient experience survey...

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