Patient Experience Strategy

Size: px
Start display at page:

Download "Patient Experience Strategy"

Transcription

1 Patient Experience Strategy V1.0 May 2013 Graham Nice Chief Nurse Putting excellent community care at the heart of the NHS Page 1 of 26

2 CONTENTS INTRODUCTION 3 PURPOSE, BACKGROUND AND NATIONAL CONTEXT 3 DEFINITIONS 5 DUTIES 6 STEPS TO IMPROVE PATIENT AND SERVICE USER EXPERIENCE 7 USING PATIENT AND SERVICE USER EXPERIENCE TO IMPROVE SERVICES: THE FIVE STAGES 8 Stage 1. Capturing the Patient Experience 9 Stage 2. Analysing The Information 11 Stage 3. Making Improvements 13 Stage 4. Measuring The Change 15 Stage 5. Feeding Back What We Have Done 16 WORKING WITH PARTNERS 17 CONSULTATION, APPROVAL, RATIFICATION AND REVIEW 17 EQUALITY AND ANALYSIS 18 TRAINING, DISSEMINATION AND IMPLEMENTATION 18 DOCUMENT CONTROL AND ARCHIVING 19 REFERENCES 19 APPENDIX A: IMPLEMENTATION PLAN 20 Page 2 of 26

3 Introduction Sussex Community NHS Trust (SCT) is the main provider of community healthcare across Brighton & Hove and West Sussex. The Trust was formed in 2010 through the integration of South Downs Health NHS Trust and West Sussex Health, resulting in an organisation with more than 4,000 staff. SCT provides essential assessment, diagnostics, treatment and care to over 8,000 people a day. The Trust s vision is to put: Excellent community care at the heart of the NHS. The Trust has three strategic objectives: Support people to stay well and care for people who are not well or injured Sustain and improve our financial strength To have high quality services led and delivered by excellent staff informed by public and wider stakeholder engagement The experiences of patients and service users and their families are extremely important to SCT. Patient and service user experience is critical to both individual patients and their families and goes beyond the health outcomes of care. This strategy sets out to identify the key objectives over a 3 year period to use and improve patient and service user experience within SCT. This strategy covers all services provided by Sussex Community NHS Trust. Purpose, Background and National Context The purpose of this strategy is to: Set out the organisation s vision and values in relation to patient and service user experience Develop a culture that places quality of care at the heart of our services In October 2011 the NHS National Quality Board defined patient and service user experience as: A patient s direct experience of specific aspects of treatment or care. Based on this definition, on 21st February 2012 the Department of Health launched the NHS Patient Experience Framework which serves to outline the key elements of patient and service user experience: Page 3 of 26

4 Respect for patient-centred values, preferences, and expressed needs, including: cultural issues; the dignity, privacy and independence of patients and service users; an awareness of quality-of-life issues; and shared decision making Coordination and integration of care across the health and social care system Information, communication, and education on clinical status, progress, prognosis, and processes of care in order to facilitate autonomy, self-care and health promotion Physical comfort including pain management, help with activities of daily living, and clean and comfortable surroundings Emotional support and alleviation of fear and anxiety about such issues as clinical status, prognosis, and the impact of illness on patients, their families and their finances Welcoming the involvement of family and friends, on whom patients and service users rely, in decision-making and demonstrating awareness and accommodation of their needs as care-givers Transition and continuity as regards information that will help patients care for themselves away from a clinical setting, and coordination, planning, and support to ease transitions Access to care with attention for example, to time spent waiting for admission or time between admission and placement in a room in an inpatient setting, and waiting time for an appointment or visit in the outpatient, primary care or social care setting. The SCT Patient Experience Strategy is based on these values. In addition, it serves to support a number of other core national frameworks, standards and recommendations including: Annual Quality Account Care Quality Commission Essential Standards of Quality and Safety Mid Staffordshire NHS Foundation Trust Public Enquiry 2013 Monitor Quality Governance Framework NHS Litigation Authority Risk Management Standards NHS Operating Framework National Institute for Health and Clinical Excellence (NICE) Quality Standards / Guidance on patient experience NHS Outcomes Framework 2012/13 Page 4 of 26

5 Definitions Care Quality Commission (CQC) Commissioning for Quality and Innovation (CQUIN) Independent regulator of health an social care provider in England and Wales A framework for payment that enables commissioners to reward excellence. Friends and Family Test Healthwatch Monitor Parliamentary Health Service Ombudsman Patient A single question, How likely are you to recommend our [ward / A&E department] to friends and family if they needed similar care or treatment?, introduced by the Department of Health (DoH) to create a simple, comparable test which, when combined with follow-up questions, provides a mechanism to identify poor performance and encourage staff to make improvements where services do not live up to the expectations of our patients (DoH, 2012) Independent consumer champion for health and social care in England Authorises and regulates NHS Foundation Trusts Considers complaints from members of the public who feel a public body, such as the NHS, has not acted properly or fairly. For the purpose of this document, the term patient is used to include loved ones, carers, family and friends Patient experience A patient s direct experience of specific aspects of treatment or care. Patient experience feedback Information received from patients, through a variety of mechanisms, that is used to design and improve services Primary Care Trust (PCT) The commissioning body for health services. Service User People who use health and social care services as patients Carers, parents and guardians Organisations and communities that represent the interests of people who use health and social care services Members of the public and communities who are potential users of health services and social care interventions. Page 5 of 26

6 Staff The term service user also takes account of the rich diversity of people in our society whether defined by age, colour, race, ethnicity or nationality, religion, disability, gender or sexual orientation, and may have different needs and concerns. Definition taken from Health Service Executive, 2011 All staff, whether substantive or temporary, employed by the Trust or working for the Trust through a 3 rd party contract, volunteers, trainees or secondees. Duties STAFF Responsible, appropriate to job role, for ensuring that patients are provided with clear verbal and written information. Responsible for ensuring that patients are given the opportunity to ask about benefits, risks and alternative options for treatment through open, honest and sensitive conversation. TRUST BOARD Responsible for ensuring it receives and acts appropriately on information about the areas of public concern and assuring itself that consultation with patients and service users, relatives, carers and the public has taken place before decisions on service planning are made. CHIEF EXECUTIVE Ultimately responsible for ensuring that there are effective systems and processes in place for capturing and using patient and service user feedback and patient and service user experience. CHIEF NURSE As lead executive accountable for patient and service user experience, responsible for the effective delivery of this strategy. EXECUTIVE DIRECTOR OF OPERATIONS Responsible for ensuring that services act on patient and service user feedback and patient and service user experience to improve the quality of services delivered. DIRECTOR OF HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT Responsible for ensuring that improving patient and service user experience is reflected in the Trust s appraisal system. CALDICOTT GUARDIAN (IN SCT THIS IS THE MEDICAL DIRECTOR) Responsible for ensuring that all patient identifiable information is managed in accordance with the Caldicott principles. COMPLAINTS AND ASSURANCE LEAD Page 6 of 26

7 Responsible for ensuring an effective and efficient PALS and complaints service. Responsible for providing complaints, PALS and compliment data relating to patient and service user experience and outcomes. PATIENT EXPERIENCE SUB COMMITTEE Ensure SCT engages with patients and carers from diverse backgrounds in a meaningful way to help plan, deliver and improve our services. HEADS OF SERVICE / STRATEGIC BUSINESS UNIT LEADS Responsible for ensuring that the views of patients, relatives, carers and the public are considered in all service development plans in a timely and effective manner. Responsible for ensuring the results of feedback influence service changes and the results are fed back to patients and service users. Steps To Improve Patient and Service User Experience SCT understands that the patient is the most important person and the reason for the existence of the Trust. Therefore we are committed to providing a consistently high standard of service which meets the needs of the local population and is truly patient-centred. We consider the patient, their families and carers to be the expert by experience as they hold a unique vantage point as knowledgeable witnesses in the delivery of care. As a Trust we need to be proactively seeking patient feedback will help us deliver services and enable us to continually develop, learn and improve. SCT strives exceed the standards set out by Care Quality Commission in their Essential Standards for Quality and Safety. These standards are outcome focused and have a clear set of statements around what people who use services should experience. By collecting meaningful patient and service user experience information we can assure ourselves we are complaint with the expected standards, and where we are not we can take active steps to become compliant. Measuring patient experience, not just patient satisfaction, is essential. Collecting information in itself has no value; it is how the information is used to transform services which matters and this comes from the experiences of people using those services. This strategy has been designed using three basic steps. Each of these have been applied to a series of stages (outlined in the next section). These steps involve exploring: Page 7 of 26

8 Using Patient and Service User Experience to Improve Services: The Five Stages SCT has identified five key stages in the use of patient experience information: 1. Capturing the experience Obtaining information from patients and service users on their experience(s) of using SCT services 2. Analysing the information Looking at what the information is telling us, good or bad; looking for trends, looking for where improvements are required, and looking for examples of great practice we can share across the organisation 3. Improving the services Making changes that should have a positive impact on patient care 4. Measuring the change Assessing the impact of the changes made to ensure they have made a positive difference. 5. Feeding back what we have done Telling you what we have done, and the impact of what we have done. Each of these stages flow in a constant cycle of quality improvement: Page 8 of 26

9 Stage 1. Capturing the Patient Experience A. Where are we now? The current situation. The Trust already uses a number of methods to collect patient and service user experience information these include: Complaints feedback Friends and Family Test (pilot) PALS enquiries Patient Experience Sub Committee Patient and service user surveys Compliments Web based feedback forms Verbal feedback during assurance reviews B. Where do we want to be? Our objectives. OBJECTIVE 1: Build on existing work to further develop robust systems and processes for gaining both quantitative and qualitative feedback from patients, their families and carers. In order to achieve the best possible picture of its services, SCT will build on its existing feedback collection mechanisms. This means gathering quality information on a regular basis about how people feel about our services, including roll-out of the Friends and Family Test. In order to make improvements we need to capture both quantitative and qualitative information. Quantitative information includes collecting statistical information, such as the number of complaints or compliments and qualitative information is about capturing people s perceptions, opinions and reasons for their experience. As information technology improves we will look at using increasingly varied and innovative ways to capture patient and service user experience such as: Page 9 of 26

10 Touch Screen Tablet Surveys SMS Surveys On-Line forums Social Media To gain robust qualitative information we need to be proactively asking people what it is like to use our services and where they feel any issues and problems may lie. To improve the way we do this we will be exploring how we can develop this area looking at options such as: Public Meetings Comment Cards Telephone Surveys Use Of PALS Contacts Focus Groups In addition to these direct methods, the Trust has a body of information already in place through its own quality and safety systems and this information will also be used to identify areas of excellence and areas requiring improvement. These other sources of data include: External regulator such as the Care Quality Commission Reviews of Compliance, Patient Environment Action Team assessments etc Feedback from the Parliamentary Health Service Ombudsman Incidents and Serious Incidents National surveys and reports Annual staff survey C. How are we going to get there? Our plan. Development and implementation of a system and process to collect consistent, high quality patient and service user experience information. Development of a more robust approach to collecting, sharing and using feedback from websites such as NHS Choices, Patient Opinion, IWantGreatCare and the friends and family test. Page 10 of 26

11 Development and implementation of systems and processes for collection, analysis and use of patient stories - where an individual patient, or carer, describes their experience of healthcare in their own words Development of a protocol and quality assurance process for surveys and questionnaires developed and used within the Trust. Development of patient drop in sessions for patients and relatives to share their views and experiences of services. Stage 2. Analysing The Information A. Where are we now? The current situation. Our current incident, complaints, claims, Patient Liaison and Advice Service (PALS) and patient and service user survey data gives us information on individual patient s experience, when things have gone wrong or were not as the patient, or their family and carers had expected. This information provides a useful resource for supporting services to learn from patient and service users experiences. Concerns and complaints are often dealt with at a local service level and have resulted in local improvements and developments. Learning and improvements need to be effectively analysed and shared wider across the organisation to ensure there is no repetition of the same negative experience. In addition sharing of good practice and compliments can support to aid developments across the organisation. On a regular basis quality reports are produced for services and for Board assurance using the data collected. Each of the different aspects e.g. incidents or complaints are analysed and reported on but results from patient surveys, complaints, PALS contacts and incidents could be analysed further and against each other. This triangulated view will help identify Trust wide themes and trends to inform both targeted service developments and Trustwide improvements. Complaints received provide not only an opportunity to put things right where they have gone wrong but also to learn important lessons and develop new approaches to improve our services. The way in which we deal with complaints can improve the experience of users - where complaints are not handled so well this could make it worse. B. Where do we want to be? Our objectives. Page 11 of 26

12 OBJECTIVE 2: Develop more robust analysis of complaints, claims, PALS enquiries and compliments to inform both service specific and Trust wide improvements. OBJECTIVE 3: Build on existing work to further develop a triangulated and robust system and process for gaining both quantitative and qualitative feedback from patients, their families and carers, from all available information sources. Information captured will be analysed both within the service to which the data relates and across larger organisational areas to identify what it is really telling us about the quality and safety of the services we provide as well as the trends and themes such as: Common issues arising across a number of different services Common issues arising within a specific service A specific service receiving significantly better / worse results than others A specific service showing particularly exceptional performance C. How are we going to get there? Our plan. Develop systems for the triangulation of different types of data to identify where there are common issues arising. Development of a robust system to review information collected from all aspects of patient and service user experience to identify themes, trends and learning A review of the quality of our response to complaints and PALS enquiries including systems, processes, human interactions and written communications Collation and disseminating of learning from complaints, claims, incidents and PALS enquiries. Development of a standardised process for handling informal complaints Active promotion the PALS services to users of Trust services and the wider population Development of strategic action plans to address common themes raised in complaints, claims, incidents and PALS enquiries. Page 12 of 26

13 Stage 3. Making Improvements A. Where are we now? The current situation. Services within SCT vary in terms of levels of service development in response to patient and service user experience information. Equally some services and individuals are more active in promoting their developments and improvements than others. The actions, words and behaviours of SCTs senior management team set the tone of the organisation and influence how staff and managers feel about the Trust which in turn has an impact on how they behave towards each other and towards patients and their families. Executive and Non-Executive Directors undertake visits to services, invite patients to tell their stories at the Trust Board and participate in assurance reviews, which includes interviewing patients and service users about their experience of Trust services. The Chief Executive personally reviews and signs all complaint responses. The Chief Executive also sends out a weekly e-bulletin informing staff of developments, improvements and future organisational direction. Staff also receive a Quality Focus newsletter which includes examples of identified learning from incidents, complaints and the management of risk. B. Where do we want to be? Our objectives. OBJECTIVE 4: Every service within the Trust will use patient experience to gain insight and identify opportunities for improvement. It is important that all services within SCT see that they contribute either directly or indirectly towards a positive patient and service user experience, even back office services such as Human Resources, Finance and Estates. Each area needs to reflect on the feedback received from patients, their families and carers to identify opportunities for improvement. OBJECTIVE 5: Every service within the Trust will, having identified opportunities for improvement, implement at least one patient experience improvement project annually. We recognise the importance of responding and acting upon issues and concerns raised by patients and their families and carers as soon as possible. Page 13 of 26

14 Where possible immediate remedial action will be taken locally to respond to issues of concern to rectify the situation to the satisfaction of those involved. Once the immediate problem is resolved it is essential that we learn from situation and use the information to make improvements that will impact on patient and service users experiences in the future. Individual services will use local user feedback to identify opportunities and plan for local service improvements. OBJECTIVE 6: The Service Experience team will lead a Trust wide support campaign to support services in making improvements where themes are identified SCT plans to develop a campaign style approach to improve the experiences of patients, their families and carers in relation to the NHS Patient Experience Framework: Respect for patient-centred values, preferences, and expressed needs, Coordination and integration of care Information, communication, and education Physical comfort Emotional support Welcoming the involvement of family and friends Transition and continuity Access to care OBJECTIVE 7: The Trust Board will continue to take an active leadership role in advocating improvements in experiences of patients in receipt of SCT services. Learning and improvements will be reported to the Quality Committee and Patient Experience Sub Committee on a regular basis. Ongoing embedment of a Trust wide a culture where all services and individuals understand their impact on the patient and service user experience C. How are we going to get there? Our plan. Ensuring we actively learn from the outcome of complaints and incident investigations Consistent identification of specific actions that need to be undertaken to make improvements Supporting services to gather robust patient and service user experience feedback using a range of methods Page 14 of 26

15 Enabling our teams to take action to rectify issues of concern in a timely manner, immediately wherever possible Ensuring that local services take action based on the feedback from patients, their families and carers to make improvements and developments that positively impact on patient and service user experience Development of a process to ensure that services share their improvements in order to influence Trust-wide developments. Development of clear Trust wide messages and communications to support and improve patient and service user experience. Design of a focussed plan to support our campaign on the identified themes for improvements in patient and service user experience. Development of the existing Executive and Non Executive Directors walkabouts in services to explicitly and consistently include patient and service user experience questions Ensuring the Board receives regular information about patient and service user experience in a variety of formats including not only statistical information but with a focus on outcomes and improvements Stage 4. Measuring the Change A. Where are we now? The current situation. We measure patient and service users experiences by using existing information collection methods such as complaints and PALS data. We report on our findings in board quality performance reports and in our annual Quality Account. Internal assurance review visits also report on both patient and service user experience and, through follow up reviews, what action(s) has been taken as a result. However, we currently have limited methods in place to report on or measure service developments and improvements where there have been no complaints, incidents or compliments etc, reported or if a service has not been subject to an assurance review. B. Where do we want to be? Our objectives. OBJECTIVE 8: Develop a robust system to audit and measure improvements made as a direct result of patient experience information. It is essential that we regularly audit changes made to our services in response to patient and service user experience information to ensure the Page 15 of 26

16 change really does make a difference. We will also continually review the way we capture information to ensure it is fit for purpose and responds to patient and service user s preferences. C. How are we going to get there? Our plan. Development of an audit tool to ensure services are focussing on improvements based on patient experiences Development of robust system to report and share developments trust wide Continual review of the way we capture information to ensure it responds to patient and service user s preferences Stage 5. Feeding Back What We Have Done It is essential for patients and service users to know that the time and effort they spend providing us with information on their experience of our services is valued and used. Processes already in place for dealing with specific queries (eg PALS and complaints processes) provide direct feedback on individual issues. B. Where do we want to be? Our objectives. OBJECTIVE 9: Develop systems and processes to provide feedback to patients and other stakeholders on changes made both service specific and Trust-wide. Patients, their families and carers feel more confident in services when they can see they have been listened to. By providing feedback to patients, their families, carers and other stakeholders about how we have used patient and service user experiences to improve services, not only are we closing the loop, we are also celebrating our joint successes and encouraging future involvement. C. How are we going to get there? Our plan. Providing feedback to patients, their families and carers on a regular basis. Development of appropriate publicity on the key improvements we make to deliver messages to the wider community Provide a patient and service user experience emphasis in Trust publications such as the annual report, annual Quality Account, Quality Focus, Trust Talk and on the Website. Page 16 of 26

17 Working With Partners HEALTHWATCH SCT has established strong links with local patient and service user groups including Healthwatch. Healthwatch is a new independent consumer champion created to gather and represent the views of the public. Healthwatch England was launched in October 2012 and from April 2013 local Healthwatch organisations will be in place. We will continue to develop these relationships to ensure the views and opinions of patients and service users are taken into account when developments are being planned to improve patient and service user experience. SCT PATIENT EXPERIENCE SUB-COMMITTEE The Patient Experience Sub-Committee reports into the Executive Leadership Team and its membership includes patient representatives, the Trust Equality and Diversity Lead, the Head of Marketing, Communication and Intelligence and a Non-Executive Director. The group reports into the Executive Leadership Team and has links with external patient and service user groups. The Patient Experience Sub-Committee will take a lead role in the implementation of this strategy and associated activities. DEVELOPING PATIENT AND SERVICE USER INVOLVEMENT The Trust will continue to build on its existing relationship with local Healthwatch networks and aims to establish a strong working relationship with Seldom Heard from Groups, Focus Groups and public meetings. DEVELOPING STAFF INVOLVEMENT It is essential that all members of staff, clinical or non-clinical, understand the role they have in making a difference to the experience of our patients and service users. Every patient interaction should demonstrate the highest possible standards of care and should actively reflect the values in the NHS Patient Experience Framework. Consultation, Approval, Ratification and Review The following groups and individuals have been involved in the development of this strategy: Patient Experience Sub-Committee inc Healthwatch representatives) Chief Nurse The Patient Experience Sub-Committee will approve this strategy. The Chief Nurse will ratify this strategy. This strategy will be reviewed every 2 years by the Patient Experience Sub Committee. Page 17 of 26

18 Equality and Analysis The Trust aims to design and implement services, policies & other procedural documents and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. Under the Equality Act 2010, policy or other procedural document authors have a statutory duty to give due regard to issues of race, disability, gender (including transgender), religion or belief, age, sexual orientation and human rights when developing their policy or other procedural document. This means that policy or other procedural document authors have to assess the potential for their document to discriminate on any of these grounds. Alternatively, the impact of the policy or other procedural document on these groups might be positive or the same for everyone. This strategy has been equality impact assessed and a copy is available on request. Training, Dissemination and Implementation TRAINING SCT is committed to equipping staff with the necessary skills required to undertake their roles competently and confidently. In turn, staff must take responsibility for developing these skills and participating in the lifelong learning process. There may be a requirement to undertake some workshop activities with Trust staff on the implementation of various aspects of this strategy. DISSEMINATION This strategy will be publicised and published on the internal staff intranet, the Pulse and also be published on the Trusts website. Copies of this strategy will be sent to key partners and stakeholders. Managers will be responsible for ensuring their teams are aware of this strategy as all staff, clinical and non clinical have a role in improving patient and service user experience. The Trust offers translations of all essential leaflets for patients in all major languages, plus Braille, easy read, large print and audio formats. Non-compliance with strategies, policies and procedural documents can affect patient safety, SCT s compliance with the Care Quality Commission (CQC) regulations, NHS Litigation Authority standards, and audits or inspections carried out by internal and external auditors. Compliance with Trust strategies, policies and other procedural documents is a contractual condition of SCT employment. Page 18 of 26

19 IMPLEMENTATION This strategy will have an associated implementation plan. Monitoring of compliance against the implementation plan associated with this strategy will be undertaken via the Patient Experience Sub Committee, which feeds into the Quality Committee. Document Control and Archiving The Trust s Policies & Projects Coordinator will keep and maintain a Trust s Policy & other Procedural Documents Register by setting out the name of the responsible service area, author, date of last review and date of next review and will alert the relevant owner/author. Authors are responsible for ensuring the responsible Director is kept up to date on the review status of their policies and other procedural documents. References Quality Account Toolkit (Department of Health, 2010) Care Quality Commission Essential Standards of Quality and Safety (Care Quality Commission, 2010) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry Robert Francis QC (TSO, 2013) Monitor Quality Governance Framework (Monitor, 2010) NHS Friends and Family Test Implementation Guidance (Department of Health, 2012) NHS Litigation Authority Risk Management Standards NHS Operating Framework (Department of Health, 2011) NICE Guidance CG138: Patient Experience in Adult Services: Improving the Experience of Care for People who Use Adult NHS Services (NICE, 2012) NICE Quality Standard 15: Patient Experience in Adult NHS Services (NICE, 2012) NHS Outcomes Framework 2012/13 Page 19 of 26

20 Appendix A: Implementation Plan Objective Year One 2013/2014 Year Two 2014/2015 Years OBJECTIVE 1: Build on existing work to further develop robust systems and processes for gaining both quantitative and qualitative feedback from patients, their families and carers Research electronic /real time systems options available for data collection and create a project initiation document. Development and implementation of an ongoing process to collect qualitative and present information. Implementation of electronic/real time system for data collection Implementation of process Review and refresh system. Review process Development of a more robust approach to collecting, sharing and using feedback from websites such as NHS Choices, Patient Opinion, and IWantGreatCare Implementation of process Review process Implementation of the friends and family test in inpatient wards, urgent treatment centres and minor injury units Audit of implementation success, review of process and technology used Review process Page 20 of 26

21 Objective Year One 2013/2014 Year Two 2014/2015 Years Development and implementation of systems and processes for collection, analysis and use of patient stories. Roll out and implement Implementation of process Review process Develop a protocol and quality assurance process for surveys and questionnaires developed within the Trust. Roll out, provide briefings to services and implement Review process Develop a patient drop in service for sessions for patients and relatives to share their views and experiences of services. Pilot drop in sessions and review Implement changes and review OBJECTIVE 2: Develop more robust analysis of complaints, claims, PALS enquiries and compliments to inform service Trust wide improvements. Review of the quality of our response to complaints, including systems, processes, human interactions and written communications Devise and action plan to improve processes and systems and implement Review, amend and implement further developments Establish an implement a system for the collation and Review system Page 21 of 26

22 Objective Year One 2013/2014 Year Two 2014/2015 Years disseminating of learning from complaints, claims, incidents and PALS enquiries. Development of a standardised process for handling informal complaints Review system Commence active promotion the PALS services to patients and families across the Trust Continue promotion of PALS service and measure success Continue to promote PALS service and monitor success Development of strategic action plans to address common themes raised in complaints, claims, incidents and PALS enquiries. Appraise existing action plan and review and update OBJECTIVE 3: Build on existing work to further develop a triangulated and robust system and process for gaining both quantitative and qualitative feedback from patients, their families and carers, from all available Develop and implement systems for triangulation of different types of data against each other to identify where there are common issues arising. Review system and monitor progress Page 22 of 26

23 Objective Year One 2013/2014 Year Two 2014/2015 Years information sources. Development and implementation of a robust system to review information collected from all aspects patient experiences to identify themes, trends and learning. Review system and monitor progress OBJECTIVE 4: Every service within the Trust will use patient experience to gain insight and identify opportunities for improvement. Development of Trust wide a culture where all services understand their impact on the patient and service user experience Continuation of development of Trust wide a culture where all services understand their impact on the patient and service user experience Test and challenge the trust wide culture. Audit existing patient and service user experience information within Trust and ensure that all services are undertaking appropriate activity and are identifying opportunities. All services to produce action plans on their results and highlight how they will continue to identify opportunities. Review system and success. OBJECTIVE 5: Every service within the Trust will, having identified opportunities for improvement, implement at least one patient and service user experience improvement project annually. Monitor compliance with the learning lessons policy in order for The Trust to ensure that it actively learns from the outcome of complaints and incident investigations Identification of specific actions that need to be taken to make improvements Review processes to ensure that local services take action based on the feedback from patients, their families and carers to make improvements and developments that positively impact on patient and service user experience Page 23 of 26

24 Objective Year One 2013/2014 Year Two 2014/2015 Years Support services to gather robust patient and service user experience feedback using a range of methods Review support provided and plan for further input where required Enable teams to take action to rectify issues of concern, immediately wherever possible Review and provide additional support where required. Development and implementation of a process to ensure that services share their improvements in order to influence Trust wide developments. Review effectiveness and amend where required Development and implementation of clear Trust wide messages to support and improve patient and service user experience. Review effectiveness and amend where required OBJECTIVE 6: The Service Experience team will lead a Trust wide support campaign to support services in making improvements where themes are identified. Design a 2 year focus plan to support our campaign on the identified themes for improvements in patient and service user experience. Implement year one of plan and review success Implement year two of the plan and review success Page 24 of 26

25 Objective Year One 2013/2014 Year Two 2014/2015 Years OBJECTIVE 7: The Trust Board will continue to take an active leadership role in advocating improvements in experiences of patients in receipt of SCT services. Review assurance review documentation to ensure that those reviews accompanied by Trust Board members have a patient and service user experience focus. Development of the existing Executive and Non Executive Directors walkabouts in services to explicitly include patient and service user experience using reviewed documentation Review and amend documentation Review how the Board receives regular information about patient and service user experience in a variety of formats, not just high level quantitative information and agree format. Implement new format for reporting to the Board. Review and amend OBJECTIVE 8: Develop a robust system to audit and measure improvements made in patient and service user experience. Development and implementation of an audit tool to ensure services are focussing on improvements based on patient and service user experiences. Review and amend Development and implementation of robust system to report and share developments trust wide. Review and amend Continual review of the way Page 25 of 26

26 Objective Year One 2013/2014 Year Two 2014/2015 Years Continual review of the way we capture information to ensure it responds to patient s preferences information is captured OBJECTIVE 9: Develop systems and processes to provide feedback to patients and other stakeholders on changes made both service specific and Trust-wide Develop a proposal for a process to provide feedback to patients, their families and carers on a regular basis including use of appropriate publicity on the key improvements we make to deliver messages to the wider community Agree and implement proposal Review and amend Provide a patient and service user experience emphasis in Trust publications such as the annual report, annual Quality Account, Quality Focus, Trust Talk and on the Website. Review and amend Review and amend Page 26 of 26

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do Solent NHS Trust Patient Experience Strategy 2015-2018 Ensuring patients are at the forefront of all we do Executive Summary Your experience of our services matters to us. This strategy provides national

More information

Patient Experience Strategy

Patient Experience Strategy Patient Experience Strategy Published: June 2017 Find us online at cornwallft 1.Introduction At Cornwall Partnership NHS Foundation Trust (CFT) we believe in delivering high quality care. We care deeply

More information

Policies, Procedures, Guidelines and Protocols

Policies, Procedures, Guidelines and Protocols Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure

More information

Annual Complaints Report 2014/15

Annual Complaints Report 2014/15 Annual Complaints Report 2014/15 1.0 Introduction This report provides information in regard to complaints and concerns received by The Rotherham NHS Foundation Trust between 01/04/2014 and 31/03/2015.

More information

Vision 3. The Strategy 6. Contracts 12. Governance and Reporting 12. Conclusion 14. BCCG 2020 Strategy 15

Vision 3. The Strategy 6. Contracts 12. Governance and Reporting 12. Conclusion 14. BCCG 2020 Strategy 15 Bedfordshire Clinical Commissioning Group Quality Strategy 2014-2016 Contents SECTION 1: Vision 3 1.1 Vision for Quality 3 1.2 What is Quality? 3 1.3 The NHS Outcomes Framework 3 1.4 Other National Drivers

More information

COMMISSIONING FOR QUALITY FRAMEWORK

COMMISSIONING FOR QUALITY FRAMEWORK This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version COMMISSIONING FOR QUALITY FRAMEWORK Document Title: Commissioning for Quality Framework

More information

OUR COMMITMENTS TO CARE A STRATEGY FOR NURSES & ALLIED HEALTH PROFESSIONALS

OUR COMMITMENTS TO CARE A STRATEGY FOR NURSES & ALLIED HEALTH PROFESSIONALS OUR COMMITMENTS TO CARE A STRATEGY FOR NURSES & ALLIED HEALTH PROFESSIONALS Version: 2 Ratified by: Trust Board Date ratified: January 2014 Name of originator/author: Acting Head of Nursing Nursing & AHP

More information

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Patient and Public Involvement Strategy Report to: Trust Board: 27 th September 2011 Report from: Julia Barton Associate Director of Nursing & Patient Experience

More information

Patient Advice and Liaison Service (PALS) policy

Patient Advice and Liaison Service (PALS) policy Patient Advice and Liaison Service (PALS) policy Incorporating Have Your Say (HYS) First Issued May 04 by Birkenhead & Wallasey PCT. Responsibility of Wirral PCT since October 2006 Issue Purpose of Issue/Description

More information

First Community Health & Care Board POLICY FOR HANDLING COMPLAINTS

First Community Health & Care Board POLICY FOR HANDLING COMPLAINTS First Community Health & Care POLICY FOR HANDLING COMPLAINTS Version: 4 Name of Approval body : Name of Ratification Body: Date of Ratification April, 2013 Name of originator/author: Effective From April

More information

NHS Equality Delivery System for Isle of Wight NHS Trust. Interim baseline assessment against the

NHS Equality Delivery System for Isle of Wight NHS Trust. Interim baseline assessment against the Interim baseline assessment against the NHS Equality Delivery System for Isle of Wight NHS Trust The NHS Isle of Wight has adopted the NHS Equality Delivery System as the framework to achieve compliance

More information

TRUST BOARD 27 OCTOBER 2011 QUARTERLY CUSTOMER CARE REPORT

TRUST BOARD 27 OCTOBER 2011 QUARTERLY CUSTOMER CARE REPORT TRUST BOARD 27 OCTOBER 2011 QUARTERLY CUSTOMER CARE REPORT D Summary The Trust Board at its 28 July 2011 meeting (minute TB/11/192) approved a quarterly high level customer care report be developed for

More information

KEY AREAS OF LEARNING FROM THE FRANCIS REPORT

KEY AREAS OF LEARNING FROM THE FRANCIS REPORT KEY AREAS OF LEARNING FROM THE FRANCIS REPORT The public inquiry provided detailed and systematic analysis of what contributed to the failings in care at Mid Staffordshire NHS Foundation Trust. It identified

More information

QUALITY STRATEGY

QUALITY STRATEGY NHS Nene and NHS Corby Clinical Commissioning Groups QUALITY STRATEGY 2017-2021 Approved: By the Joint Quality Committee on 11 April 2017 Ratified: By the NHS Corby Clinical Commissioning Group on 25 April

More information

4 Year Patient and Public Involvement Strategy

4 Year Patient and Public Involvement Strategy 4 Year Patient and Public Involvement Strategy 2015-18 Contents Page(s) 1. Introduction - 2. Summary of the patient and public involvement strategy 2015-18 - 3. Definitions of involvement and best practice

More information

Quality Assurance Framework Adults Services. Framework. Version: 1.2 Effective from: August 2016 Review date: June 2017

Quality Assurance Framework Adults Services. Framework. Version: 1.2 Effective from: August 2016 Review date: June 2017 Quality Assurance Framework Adults Services Framework Version: 1.2 Effective from: August 2016 Review date: June 2017 Signed off by: Sharon Gogan Title: Head of Adult Social Care Date: 20 th May 2014 Quality

More information

Quality Strategy and Improvement Plan

Quality Strategy and Improvement Plan Quality Strategy and Improvement Plan 2015-2018 STRATEGY DOCUMENT DETAILS Status: FINAL Originating Date: October 2015 Date Ratified: Next Review Date: April 2018 Accountable Director: Strategy Authors:

More information

QUALITY STRATEGY

QUALITY STRATEGY QUALITY STRATEGY 2012-2016 SPONSOR: Sue Hardy Director of Nursing Signature: AUTHORS: Sue Hardy Director of Nursing Denise Flowers Associate Director Clinical Effectiveness APPROVED BY: Southend University

More information

Children and Families Service Quality Assurance Framework

Children and Families Service Quality Assurance Framework Children and Families Service Quality Assurance Framework 2016-2018 [IL0: UNCLASSIFIED] Document Control Version Date Summary of Changes Changes Made by Draft / V001 28 July 2016 First draft of the Quality

More information

Quality Strategy

Quality Strategy Quality Strategy 2017-2020 Contents 05 Foreword 06 Introduction 06 Equality & Diversity 07 Context for this Strategy 08 Definition of Quality 10 Quality Objectives 10 Strategic Quality Objectives 16 Quality

More information

Patient Experience Strategy

Patient Experience Strategy POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department

More information

Responsive, Flexible & Sensitive Domiciliary Care. Service User Handbook

Responsive, Flexible & Sensitive Domiciliary Care. Service User Handbook Responsive, Flexible & Sensitive Domiciliary Care. Service User Handbook PRACTICAL CARE BACKGROUND Practical care is a domiciliary care agency established by C.C.C. LTD (Caring, Catering, Cleaning) to

More information

Can I Help You? V3.0 December 2013

Can I Help You? V3.0 December 2013 Can I help you? Policy for the provision and management of patient feedback: comments, concerns or compliments, or complaints about NHS 24 and its services. Author: Patient Affairs Manager/ ADoN Clinical

More information

Central Alerting System (CAS) Policy

Central Alerting System (CAS) Policy Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray

More information

Learning from Deaths Policy LISTEN LEARN ACT TO IMPROVE

Learning from Deaths Policy LISTEN LEARN ACT TO IMPROVE Learning from Deaths Policy LISTEN LEARN ACT TO IMPROVE EQUALITY IMPACT The Trust strives to ensure equality and opportunity for all, both as a major employer and as a provider of health care. This policy

More information

CARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee

CARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee CARERS POLICY Department / Service: Originator: All Associate Director of Patient Experience Accountable Director: Chief Nursing Officer Approved by: Patient & Carers Experience Committee & Trust Management

More information

PATIENT EXPERIENCE AND INVOLVEMENT STRATEGY

PATIENT EXPERIENCE AND INVOLVEMENT STRATEGY Affiliated Teaching Hospital PATIENT EXPERIENCE AND INVOLVEMENT STRATEGY 2015 2018 Building on our We Will Together and I Will campaigns FOREWORD Patient Experience is the responsibility of everyone at

More information

Our vision for. resident involvement

Our vision for. resident involvement Our vision for resident involvement Introduction Moat recognises the critical role residents play in making sure that we deliver effective, efficient and accessible services to all of our residents. The

More information

Agreement between: Care Quality Commission and NHS Commissioning Board

Agreement between: Care Quality Commission and NHS Commissioning Board Agreement between: Care Quality Commission and NHS Commissioning Board January 2013 1 Joint Statement This agreement sets out the strategic intent and commitment for the Care Quality Commission (CQC) and

More information

NHS Constitution The NHS belongs to the people. This Constitution principles values rights pledges responsibilities

NHS Constitution The NHS belongs to the people. This Constitution principles values rights pledges responsibilities for England 8 March 2012 2 NHS Constitution The NHS belongs to the people. It is there to improve our health and well-being, supporting us to keep mentally and physically well, to get better when we are

More information

Complaints, Compliments and Concerns (CCC) Policy

Complaints, Compliments and Concerns (CCC) Policy Complaints, Compliments and Concerns (CCC) Policy Central and North West London NHS Foundation Trust (CNWL) is committed to providing quality NHS services and adopting best practice in listening and responding

More information

Version: 3.0. Effective from: 29/08/2012

Version: 3.0. Effective from: 29/08/2012 Policy No: RM51 Version: 3.0 Name of policy: Learning from Experience Policy A systematic approach to incident, complaint and clai management, analysis and sharing safety lessons Effective from: 29/08/2012

More information

The NHS Constitution

The NHS Constitution 2 The NHS Constitution The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot

More information

NHS CONSTITUTION (MARCH 2013) RIGHTS AND PLEDGES TO PATIENTS AND THE PUBLIC

NHS CONSTITUTION (MARCH 2013) RIGHTS AND PLEDGES TO PATIENTS AND THE PUBLIC NHS CONSTITUTION (MARCH 2013) RIGHTS AND PLEDGES TO PATIENTS AND THE PUBLIC APPENDIX A Access to Health Services o Receive NHS services free of charge, apart from certain limited exceptions sanctioned

More information

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss

More information

Document Control Page Version number as from December 2004: 2. Title: Information Quality Assurance Policy

Document Control Page Version number as from December 2004: 2. Title: Information Quality Assurance Policy Title: Information Quality Assurance Policy Document type: Policy Document Control Page Version number as from December 2004: 2 Classification: Policy Scope: Trust wide Author: Rachel Dunscombe Chief Informatics

More information

Indicators for the Delivery of Safe, Effective and Compassionate Person Centred Service

Indicators for the Delivery of Safe, Effective and Compassionate Person Centred Service Inspections of Mental Health Hospitals and Mental Health Hospitals for People with a Learning Disability Indicators for the Delivery of Safe, Effective and Compassionate Person Centred Service 1 Our Vision,

More information

Equality Objectives

Equality Objectives Equality Objectives 2015 2019 This document is available in alternative community languages and formats upon request, such as large print and electronically. Please contact the Equality, Diversity and

More information

CUSTOMER CARE POLICY Compliments, Comments, Concerns and Complaints

CUSTOMER CARE POLICY Compliments, Comments, Concerns and Complaints CUSTOMER CARE POLICY Compliments, Comments, Concerns and Complaints Document reference number IML002 Status Approved Version number 5.0 Replacing/superseding policy or Customer Care Policy version 4.0

More information

Equality Delivery System. South Tyneside NHS Foundation Trust. Goals, Outcomes and Grades

Equality Delivery System. South Tyneside NHS Foundation Trust. Goals, Outcomes and Grades Equality Delivery System South Tyneside NHS Foundation Trust Goals, Outcomes and Grades 1 EQUALITY DELIVERY SYSTEM Introduction South Tyneside NHS Foundation Trust are committed, and as a public sector

More information

is asked to Approve the Patient Experience Strategy

is asked to Approve the Patient Experience Strategy Recommendation DECISION NOTE (select) Reporting to: The Trust Board is asked to Approve the Patient Experience Strategy The Trust Board Date 27 th July 2017 Paper Title Brief Description Patient Experience

More information

End of Life Care Strategy

End of Life Care Strategy End of Life Care Strategy 2016-2020 Foreword Southern Health NHS Foundation Trust is committed to providing the highest quality care for patients, their families and carers. Therefore, I am pleased to

More information

COMPLAINTS POLICY. Head of Complaints & Customer Service Improvement

COMPLAINTS POLICY. Head of Complaints & Customer Service Improvement COMPLAINTS POLICY POLICY REFERENCE NUMBER CP2 VERSION NUMBER 1 REPLACES SEPT DOCUMENT CP2 REPLACES NEP DOCUMENT CRP7 KEY CHANGES FROM PREVIOUS Not applicable VERSION AUTHOR Head of Complaints & Customer

More information

Children, Families & Community Health Service Quality Assurance Framework

Children, Families & Community Health Service Quality Assurance Framework Children, Families & Community Health Service Quality Assurance Framework Introduction Quality assurance involves the systematic monitoring and evaluation of practice with the aim of improving our services

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Implementation Policy for NICE Guidelines

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Implementation Policy for NICE Guidelines The Newcastle upon Tyne Hospitals NHS Foundation Trust Implementation Policy for NICE Guidelines Version No.: 5.3 Effective From: 08 May 2017 Expiry Date: 02 March 2019 Date Ratified: 23 February 2017

More information

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed:

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed: Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Cleaning Policy NTW(O)71 James Duncan Deputy Chief Executive / Executive Director of Finance Steve Blackburn Deputy

More information

NHS Borders. Local Report ~ November Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services

NHS Borders. Local Report ~ November Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services NHS Borders Local Report ~ November 2009 Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services NHS Borders Local Report ~ November 2009 Clinical Governance

More information

NHS and independent ambulance services

NHS and independent ambulance services How CQC regulates: NHS and independent ambulance services Provider handbook March 2015 The Care Quality Commission is the independent regulator of health and adult social care in England. Our purpose We

More information

Dignity and Respect Charter for patients. Version 6.0

Dignity and Respect Charter for patients. Version 6.0 Dignity and Respect Charter for patients Version 6.0 Purpose: For use by: This document is compliant with /supports compliance with: To advise and inform hospital staff of the right for all patients, their

More information

Your guide to the CQC Fundamental Standards

Your guide to the CQC Fundamental Standards Your guide to the CQC Fundamental Standards RDaSH Introduction In order to get to the heart of people s experiences of care and support, the focus of the Care Quality Commission (CQC) Regulatory Framework

More information

Version Number Date Issued Review Date V1: 28/02/ /08/2014

Version Number Date Issued Review Date V1: 28/02/ /08/2014 Corporate CCG CO01 Access and Choice Policy Version Number Date Issued Review Date V1: 28/02/2013 31/08/2014 Prepared By: Consultation Process: Governance Lead, NHS South of Tyne and Wear Information Governance

More information

Transforming Mental Health Services Formal Consultation Process

Transforming Mental Health Services Formal Consultation Process Project Plan for the Transforming Mental Health Services Formal Consultation Process June 2017 TMHS Project Plan v6 21.06.17 NOS This document can be made available in different languages and formats on

More information

Patient Experience Strategy. Director of Nursing & Quality

Patient Experience Strategy. Director of Nursing & Quality Reporting to: Trust Board 2 February 2017 Paper 8 Title Sponsoring Director Author(s) Patient Experience Strategy Director of Nursing & Quality Graeme Mitchell Previously considered by Executive Summary

More information

Sources of evidence [note: you may reference other sources of evidence] Quarterly National Reporting Systems to the SHA on Waiting Times.

Sources of evidence [note: you may reference other sources of evidence] Quarterly National Reporting Systems to the SHA on Waiting Times. PATIENT RIGHTS/PLEDGES Rights/pledges/Actions 1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the. The Primary Care Trust has a process

More information

A Participation Standard for the NHS in Scotland Standard Document

A Participation Standard for the NHS in Scotland Standard Document A Participation Standard for the NHS in Scotland Standard Document Scottish Health Council Scottish Health Council 2010 Published August 2010 ISBN 1-84404-916-7 You can copy or reproduce the information

More information

PATIENT AND SERVICE USER EXPERIENCE STRATEGY

PATIENT AND SERVICE USER EXPERIENCE STRATEGY PATIENT AND SERVICE USER EXPERIENCE STRATEGY APRIL 2017 TO MARCH 2020 Date 24 March 2017 Version Final Version Previously considered by The Patient Experience Group version 0.1 draft The Executive Management

More information

Replacement. Supersedes: Complaints Procedure ( ) and the Patient Advice and Liaison Service Policy ( )

Replacement. Supersedes: Complaints Procedure ( ) and the Patient Advice and Liaison Service Policy ( ) Corporate Complaints: Standard Operating Procedure Document Control Summary Status: Replacement. Supersedes: Complaints Procedure (28.10.10) and the Patient Advice and Liaison Service Policy (28.07.11)

More information

Trust Board Meeting: Wednesday 13 May 2015 TB

Trust Board Meeting: Wednesday 13 May 2015 TB Trust Board Meeting: Wednesday 13 May 2015 Title Update on Quality Governance Framework Status History For information, discussion and decision This paper has been presented to Quality Committee in April

More information

1st Class Care Solutions Limited Support Service Care at Home Argyll House Quarrywood Court Livingston EH54 6AX Telephone:

1st Class Care Solutions Limited Support Service Care at Home Argyll House Quarrywood Court Livingston EH54 6AX Telephone: 1st Class Care Solutions Limited Support Service Care at Home Argyll House Quarrywood Court Livingston EH54 6AX Telephone: 01506 412698 Type of inspection: Unannounced Inspection completed on: 13 March

More information

Briefing: Quality governance for housing associations

Briefing: Quality governance for housing associations 25 March 2014 Briefing: Quality governance for housing associations Quality and clinical governance in housing, care and support services Summary of key points: This paper is designed to support housing

More information

Date 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager

Date 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager TB 099/15 Meeting title Report title Trust Board Risk Management Strategy Date 4 th September 2015 Lead director Report author FOI status Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate

More information

CLINICAL AND CARE GOVERNANCE STRATEGY

CLINICAL AND CARE GOVERNANCE STRATEGY CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016

More information

Birmingham, Sandwell and Solihull Eligibility Criteria Policy for NHS Non-Emergency Patient Transport (NEPT)

Birmingham, Sandwell and Solihull Eligibility Criteria Policy for NHS Non-Emergency Patient Transport (NEPT) Birmingham, Sandwell and Solihull Eligibility Criteria Policy for NHS Non-Emergency Patient Transport (NEPT) Version: 0.1 Ratified by: Date ratified: 1 st June 2016 Name of originator/author: Name of responsible

More information

Specialist mental health services

Specialist mental health services How CQC regulates: Specialist mental health services Provider handbook March 2015 The Care Quality Commission is the independent regulator of health and adult social care in England. Our purpose We make

More information

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Job Description Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Grade 8b Tenure: Permanent Location of Post:

More information

Annual Report

Annual Report Equality and Diversity Steering Group Annual Report 2012-2013 April 2013 1 Contents Page No Introduction 3 Equality Act 2010 3 NHS Lanarkshire s Equality and Diversity Reporting Structure Equality and

More information

Woodbridge House. Aitch Care Homes (London) Limited. Overall rating for this service. Inspection report. Ratings. Good

Woodbridge House. Aitch Care Homes (London) Limited. Overall rating for this service. Inspection report. Ratings. Good Aitch Care Homes (London) Limited Woodbridge House Inspection report 151 Sturdee Avenue Gillingham Kent ME7 2HH Tel: 01634281890 Website: www.regard.co.uk Date of inspection visit: 14 March 2017 Date of

More information

Clinical Audit Policy

Clinical Audit Policy Clinical Audit Policy DOCUMENT CONTROL Version: 5 Ratified by: Quality Assurance Group Date ratified: 3 July 2017 Name of originator/author: Clinical Quality Lead Senior Clinical Audit Facilitator Name

More information

CO119, Learning from Deaths policy

CO119, Learning from Deaths policy CO119, Learning from Deaths policy Consultation Draft v.1* September 2017 *Awaiting standardised Structured Judgement Review for Mental Health Trusts & wider consultation with workforce and stakeholder

More information

5 Boroughs Partnership NHS Foundation Trust. Quality Account Version: QA FINAL

5 Boroughs Partnership NHS Foundation Trust. Quality Account Version: QA FINAL 5 Boroughs Partnership NHS Foundation Trust Quality Account 2016-2017 Version: QA FINAL 1 Contents Part 1- Our Commitment to Quality 1.1 Our Quality Report / Quality Account 2016-17...5 1.2 Chief Executive

More information

Patient Experience, Engagement and Involvement Strategy. Seeing the Person in the Patient *

Patient Experience, Engagement and Involvement Strategy. Seeing the Person in the Patient * Patient Experience, Engagement and Involvement Strategy Seeing the Person in the Patient * Version: Ratified by: Date ratified: April 2014 Title of originator/author: Title of responsible committee/individual:

More information

Prevention and control of healthcare-associated infections

Prevention and control of healthcare-associated infections Prevention and control of healthcare-associated infections Quality improvement guide Issued: November 2011 NICE public health guidance 36 guidance.nice.org.uk/ph36 NHS Evidence has accredited the process

More information

Agenda Item number: 9.1. Maggie Bayley, Director of Nursing and Quality

Agenda Item number: 9.1. Maggie Bayley, Director of Nursing and Quality Board meeting date: 15 December, 2011 Agenda Item number: 9.1 Enclosure: 6 Title Quality report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Maggie Bayley,

More information

Creative Support - North Lincolnshire Service

Creative Support - North Lincolnshire Service Creative Support Limited Creative Support - North Lincolnshire Service Inspection report Scotter House West Common Lane Scunthorpe South Humberside DN17 1DS Tel: 01724843076 Date of inspection visit: 04

More information

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE. 1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards

More information

IT ALL STARTS WITH YOU

IT ALL STARTS WITH YOU Email: jo.curtis@nhs.net IT ALL STARTS WITH YOU Tell us about your experience Help us improve NHS services This guide takes you through the different ways you can tell the NHS about your experiences, so

More information

Complaints Policy and Procedure

Complaints Policy and Procedure Complaints Policy and Procedure NHS East and North Hertfordshire Clinical Commissioning Group Page 1 of 45 DOCUMENT CONTROL SHEET Document Owner: Document Author(s): Version: 1 Directorate: Nursing and

More information

Quality Strategy (Refreshed March 2015)

Quality Strategy (Refreshed March 2015) Quality Strategy 2012-2017 (Refreshed March 2015) 1 Table of Contents 1. Executive Summary... 3 2. Drivers for improvement... 4 2.1 The Trust s ambition - vision and mission... 4 2.2 Corporate Strategy...

More information

A Case Review Process for NHS Trusts and Foundation Trusts

A Case Review Process for NHS Trusts and Foundation Trusts A Case Review Process for NHS Trusts and Foundation Trusts 1 1. Introduction The Francis Freedom to Speak Up review summarised the need for an independent case review system as a mechanism for external

More information

Quality Framework Supplemental

Quality Framework Supplemental Quality Framework 2013-2018 Supplemental Staffordshire and Stoke on Trent Partnership Trust Quality Framework 2013-2018 Supplemental Robin Sasaru, Quality Team Manager Simon Kent, Quality Team Manager

More information

Burton Hospitals NHS Foundation Trust POLICY DOCUMENT. On: 26 October Review Date: October Department Responsible for Review:

Burton Hospitals NHS Foundation Trust POLICY DOCUMENT. On: 26 October Review Date: October Department Responsible for Review: POLICY DOCUMENT Burton Hospitals NHS Foundation Trust COMPLAINTS POLICY AND PROCEDURE Approved by: Quality Committee On: 26 October 2017 Review Date: October 2020 Corporate / Division Corporate Clinical

More information

NURSES HOLDING POWER SECTION 5(4) MENTAL HEALTH ACT 1983 NOVEMBER 2015

NURSES HOLDING POWER SECTION 5(4) MENTAL HEALTH ACT 1983 NOVEMBER 2015 NURSES HOLDING POWER SECTION 5(4) MENTAL HEALTH ACT 1983 NOVEMBER 2015 This policy supersedes all previous policies for Nurses Holding Power Section 5(4) MHA 1983. 1 Policy title Nurses Holding Power Section

More information

NHSLA Risk Management Standards

NHSLA Risk Management Standards NHSLA Risk Management Standards 2012-13 for NHS Trusts providing Acute Services Brighton and Sussex University Hospitals NHS Trust Level 1 October 2012 Contents Executive Summary... 3 Assessment Outcome...

More information

Special Measures Action Plan. Norfolk and Suffolk NHS Foundation Trust

Special Measures Action Plan. Norfolk and Suffolk NHS Foundation Trust Special Measures Action Plan Norfolk and Suffolk NHS Foundation Trust June 2015 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver 1 Norfolk and Suffolk NHS Foundation

More information

High level guidance to support a shared view of quality in general practice

High level guidance to support a shared view of quality in general practice Regulation of General Practice Programme Board High level guidance to support a shared view of quality in general practice March 2018 Publications Gateway Reference: 07811 This document was produced with

More information

Action Plan. This Action Plan has been completed by the Provider and the Authority has not made any amendments to the returned Action Plan.

Action Plan. This Action Plan has been completed by the Provider and the Authority has not made any amendments to the returned Action Plan. Action Plan This Action Plan has been completed by the Provider and the Authority has not made any amendments to the returned Action Plan. Provider s response to Inspection Report No: Name of Agency: 757

More information

Communication & Engagement Strategy Stoke-on-Trent & North Staffordshire Clinical Commissioning Groups

Communication & Engagement Strategy Stoke-on-Trent & North Staffordshire Clinical Commissioning Groups Communication & Engagement Strategy Stoke-on-Trent & North Staffordshire Clinical Commissioning Groups 2017 2021 The NHS belongs to all of us. It is there to improve our health and wellbeing, supporting

More information

End Of Life Care Strategy

End Of Life Care Strategy End Of Life Care Strategy Document Control: Document Author: Director of Nursing Document Owner: Board Of Directors Electronic File Name: End of Life Care Strategy dated June 2016 Document Type: Corporate

More information

This policy is intended to ensure that we handle complaints fairly, efficiently and effectively.

This policy is intended to ensure that we handle complaints fairly, efficiently and effectively. Introduction 1.1 Purpose This policy is intended to ensure that we handle complaints fairly, efficiently and effectively. Our complaint management system is intended to: enable us to respond to issues

More information

PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE

PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE Page 1 DOCUMENT CONTROL SHEET Name of Document: Patient Safety and Quality Committee Terms of Reference Version: 5 File Location / Document Name:

More information

Learning to Get Better

Learning to Get Better LEARNING TO GET BETTER: An investigation by the Ombudsman into how public hospitals handle complaints Learning to Get Better Executive Summary and Recommendations An investigation by the Ombudsman into

More information

Homecare Support Support Service Care at Home 152a Lower Granton Road Edinburgh EH5 1EY

Homecare Support Support Service Care at Home 152a Lower Granton Road Edinburgh EH5 1EY Homecare Support Support Service Care at Home 152a Lower Granton Road Edinburgh EH5 1EY Type of inspection: Unannounced Inspection completed on: 19 December 2014 Contents Page No Summary 3 1 About the

More information

James Blythe, Director of Commissioning and Strategy. Agenda item: 09 Attachment: 04

James Blythe, Director of Commissioning and Strategy. Agenda item: 09 Attachment: 04 Title of paper: Author: Exec Lead: Community Hospital Services Review Tom Elrick, Urgent Care Programme Lead James Blythe, Director of Commissioning and Strategy Date: 23 rd February 2015 Meeting: Executive

More information

EDS 2. Making sure that everyone counts Initial Self-Assessment

EDS 2. Making sure that everyone counts Initial Self-Assessment EDS 2 Making sure that everyone counts Initial Self-Assessment Equality Delivery System for the NHS EDS2 Summary Report Implementation of the Equality Delivery System EDS2 is a requirement on both NHS

More information

NHS East and North Hertfordshire Clinical Commissioning Group. Quality Committee. Terms of Reference Version 4.0

NHS East and North Hertfordshire Clinical Commissioning Group. Quality Committee. Terms of Reference Version 4.0 NHS East and North Hertfordshire Clinical Commissioning Group Quality Committee Terms of Reference Version 4.0 1. Introduction 1.1 The Quality Committee (the committee) is established in accordance with

More information

Report on Call for Evidence: Elderly Hospital Care, Hospital Discharge & Dementia Identification

Report on Call for Evidence: Elderly Hospital Care, Hospital Discharge & Dementia Identification Report on Call for Evidence: Elderly Hospital Care, Hospital Discharge & Dementia Identification Healthwatch Sunderland October 2014 Elderly People are not always thoroughly assessed in hospital. This

More information

SAFEGUARDING ADULTS COMMISSIONING POLICY

SAFEGUARDING ADULTS COMMISSIONING POLICY SAFEGUARDING ADULTS COMMISSIONING POLICY Director Responsible: Responsible person Target Audience: Name of Responsible Committee Nursing Matt O Connor Safeguarding Adults Lead All NHSBA staff and contractors

More information

Corporate plan Moving towards better regulation. Page 1

Corporate plan Moving towards better regulation. Page 1 Corporate plan 2014 2017 Moving towards better regulation Page 1 Protecting patients and the public through efficient and effective regulation Page 2 Contents Chair and Chief Executive s foreword 4 Introduction

More information

FT Keogh Plans. Medway NHS Foundation Trust

FT Keogh Plans. Medway NHS Foundation Trust FT Keogh Plans Medway NHS Foundation Trust July 2014 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver Medway - Our improvement plan & our progress What are we

More information

Patient Experience Policy

Patient Experience Policy Teamwork Innovation Professionalism Caring Patient Experience Policy Complaints Concerns Healthcare Professional Feedback Compliments/Commendations Version: 3.0 Policy Lead: Head of Patient Experience

More information