National InPatient Survey 2013 Analysis of the Care Quality Commission s Benchmark Report and Local Action Plans

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1 PAPER: SFT 3537 National InPatient Survey 2013 Analysis of the Care Quality Commission s Benchmark Report and Local Action Plans PURPOSE: To provide the Board with an analysis of the Care Quality Commission s benchmark report on the National Inpatient Survey 2013 and the actions to be taken by the Trust. MAIN ISSUES: 1.0 Introduction Salisbury NHS Foundation Trust participated in the eleventh national inpatient survey between October 2013 and January Questionnaires were sent to 850 randomly selected patients who had spent at least one night at Salisbury District Hospital during the month of July The Trust achieved a response rate of 65% which was 5% above target and 16% higher than the national average. 2.0 The Benchmark Report Each year the Care Quality Commission (CQC) produces a report for each acute Trust in England showing the results weighted against other Trusts. Weighting is applied in three specific areas:- a) a high percentage of responses from older people who tend to report more positive experiences than younger respondents; b) a high percentage of women respondents who tend to report less positive experiences than men; c) a high percentage of respondents from emergency admissions who tend to be more negative than those respondents who had a planned admission. The CQC is continuing to use the scoring format introduced last year whereby results are scored out of 10, rather than 100, to avoid confusion with percentages. In the report, the word better or worse is displayed if a Trust s score is significantly better or worse than most other Trusts, as shown in Example 1 below. Example 1 The tables at the back of the report show SFT s score compared to the lowest and highest score across all Trusts, and the number of SFT respondents for that question. The tables also indicate with an arrow whether a Trust s score is significantly up or down on the previous year, as shown in Example 2 below. 1

2 Example 2 The CQC expects Trusts to use the report to understand their own performance and to identify areas for improvement. 3.0 Analysis of the Benchmark Report The survey contained 60 core questions which could be analysed. Other questions (known as filters) instructed respondents to skip certain questions or sections that did not apply to them. The results are grouped into ten sections and Trusts are scored for their overall performance in each section. SFT scored about the same as all other Trusts in each of the ten categories:- The Emergency/A&E Department Waiting list and planned admissions Waiting to get to a bed on a ward The hospital and ward Doctors Nurses Care and treatment Operations and procedures Leaving hospital Overall views and experiences For the 60 individual questions, SFT scored significantly better for one question:- Did you get enough help from staff to eat your meals? The remaining 59 questions scored about the same as all other Trusts. When compared with its own 2012 benchmark results, SFT significantly improved in three areas:- Nurses not talking in front of patients as if they were not there. A member of staff explaining to the patient how the operation or procedure had gone, in a way they could understand. Patients being asked, whilst they were in hospital, to give their views on the quality of the care they were receiving. There were no significant declines. 4.0 Comparisons with Demographic Characteristics The split between male and female respondents was exactly 50/50, compared with 46% male and 54% female nationally. Age group, religion and sexual orientation responses were in line with national figures. SFT s ethnicity responses for the White 2

3 group were slightly higher than nationally (95% compared with 89%); responses from other ethnic groups were 5% compared with 11% nationally. 5.0 Local Results Analysis and The Next Steps In addition to the standard questions, patients were invited to make comments about anything which they felt was particularly good about their care or things that they felt could be improved. A total of 282 good comments were received and 252 improve comments. These have been categorised and analysed to show the areas where further attention is required, as indicated in the graph below: Issues regarding the environment mainly related to the fact that the weather was hot in July and wards found it difficult to keep their areas cool. Issues relating to discharge have been incorporated into ward action plans where appropriate. Whilst 38 more negative than positive comments were received, the overall score for hospital food has not significantly changed from the previous year (down 0.3%); an achievement given that between July and September 2013 the catering service was provided from temporary facilities whilst the main kitchen underwent a major capital refurbishment. Following this work, the results from real-time feedback have improved. It is anticipated that following the introduction of new food trolleys in May 2014 feedback will continue to improve and it is believed that this will be reflected in the 2014 national inpatient survey results. The Patient Experience Analysis Group met in February 2014 to look at the results in conjunction with themes arising from incidents, concerns and complaints. Action plans have been drawn up by the wards with the over-arching theme of improving communication (see Appendices 1 4). A progress report will be presented to the Clinical Governance Committee in November ACTION REQUIRED BY THE BOARD: Board members are invited to endorse this approach and note the contents of this report. 3

4 ATTACHMENT/S AVAILABLE TO VIEW ON WEBSITE: Appendix A IP2013 Action Plan_Medicine Appendix B IP2013 Action Plan_Surgery Appendix C IP2013 Action Plan_Musculo-Skeletal Appendix D IP2013 Action Plan_Spinal Unit AUTHOR: TITLE: Fiona Hyett Interim Director of Nursing 4

5 Pitton/ Whiteparish/Redlynch/Durrington/Tisbury/Farley/Pembroke/Winterslow and Breamore Ward National In Patients Action plan for 2013 survey results APPENDIX A Name of Ward reporting Communication between all grades of staff that work in clinical areas of the Trust with carers, patients and relatives. Poor communication is the cause of people raising concerns and complaints, and not understanding what is planned for their care and discharge. Senior sister of each ward. Ensure all grades and disciplines of staff communicate at a level appropriate to the person they are talking to. Ensure the patient/relative/carer has the opportunity for questions. Ensure the patient/relative/carer is asked if they understand what they have been told. This applies to all grades of staff working with the patients. Ensure all medication is fully explained. Ensure that discharge arrangements are explained fully and that all carers and relatives are fully informed in a timely manner. Ensure all patients being discharged receive a copy of their discharge information. Ensure that all grades and disciplines of staff are constantly reminded of the need for clear and consistent information giving to all patients and their carers/relatives/partners. All areas should show and Family Test and Real-Time feedback results, as well as monthly basis.

6 Action plan for 2013 National Inpatient Survey Britford and Downton wards APPENDIX B Name of Ward reporting Communication and information giving to patients that are being discharged is not always timely and adequate. Patients and carers not always aware of what care they will need when they go home. The aim of the actions is to improve the knowledge of the patient of what to expect on discharge. Ensure patients and their carers are given as much notice as possible re potential discharge date. Ensure, if applicable, that any further health or social care service, physio or community nurse needs are discussed with the patient/family/carer prior to discharge and that the patient it aware of what they will need and what is going to be arranged. Ensure nurse discharging patients asks if they understand all the information and if they have any questions (all patients to be given the discharge checklist sheet that they need to complete and return to nurse to confirm understanding of information given). Ensure nurse discharging patient informs patient who to contact if they are worried about their condition or treatment after they have left hospital (give discharge information sheet which has these details). Ensure all patients are given the Friends and Family Test questionnaire on discharge to enable feedback. Ensure all patients are given a copy of their electronic discharge forms. All relevant patients to be given relevant information from the physiotherapy team. Page 1 of 2 Senior sister of ward All areas should show and Family test, Real time feedback results as well as monthly basis Audit discharge check lists given out to patients for the month of June 2014.

7 Action plan for 2013 National Inpatient Survey Britford and Downton wards Communication between all grades of staff that work in clinical areas of the Trust with carers, patients and relatives. Poor communication is the cause of people raising concerns and complaints, and not understanding what is planned for their care and discharge. Senior sister of each ward. Ensure all grades and disciplines of staff communicate at a level appropriate to the person they are talking to. Ensure the patient/relative/carer has the opportunity for questions. Ensure the patient/relative/carer is asked if they understand what they have been told. This applies to all grades of staff working with the patients. Ensure all medication is fully explained. Ensure that discharge arrangements are explained fully and that all carers and relatives are fully informed in a timely manner. Ensure all patients being discharged receive a copy of their discharge information. Ensure that all grades and disciplines of staff are constantly reminded of the need for clear and consistent information giving to all patients and their carers/relatives/partners. All areas should show and Family Test and Real-Time feedback results, as well as monthly basis. Page 2 of 2

8 Action plan for 2013 National Inpatient Survey Musculo-Skeletal wards APPENDIX C Name of Ward reporting Communication and information giving to patients that are being discharged is not always timely and adequate. Clare Wood Gill Hibberd (physio) Patients and carers not always aware of what care they will need when they go home. The aim of the actions is to improve the knowledge of the patient of what to expect on discharge. Ensure patients and their carers are given as much notice as possible re potential discharge date. Ensure, if applicable, that any further health or social care service, physio or community nurse needs are discussed with the patient/family/carer prior to discharge and that the patient it aware of what they will need and what is going to be arranged. Ensure nurse discharging patients asks if they understand all the information and if they have any questions (all patients to be given the discharge checklist sheet that they need to complete and return to nurse to confirm understanding of information given). Ensure nurse discharging patient informs patient who to contact if they are worried about their condition or treatment after they have left hospital (give discharge information sheet which has these details). Ensure all patients are given the Friends and Family Test questionnaire on discharge to enable feedback. Ensure all patients are given a copy of their electronic discharge forms. All relevant patients to be given relevant information from the physiotherapy team. Page 1 of 2 Catherine Whitmarsh (OT) All areas should show and Family test, Real time feedback results as well as monthly basis Audit discharge check lists given out to patients for the month of June 2014.

9 Action plan for 2013 National Inpatient Survey Musculo-Skeletal wards Communication between all grades of staff that work in clinical areas of the Trust with carers, patients and relatives. Poor communication is the cause of people raising concerns and complaints, and not understanding what is planned for their care and discharge. Senior sister of each ward. Ensure all grades and disciplines of staff communicate at a level appropriate to the person they are talking to. Ensure the patient/relative/carer has the opportunity for questions. Ensure the patient/relative/carer is asked if they understand what they have been told. This applies to all grades of staff working with the patients. Ensure all medication is fully explained. Ensure that discharge arrangements are explained fully and that all carers and relatives are fully informed in a timely manner. Ensure all patients being discharged receive a copy of their discharge information. Ensure that all grades and disciplines of staff are constantly reminded of the need for clear and consistent information giving to all patients and their carers/relatives/partners. All areas should show and Family Test and Real-Time feedback results, as well as monthly basis. Page 2 of 2

10 Tamar and Avon Ward National In Patients Action plan for 2013 survey results Name of Ward reporting Patients state in the national survey that they are not always given sufficient discharge information. Dominic Holbourne Ensure all patients have a copy of the SIA Patient learning pack, and that they have read it and understand it. Ensure the patient has a copy of their care plans and check list. Ensure monthly review meeting of the patient s care plan with the named nurse. Ensure that check list covers all areas of the patients needs. Encourage use of Trust discharge check list one week prior to discharge to ensure that all needs are covered. Liaise with discharge co-ordinator to ensure package ready for patient s discharge and ensure completion of spinal discharge check list. APPENDIX D All areas should show and Family Test and Real-Time Feedback results, as well as monthly basis. Page 1 of 2

11 Tamar and Avon Ward National In Patients Action plan for 2013 survey results Name of Ward reporting Communication between all grades of staff that work in clinical areas of the Trust with carers, patients and relatives. Poor communication is the cause of people raising concerns and complaints, and not understanding what is planned for their care and discharge. Senior sister of ward. Ensure all grades and disciplines of staff communicate at a level appropriate to the person they are talking to. Ensure the patient/relative/carer has the opportunity for questions. Ensure the patient/relative/carer is asked if they understand what they have been told. This applies to all grades of staff working with the patients. Ensure all medication is fully explained. Ensure that discharge arrangements are explained fully and that all carers and relatives are fully informed in a timely manner. Ensure all patients being discharged receive a copy of their discharge information. Ensure that all grades and disciplines of staff are constantly reminded of the need for clear and consistent information giving to all patients and their carers/relatives/partners. All areas should show and Family Test and Real-Time feedback results, as well as monthly basis. Page 2 of 2

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