CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.4 Report of: Cheryl Lenney, Chief Nurse Paper prepared by: Sue Ward, Director of Nursing Debra Armstrong, Deputy Director of Nursing (Quality) Kathryn Krinks, Head of Quality Improvement Date of paper: September 2015 Subject: Patient Experience Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) The National Patient Surveys and planned Patient Experience Framework impact on the Trust key objectives: Patient experience Staff experience Recommendations: The Board of Directors is asked to note the content and actions contained within the report and to support the development of a new Patient Experience Framework. Contact: Name: Sue Ward, Director of Nursing Tel: Page 1 of 16

2 1. Executive summary 1.1 Patient experience feedback provides a rich source of data to support continuous improvement of the Trust s services. Patient feedback is sought and received through a range of formats. 1.2 This report provides a summary of the 2014 National Adult Inpatient Survey and 2014 National Children and Young People s Inpatient and Daycase Survey findings. Comparisons are made with local and Shelford Trusts as well as with the Trust s own Patient Experience Tracker data. 1.3 Many positive elements of patient experience are identified by the Survey results; however, the findings show that the Trust generally falls within the average range for most factors that influence patient experience when compared to other Trusts. Analysis of the findings is presented followed by triangulation with local data, which demonstrates similar themes. 1.4 The Trust has a track record of making improvements in patient experience through an intensive focus on a specific issue and through high profile calls to action, however, in order to embed and sustain improvements it is evident that a new approach is required. The final section of this report presents the principles that will underpin a new Patient Experience Framework, which aims to draw together patient and staff experience at a strategic and operational level, placing frontline leaders at the heart of driving a shift from average to excellent patient experience National Inpatient Survey (Adults): Methodology and results 2.1 Introduction The Board of Directors receive an annual report and presentation on the National Inpatient Survey. This report provides a summary of the results and the analysis of the 2014 National Inpatient Survey The annual National Inpatient Survey is a Care Quality Commission (CQC) requirement to obtain feedback to improve local services for the benefit of patients and the public based on patient experience. Survey results are reported to the CQC, contribute to the Trust Quality & Risk Profile outcomes and form the basis of quality improvements which are monitored through the Trust s contracts with its commissioners The Survey is undertaken on behalf of the Trust by an independent provider Quality Health, who administer a postal survey, observing nationally approved methodology. A sample of 850 adult inpatients who had at least one overnight stay in the Trust during July 2014 was required. Notification has been received that this year (2015), the sample size will increase to 1,250 and that the month has been fixed for all Trusts as July The Survey covers aspects of the patient s admission, care and treatment, operations and procedures and discharge from hospital. Page 2 of 16

3 2.1.5 The results of the adult National Inpatient Survey show that improvements have been demonstrated in a number of categories, and specifically in four of the five areas of focus identified last year, however, the Trust remains about the same as other Trusts overall for all categories Demographically, Trust respondents to the 2014 Survey consisted of 48% men and 52% women. Similar to previous years, 77% of patients classified themselves as White English/ Welsh/ Scottish/ Northern Irish / British ; 4% described themselves as Black or Black British (African, Caribbean or other Black background) and 7% described themselves as Asian or Asian British (Indian, Pakistani, Bangladeshi or other Asian background) This is significantly different to the national demographics of respondents whereby 89% of patients classified themselves as White English/ Welsh/ Scottish/ Northern Irish / British ; 1% described themselves as Black or Black British (African, Caribbean or other Black background) and 3% described themselves as Asian or Asian British (Indian, Pakistani, Bangladeshi or other Asian background) The response rate to the 2014 Survey was 38%, which was a decrease of 3% compared to 2013; this is 9% lower than the national average response rate of 47%. Each year since 2012, the Trust has undertaken an awareness campaign to promote the Survey during the months of June and July for patients and staff. Despite these campaigns, response rates have decreased year on year, which may relate to survey fatigue. This year each patient discharged in July 2015 received a letter describing the Trust s commitment to continuous improvement and advising patients that they may be randomly selected to take part in the Survey New guidance this year requires Trusts to provide a method for patients to request they are removed from the sample if they do not wish to participate in the Survey. This was explained in the letter that each patient received. 2.2 Survey Analysis The annual adult National Inpatient Survey report 1 for CMFT is published by the Care Quality Commission (CQC) and provides details of the Trust s scores Previous survey results have enabled analysis within the Trust, at individual speciality level, providing the Clinical Divisions with information to focus attention for improvement. The results for the 2014 Survey are only provided at a general medical and general surgical specialty level. Thirty responses are required per specialty to enable specialty-specific results to be extracted. None of the Trust s other specialities received sufficient responses to enable speciality-level analysis. This lack of granular detail affects local interpretation of the results. 1 Page 3 of 16

4 2.2.3 The Survey results indicate whether the Trust is better, about the same or worse than other Trusts nationally. The Trust remains about the same as other Trusts for all categories; which indicates an improvement compared to 2013, when waiting lists and planned admissions scored worse than other Trusts The Trust s scores have improved for the categories emergency department, waiting for a bed, the hospital and ward, doctors and care and treatment. Scores for the categories nurses and leaving hospital have remained the same for two consecutive years. Although the category operations and procedures has decreased by -0.1 compared to 2013, this is an increase of +0.2 from The category overall views and experience has decreased by -0.1 this year compared to This year the Trust s overall score, based on the mean average of all question scores, was 7.7 (on a scale of 0 to 10), which is an increase of +0.2 compared to This compares to other local Trusts; where the range of scores is 7.5 to 8.5 and to the Shelford group; where the range of scores is 7.6 to 8.5. Although, the overall score is calculated within the Trust and is not published nationally, it is noteworthy that this score has improved this year compared to all previous years Relatively high scores: Internally the same approach has been taken to that taken in previous years to identify relatively high scores, which is to include responses where the Trust scores were within 0.5 of a point of the best local Trust and/or the best Shelford Trust. Relatively high scores were identified in 20 out of 58 questions (35%). Although this is the same position as the previous year, most of the questions had scores that were higher than the previous year. The Trust score for the question were you bothered by noise at night from other patients was the best score in comparison to all other Shelford Trusts and reflects work undertaken through the Brilliant Basics quality campaign Areas of concern: Internally the same approach has been taken to that taken in previous years to identify areas of concern, which is to include responses where the Trust s scores were more than 1.0 point below the best local Trust and/or the best Shelford Trust. Areas of concern were identified in 21 of the 58 questions (36%) which is an improvement from the previous year where 50% of questions were considered as areas of concern. The Trust had the lowest scores compared to both local and Shelford Trusts for admission date changed by hospital, cleanliness, rating of food, nurses (including giving clear answers to questions, confidence and trust, talking in front of patient as if not there), pain management and time taken to respond to call bell There were only three areas where scores have deteriorated steadily over the last 3 to 4 years, these were: cleanliness (particularly bathrooms and toilets), giving information about conditions and treatments, and explanations given in a way that can be easily understood after operations / procedures Other general areas of concern where scores were significantly lower than the previous year were related to: Food overall rating and choice Pain management Information at discharge regarding medication side effects Page 4 of 16

5 Information about how to complain Being asked about views on quality of care Many of the same issues highlighted within the patient comments were similar to previous years. These comments provide a rich source of data that can be used to identify the specific areas that need attention; for example when reviewing food, patients have made very few comments regarding nursing processes and delivery of food but made specific comments relating to the quality, temperature and choice of food provided A range of work has been undertaken since the Survey was conducted to deliver improvements to the patient experience in the areas identified as concerns. A Trustwide Patient Dining and Environment Group is leading a programme of work, which includes improving food and cleanliness. Through this work a new electronic food ordering system called MAPLE has been introduced to provide better information and choice to patients and deliver a more efficient process Other improvement activities include joint workshops with Trust and Sodexo teams, led by the Director of Nursing, to focus on cleanliness and explore new ways of working. This approach will be rolled out widely to encourage effective team working and personal commitment to achieving improvements in cleanliness. The Trust has also focused on discharge processes and pain management through the Brilliant Basics campaign Improved scores: Areas where scores have improved steadily over last 3-4 years relate to feeling safer (patients feeling threatened by other patients), communication (staff saying one thing, then somebody else says something quite different) and discharges (delays at discharge, especially medicines; clear written information about medications; discussing need for on-going health/social care) Other areas where improvements have been seen, based on scores that were significantly higher than the Trust scores for the previous year, are: Information provided in A&E Sharing a sleeping area with someone of the opposite sex Noise at night from other patients and staff Help with meals Having enough nurses Someone to talk to about worries and fears Providing emotional support The improvement in scores in the above areas correlates with actions taken at ward and divisional level in response to analysis of the National Inpatient Survey 2013, where a focus on five areas was recommended and shared widely Table 1, below, shows that four of these five areas have shown significant improvement with the exception of the rating for food. Page 5 of 16

6 Table 1: Five areas of focus following 2013 National Inpatient Survey Scores 5 Areas of focus identified last year Ensuring patients are given a copy of the GP letter at (not asked) discharge Finding someone to talk to about worries and fears Ensuring patients consider there are enough nurses on duty +0.7 to care for them Providing help with meals & improving the perception of +0.6 (help) hospital food -0.6 (rating of food) Noise at night Real Time Patient feedback It is valuable to cross reference the snap shot provided by the National Inpatient Survey results with the real time feedback from the Trust s electronic Patient Experience Tracker (PET) surveys. The key themes that receive consistently low PET scores are: Pain management Presentation/ quality of meals Cleanliness Noise at night Finding someone to talk to about worries or fears Areas highlighted as being of concern within the National Inpatient Survey 2014, for example cleanliness and meals, have not shown any improvement in the monthly feedback since the survey was undertaken Scores relating to noise at night did show improvement in both the National Inpatient Survey and the real time feedback in July 2014; but have dipped since this time. Initiatives to address this concern in a sustained way include provision of eye masks and ear plugs to patients in addition to a focus on minimising staff-related noise at night. This issue continues to be a priority within the Trust s ward-level improvement activity In relation to finding someone to talk to about worries and fears ; it is encouraging that continued improvement has been seen month on month since July 2014, however, a continued focus is required to maintain the upward trajectory. Patient Focused Rounding has been introduced in all wards to ensure that patients have regular opportunities to voice any worries or fears to a staff member National Inpatient and Daycase Survey (Children and Young People): Methodology and results Page 6 of 16

7 3.1 Introduction In 2014, the care Quality Commission (CQC) conducted its first National Children and Young Peoples Inpatient and Daycase Survey. Children, young people and their parents and carers were invited to feed back about their care. Development of this Survey is underpinned by a system-wide Pledge, supported by the CQC, which includes a commitment to improve the care that children and young people receive to reduce avoidable deaths. The Pledge formed part of the Government s response to the first report of the Children and Young People s Health Outcomes Forum (CYPHOF), which recommended that by , the views of children and young people are incorporated into all national patient surveys Understanding children s experiences of care and treatment while they are in hospital provides key information to drive improvements both nationally and locally The Survey is undertaken by the same independent provider as the Adult Survey; Quality Health, and builds on the voluntary survey run annually by the Picker Institute Europe, which has previously been conducted by RMCH to inform improvement activity Quality Health administer a postal survey on behalf of the Trust, observing nationally approved survey methodology. The Survey required a sample of 330 patients under the age of 16 years, who were discharged from hospital during August The response rate to the Survey was 25%, which is similar to the national average response rate of 27% Demographically, Trust respondents comprised 49% male and 51% female. 68% of patients classified themselves as White ; 5% described themselves as multiple ethnic group; 6% Black or Black British; and 16% described themselves as Asian or Asian British; 2% Arab or other ethnic group and 3% as not known. This differs to the national demographic composition of respondents whereby 79% of patients classified themselves as White; 3% described themselves as Black or Black British and 16% described themselves as Asian or Asian British The Survey consisted of the following three separate questionnaires in which questions are tailored to the specific group: Parents and carers of children aged 0-7. Children and young people aged 8-11, with a section for their parents/carer to complete. Children and young people aged 12-15, with a section for their parents/ carers to complete. 2https:// 3 Page 7 of 16

8 3.1.8 The following aspects of the patient s and parent/carer s experience were covered within the Survey: Going to hospital The hospital ward Hospital staff Speaking with patients and providing information Facilities for parents and carers Pain Operations and procedures Being prepared to leave hospital Overall experience The results from the Children and Young People s Survey have provided a baseline for future comparison and have identified themes, which correlate with the Trust s Patient Experience Tracker data. 3.2 Survey Analysis The results and analysis are set out in report published by the CQC entitled The National Children s Inpatient and Day Case Survey 2014 for CMFT Responses are presented as scores on a scale of 0-10, where ten represents the best possible response zero the worst Results are categorised as 'about the same,' 'better' and 'worse' than other Trusts, based on an analysis technique called the 'expected range' which determines the range within which the Trust's score could fall without differing significantly from the average, taking into account the number of respondents for each Trust and the scores for all other Trusts. If the Trust's performance is presented as being outside this range, it means that it performs significantly above/below what would be expected. If it is within this range, it is defined as 'about the same'. In this methodology, where a Trust is scored as performing 'better' or 'worse' than the majority of other Trusts, this is considered very unlikely to have occurred by chance Ninety-six per cent of the Trust s scores fall into the about the same category across all 9 aspects of patient experience noted in 5.8 above Within this data two questions were identified as worse than most other Trusts: Whether children and young people liked the hospital food. Whether staff were available when their child needed attention As this is the first National Children s Inpatient and Day Case Survey there is no previous comparable Trust data, but the information provides an important baseline against which future scores will be benchmarked. 4 Page 8 of 16

9 3.2.7 Although it is not possible to directly compare the findings to previous years, internal analysis of the responses to 53 questions has been undertaken and comparisons made to other Trusts. The Trust s overall score, based on the mean average of all question scores was: 7.1 (children and young people): range for all other Trusts (parents and carers): range for all other Trusts Relatively high scores: Relatively high scores (within 0.5 of a point of the highest Trust score) can be seen for 4 responses. These relate to children and young people feeling safe and someone telling them what would be done before their operation or procedure. For parents and carers the higher scoring areas relate to having their questions about their child s operation or procedure answered, in a way they could understand and sufficiency of information on the use of a new medicine Areas where the Trust is about the same : Although performance generally fell in line with the national average, it is noteworthy that within this category the Trust achieved a score of 9 or more for feeling safe, safety of younger children, staying on a children s ward (as opposed to an adult ward), friendliness of staff, understandable explanations, information before an operation/procedure (to children and parents) and information about medicines Access rights are awaited to the free text comments collected by the Survey, which will support further analysis and provide a focus for further improvement activity Areas where the Trust is worse than the average: Two areas are reported in this category and relate to staff being available when their child needed attention and children not liking hospital food. It is of note that parents responses regarding food for younger children fell into the about the same category, suggesting that parents do not share their child s dissatisfaction with the food provided for their child. To provide context, the results of other Children s Hospitals have been reviewed for the areas identified as worse than average. CMFT scored 5/10 for food in this category, Birmingham Children s Hospital scored 6.1/10, Sheffield Children s Hospital scored 5.8/10 and Alder Hey Children s Hospital scored 6.6/10. Similarly these other children s hospitals scored 8.1/10, 8/10 and 8.1/10 respectively compared to the CMFT scores of 7.4/10 for staff being available The Trust will continue to share and explore best practice with other Children s Hospitals through established networks such as the Association of Chief Children s Nurses (ACCN) in order to make continued improvements in these areas Improvements: Since completion of the Survey, a comprehensive improvement project to address concerns regarding food has been undertaken in RMCH, led by the Director of Nursing for children and underpinned by extensive patient, family and staff engagement. This has resulted in a number of improvements including implementation of a children s nutrition and hydration policy, implementation of a revised children s menu and bespoke menus for children with specific needs such as those receiving care in the Oncology Unit and inpatients in the mental health unit, introduction of a finishing chef in the inpatient mental health unit, introduction of snack rounds and a range of ward-level improvements to the meals process. Page 9 of 16

10 Real Time Patient Feedback It is valuable to cross reference the snap shot provided by Survey results with the real time feedback from the Trust s electronic Patient Experience Tracker (PET) surveys. The key themes that receive consistently low PET scores are: Pain management Presentation/ quality of meals Cleanliness Communication Improvement activity has been undertaken to address these issues and all areas have shown an improvement in overall scores within the PET data for 2014/15 compared to the 2013/14 data. 4. Triangulation of Survey feedback with local data: Adults and Children Young People 4.1 Both the children s and the adult National Surveys identify similar overall themes providing a focus for improvement in the following key areas: Cleanliness Food Pain management Communication especially listening, involving in care and information Discharge planning and information Access to games and toys (Children and Young People) 4.2 The issues identified by the National Surveys are monitored using the Trust s Patient Experience Tracker (PET) and analysis of this data will be used to target and measure further improvement work in the identified areas. 4.3 Graphs 1 to 6 provided as Appendix 1 show the Trust PET data from January 2014 to May 2015 relating to the identified priority areas, with linear identifiers highlighting the months the patients were identified to participate in the Surveys (green for the Adult Survey and red for the Children and Young People s Survey). This data highlights specific areas for attention that accord with the identified priorities, including cleanliness of bathrooms and toilets, continued work to improve the patient dining experience, review following the administration of analgesia, providing opportunities to discuss worries and fears and ensuring that patients receive information regarding signs and symptoms to look for following discharge. 5. Actions and next steps 5.1 Since the time that the Surveys were undertaken, improvement activity has been ongoing in relation to the themes identified by the Surveys, which correlate with local PET data. Aspects of this work have been described within this report to provide assurance that the issues highlighted by the National Surveys had already been recognised through local feedback mechanisms and improvement action had been initiated to respond. Page 10 of 16

11 5.2 The results of the adult National Inpatient Survey 2014 have been disseminated to the adult divisions. The presentation of the results for general medicine and general surgery at speciality level has enabled these specialities to analyse data and develop localised action plans. The lack of other speciality-level data affects the individuality of actions for other Divisions. However, PET data provides a ward-level position alongside which the Trust level results can be utilised to inform local improvement and development plans. 5.3 Preparation has commenced for the 2015 National Inpatient Survey for adults, which will involve patients who were discharged in July The Trust has been advised that the 2015 Survey will contain four new questions; one related to staff working well together as a team, the others related to planning for continuity of care after discharge or transfer. 5.4 The Royal Manchester Children s Hospital has received the results of the Children and Young People s Survey and an action plan identifying improvements has been produced. 5.5 The next Children and Young Peoples Survey is scheduled to be undertaken in The Quality Committee, chaired by the Chief Nurse, will monitor the Divisional actions related to the Surveys. In addition a process for theming and reviewing complaints performance is being developed through this Committee to develop data in a format that Divisions can utilise in conjunction with the Survey results to inform local improvement programmes. 5.7 Whilst both survey information and real time patient feedback through the patient experience trackers provide examples of good practice as well as areas for improvement; the actions we take each year rarely takes us above average in regards to patient opinion. Our ambition is to considerably raise the bar in patient experience, taking the opportunity to build on the workforce improvement and transformation work programmes to develop a step change in our approach based on our people. 5.8 To build on the success of improvements that have been made and to provide a structure to engage all staff in making the shift from average to excellent patient experience, a value-based Patient Experience Framework is being developed through the Quality Committee to supersede the existing Patient Experience Policy. Section 6, below, describes the underpinning principles and process for development of the new Framework. 6. Patient Experience Framework 6.1 The new Patient Experience Framework will align key strategies and will recognise the interconnection of patient and staff experience. Effective leadership and good communication structures will be fundamental to successful delivery, and frontline leaders will be placed at the heart of driving patient experience, supported and coached by senior leaders. Page 11 of 16

12 6.2 The Trust s 2014 Staff Survey has shown that staff motivation is above average when compared to other organisations. Research commissioned by the Association of UK University Hospitals HR Forum 5 has demonstrated a causal relationship between staff motivation and patient satisfaction. The Trust is therefore well placed to harness this high level of staff motivation to support improvements in Patient Experience. 6.3 The Patient Experience Framework will be underpinned by the following key principles: Patient and staff experience are intrinsically linked; Frontline leaders are champions for Patient Experience; Patient Experience is the responsibility of every member of staff; Multi-professional engagement in development and delivery of the Framework is essential; Individual needs, values and preferences must be respected; Patients are active partners in care; Environments of care must be conducive to supporting delivery of dignified, healing, compassionate and age appropriate care; Effective information, communication and education underpins patient and staff experience; Emotional and spiritual support and involvement of friends and family enhance patient experience; Patient and staff experience feedback must be sought through a variety of mechanisms most suited to individual preferences. 6.4 A series of high level commitments will be delivered through a comprehensive delivery plan focused on a shared, multidisciplinary goal. A draft of these commitments, which has been presented to the Quality and Performance Scrutiny Committee, is provided as Appendix Through extensive engagement and consultation with patients and with all staff groups, the Patient Experience Framework will define the elements that make a patient s experience excellent and the factors that motivate staff to drive improvement. 6.6 Leadership, at every level, will form a thread through the Patient Experience Framework, from strategic alignment and support by the Board of Directors to front line leaders championing patient experience in their area. 6.7 Skills training will be developed and delivered to all staff to ensure that everyone in the organisation is equipped and empowered to drive improvements in patient experience. 6.8 The findings from existing tools, such as National Patient Surveys, the Friends and Family Test and Patient Experience Tracker surveys will be drawn together along with the introduction of additional methods to monitor progress, and a communication framework is being developed to ensure that front line staff know what patients say about their experience of the Trust s services, have clear routes to share their ideas for improvement and have authority to drive change locally. 5 Trovus (2014) NHS Staff Motivation to Inpatient Satisfaction: Analysing the Relationship. Page 12 of 16

13 6.9 Personal accountability will be core to the delivery of the Patient Experience Framework and will be reflected within the appraisal process and in personal development plans The draft Patient Experience Framework will be reviewed by the Quality Committee in September 2015 before a period of wider engagement and consultation, with a view to presenting progress to the Board of Directors in January Conclusion 7.1 The information presented in this report demonstrates that a range of tools are used to gather patients opinions about the quality of their experience of the Trust s services. This feedback provides a wealth of data to inform improvement activity. However, the value of this data could be enhanced by more effective triangulation and co-ordinated dissemination to the front line staff, who have a direct impact on the patient s experience in every patient interaction that they undertake. 7.2 The relatively high scores for staff motivation found in the 2014 Staff Survey suggest that the Trust is well-placed to harness the workforce to champion patient experience. The development of a new Patient Experience Framework will respond to feedback from patients and staff and engage with front line leaders with a view to achieving excellence. 8. Recommendation 8.1 The Board of Directors is asked to note the findings of the National Patient Surveys and the improvements made to date and to support the development of a new Patient Experience Framework. Appendix 1: CMFT Patient Experience Tracker January 2014 to May 2015 relating to areas identified for focused improvement activity Graph 1: Cleanliness Graph 2: Food and Nutrition Page 13 of 16

14 Graph 3: Pain Graph 4: Worries and Fears: 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% talk about your worries and fears? told who to contact if worried? Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Graph 5: Discharge Planning and Information: Page 14 of 16

15 Graph 6: Play and Activities Page 15 of 16

16 Appendix 2 Patient Experience Framework Patient Experience Matters Our Commitments to Care Page 16 of 16