Patient Experience Committee. Annual Board Report 2015/16

Transcription

1 Patient Experience Committee Annual Board Report 2015/16 Presented by: Tracy Luckett Director of Nursing and Allied Healthcare Professions Produced by: Tim Withers, Patient Experience Manager Trust Board 1 ST September 2016

2 1.0 Introduction The Patient Experience, is a broad term that encompasses not only experiences of patients, but their opinions, recommendations, ideas and engagement, and is with quality and safety, essential if Moorfields is to be a responsive, inclusive and continually improving organisation. The Patient Experience Committee is central to ensuring that areas for improvement are acknowledged, performance indicators identified and that actions taken are appropriate, achievable and completed. This report provides an overview for the board of the work overseen by the Patient Experience Committee and patient experience feedback for 2015/16 and supports the six monthly Quality and Safety Board report. This report will also be presented to the Clinical Quality Review Group (CQRG) where the quality of Moorfields services is discussed with our lead commissioners. 2.0 Patient Experience Committee Currently, much of the reporting and work relating to the patient experience is overseen by the Patient Experience Committee (PEC). The Patient Experience Committee met four times during 2015/6. Its primary role is to review patient feedback and discuss how this might be used within the trust, and to monitor and question the progress of trust wide patient experience improvement programmes, giving suggestions and advice going forward. For example, discussion of best practice and monitoring of response rates by the committee led to a 10% increase in FFT responses to 99,000 over the year. This also included monitoring and recognising the achievements of action plans created in response to the Friends and Family Test, CQC patient surveys and focus groups, ensuring these are discussed in a trust wide forum so that lessons can be learned and implemented across all departments. The main challenge for the committee has been to ensure that programmes discussed by the Patient Experience committee, e.g. the Moorfields Way and Telecommunications project etc, are translated in actions and become part of Moorfields culture. In some areas the PEC has been successful, such as the mandatory leading and guiding training, the formation of a draft patient engagement strategy, improved patient experience information on the trust website and intranet, engaging with local HealthWatch and supporting staff in preparation for the CQC inspection. However, changes made to improve communication, clinic and day care waiting times, appointment management and staff behaviours remain a challenge and should improve over the coming year as transformation and other projects embed. The Patient Experience Committee is also expecting to drive any changes as a result of the CQC recommendations Patient Experience Committee structure The PEC is a sub-committee of the Clinical Governance Committee and is chaired by the Director of Nursing and Allied Health Professions, with agenda and papers prepared by the Patient Experience Manager. The PEC terms of reference are due for renewal at the October 2016 meeting and are attached as appendix 1. Membership consists of managerial representatives from each Directorate, trust Matrons, Human Resources, representatives from the quality and safety team and there are four patient representatives. Others, e.g. project leads, are invited on an ad hoc basis. Attendance is attached as appendix 2. During 2015/16 the committee met on the following dates: 10 th June th December

3 9 th September st March 2016 During 2015/16 the committee sought assurance on: The Moorfields Way programme Telecommunication Project MEH Transformation project Uveitis and Glaucoma transformation CR Outpatient improvement Satellite patient experience improvement activities Patient Satisfaction (Picker survey) action plan review Surgical services review Discussed and identified proposals for: Visual impairment: staff awareness training Staff customer service recognition award A Moorfields Patient Engagement Strategy Patient Experience website page Noted and discussed findings from: HealthWatch activity relating to the trust CQC patient surveys Compliments, Complaints and PALS quarterly reports Quarterly Patient feedback reports Governors Week Report Customer service audits / Focus group feedback 3.0. Sources of Patient Feedback overseen by the Patient Experience Committee Depending on the context and the manner in which the information is sought, the issues that arise from patient and carer feedback will differ. However, one constant appears to be the positive light in which most patients hold Moorfields and its staff. Professionalism, friendliness, clinical outcomes and the level of individualised care are the themes that patients highlight as having been satisfied with. It is difficult to convey this positive affirmation, but the following comments left in January on the Friends and Family test and NHS Choices encapsulates the sentiments of many: I am always grateful for the excellent expert care Moorfields give when I attend for regular checks. Today in particular I was seen by a nurse who really went the extra mile to make me feel at ease and informed about what was going on, and by a doctor who again took a lot of time to review my notes and ensure I understood the current issues with my retinas. After an urgent referral from my optician I went to Moorfields where after a few hours of waiting in A&E I was placed with an absolutely fantastic consultant who went above and beyond to make me feel comfortable and was very reassuring. I was so worried beforehand but the consultant completely put me at ease. I was told what was going on, but was also told to come back the next day for a second opinion, demonstrating the level of patient care Moorfields provides. I returned in the morning and the second consultant confirmed to me what the previous one had said but it was brilliant to make double sure and completely put my mind at rest. You can be assured you will be looked after fully at Moorfields and I would highly 3

4 recommend their A&E department for anybody experiencing eye problems, you will be in the best of care. However, where feedback is received that does highlight areas for improvement, it tends to focus on trust wide issues long recognised at Moorfields or suggests that even where a good service is generally provided, this is not consistent, for every patient, on every occasion. 3.1 NHS England Friends and Family Test (FFT) The most comprehensive measure of patient satisfaction at Moorfields and overseen by the PEC is the NHS England Friends and Family Test (FFT), which is now run at 52 departments and clinics across the trust. Patients are asked: How likely are you to recommend our service to your friends and family if they needed similar care or treatment? and are asked to select from a five point scale from Extremely Likely to Extremely unlikely. The test has the dual purpose of allowing the trust a quantitative measure of performance, but it also asks them to comment on what would have improved their care. The majority complete the test by filling in a card, but there is also an online version on the trust website (however, only around patients a month use this route). It is scored by comparing the percentage of those who would recommend the trust (i.e. Extremely likely and Likely) against the percentage of those who would not (i.e. Unlikely or extremely unlikely). The trust, working with our commissioners, has set a benchmark of 90% of patients recommending the trust. (Fig.1: FFT results 2015/16 - green: would recommend / red: would not recommend). Trust total A&E (inc Paeds) Outpatients Day Care Respondents 99,104 19,031 60,445 19,628 % of patients 14.5% 18.7% 11.1% 55.0% Score 96.4% 1.3% 92.7% 1.6% 96.7% 1.4% 99.0% 0.4% Trust /Commissioner response KPI s are: >15% outpatients >20% A&E >30% day Care During 2015/16 the FFT test was completed by 99,104 patients (just over 10,000 more than the previous year) and the percentage of patients who would, or who would not; recommend the trust has remained within one or two percentage points of the previous year s score, in the mid to high 90% range. The scores are not only satisfyingly high, but compare favourably with the other 155 NHS England trusts in that outpatients were in the top scoring 25% throughout the year and day care within the top 3% FFT Patient Comments The comments left by patients are overwhelmingly positive with around 1630 citing individual staff as giving exceptional care. A word search of the most commonly used (positive and negative), adjectives (5,100 words) for March 2016 convey some sense of the positive feedback received. 4

5 A quarterly analysis of the FFT comments show that for the 1% - 2% of patients who would not recommend the trust, waiting times and delays in A&E, clinic and day care wards remain an issue, with 55% of those scoring neither, unlikely or extremely unlikely, citing this as the reason. Similarly, when the monthly FFT comments from all respondents are considered, waiting times and delays whilst in clinic or in for surgery are also raised as an issue, mostly by those who would recommend the trust and have other positive things to say about their experience. For example, in March 2016, of the 8,947patients who completed the test, 6,370 left a comment and of these, 939 (14.6%) comments related negatively to delays and waiting. This is consistent with other months and will be a useful measure of patient perception going forward as trust wide action is taken to address this issue within the transformation project. It is worth noting that of the 6,730, 409 (6%) commented on how quickly they were seen. Of the suggestions left as to what would have improved their visit (excluding waiting times), very few remarked on the appointment itself, the clinical or nursing care or the treatment received. Most are related to the experience of waiting and are again, consistent month on month. The availability of refreshments, something to occupy patients whilst waiting (TV, radio, newspapers etc.) and communication, especially in terms of being told estimated waiting times and being called clearly are the three main themes. The environment (too hot or cold depending on the season), seating (availability or quality), car parking and poor staff attitude make up the majority of other comments. (Fig.2: FFT Comments comments that suggested, or implied, improvements: March 16). 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% Refreshments, Tea, Coffee etc. Communication (*hearing name) TV/ Music /Radio/ Reading Temperature (too cold) Car Parking Seating Poor staff attitude Appointment Mgt/ Telephone Clinic or ward environment Care/Clinical Signage Wi-Fi availability Wheelchairs Other Clinic waits 8.5% 11.4% too cold 7.0% 9.2% 8.7% 6.7% 3.7% 1.2% 4.4% 4.0% 2.5% 2.2% 0.7% 0.4% warm 21.9% 3.7% *2.5% 5

6 All comments are shared with the directorate management teams and the PEC oversees action plans drawn up to address some of the issues raised. Whereas issues such as waiting times, car parking and entertainment suitable for everyone s taste are more intractable ; informing patient of waiting times, informing patients of where refreshments are available and explaining they can leave the clinic to get them, calling names clearly and staff attitude are primarily to do with staff behaviours and approach that should be manageable. Again this can be used as a measure (albeit a broad one) of patient perception to changes made (e.g. the Moorfields Way) as they embed within the trust Response Though all the actions being taken in response to these finding cannot be discussed in the context of this report some examples of the changes being undertaken include: More soothing music is to be introduced in Theatres at Northwick Park Reception staff are handing out patient information sheets in clinics advising patients they can go for refreshments without losing their place, explaining the waiting times and encouraging patients to ask if they require anything or an update on the waiting time. A business case for Patient Pagers has been developed so that if there is a wait and patients wish to leave the clinic for refreshments etc. or patients are hearing impaired, they can be alerted when their appoint with the nurse or doctor is imminent. Patients in late running clinics are offered Costa vouchers (City Road) There has been a call in the trust bulletin for staff to bring in appropriate magazines they have read to a central location to be distributed to the clinics. The availability of Wi-Fi is being written on the clinic white boards and is included as part of information screen content. Floor Walkers role established in clinics to liaise between the clinic and patients, support patients whilst waiting and coordinate clinic flow. Installation of new visible site maps, signage and easy read signage and information (e.g. Pictures on lavatory doors). Additional seating provided in glaucoma clinic 3 and visual fields waiting area and estates asked if the food machine can be placed in an alternative location this would increase seating by 6 further seats. Permanent hearing induction loops at the main reception desks. Site wide assessment (by estates) to check the effectiveness of air conditioning to clinic areas. Cold air flow has been directed from the optometry department to a new vent in clinic 4 where there is a particular problem. Portable fans are available and set up in clinic waiting areas (directed toward patients) on hot days. Staff have been instructed to advise patients of water fountains upon arrival. Easy read signs for fountains have been placed by fountains. When particularly hot, nursing staff in clinic offer waiting patients cool water. 3.2 CQC National Patient surveys (Picker surveys) During 2015/16 there were no CQC patient surveys (normally undertaken on behalf of the trust by Picker Institute), however the CQC National Children s Inpatient and Day Case survey which was sampled in 2014/15 was reported and published on the CQC website in June Paediatric surveys The CQC results scores each question response out of ten and overall the results were very positive, with only three questions scoring below 8, and for the 16 questions that can be compared to the previous survey run in 2010, all but one showed an improvement of more than 10%. As with previous CQC surveys an action plan was developed and progress against it is monitored by the Patient Experience committee, and though in-patients from the RDCEC 6

7 and St George s were included, there are lessons (play, refreshments etc.) that are perhaps transferable to Moorfields paediatric outpatient departments at the satellite sites. Actions taken in response to the survey as well as feedback from other sources included: Subsequently, surveys asking children their specific dietary preferences have been undertaken and refreshments provided to meet those preferences. Giving a choice of appointments is a long term issue and has been discussed at the paediatric service meeting to explore ways of managing admission appointments more effectively. This is ongoing. A new admission pathway has been introduced so that families are welcomed on admission directly to the ward and staff of all grades have been reminded of the lessons from the Moorfields Way project in regard to meeting and greeting patients. Improved signage within the RDCEC directing people to the RDCEC café and there is a new bedside information folder including where to seek refreshments for parents Audit of the length of time that children were fasted prior to day case surgery. Following analysis of the information fasting times have been reduced for all paediatric day care patients and a new information sheet has been produced. Paediatric counsellor has been appointed for a 2 year pilot, to support children who might can present with complex emotional and psychological issues including depression and problems with self-esteem. Developing Paediatric Emergency Nurse Practitioners in the RDCEC AE. This will enhance the families pathway through A&E by allowing the doctors to spend time with the children with complex conditions whilst the ENPs will be able to examine, treat and discharge children with agreed specific eye conditions Previous CQC surveys The action plans for CQC mandatory surveys undertaken previously for Outpatients and Accident and Emergency, and a third commissioned by Moorfields for Day Care (asking about 80 questions and encompassing the entire pathway for that service), continued to be monitored by the Patient Experience Committee. There are individual action plans for the following sites: Accident and Emergency Bedford Day Care Bedford Clinics Moorfields East Day Care Moorfields East Clinics Mile End Day Care City Road Clinics City Road Day Care St Ann s Day Care St Ann s Clinics St George Day Care St George s Clinics RDCEC Some examples of action taken as a result of some of the lower scoring questions are: The wording in the A&E Triage leaflet has been re-written to inform patients about the 7

8 purpose of the initial triage examination as the survey showed some confusion. The leaflet was also adapted to give clearer advice regarding pain management and the process for assessing and providing pain relief at the point of triage has been clarified. Bedford have put in place an Outpatient Clinic Team Leader who in effect keeps monitors the clinic floor by linking in with nurses/clinicians to get updated on any delays and verbally informs patients in the waiting area. At St George s, the survey suggested that medication information could be better, at the time patients were receiving the eye medication from the St George s pharmacy. They now have our own on site pharmacy and the feedback from a further patient survey is very positive. Eye Clinic Liaison Officers (ECLO s) have been appointed at Moorfields East and Moorfields West to better support patients through the visual certification process and others with visual impairment who need support. Extra clinics are in place at Bedford on Saturday. One extra Medical Retina per month. One glaucoma clinic plus virtual clinic on a Friday. At St Ann s, the implementation of a telephone call to patients prior to surgery to confirm their availability, ask about changes to ocular and general health, and to answer any final questions and offer support (with the added benefit of reducing cancellations). Moorfields East day care admissions team staggers the arrival time of day care patients and inform them of order of surgical list and wait times in response to comments about waiting pre-operatively. Bedford has designated information boards for specific conditions which has more detailed information about the condition displayed for reading in clinic. The paediatric and A&E surveys are due to be repeated toward the end of 2016 and the trust will likely commission a repeat of the outpatient and day care surveys in early 2017 to assess the effectiveness of the actions undertaken. 3.3 Patient Experience Audits reported to the Patient Experience Committee There were several patient experience audits that have been undertaken during the year and have been (or will be once complete) reported to the Patient Experience Committee. As with previous feedback, where appropriate, action plans are created in response. Looking at nursing care provided in day Dignity in Care Trust wide Complaint handling (Complainant perspective) Patient Experience In Theatre. care units Asking about the handling of patient s complaints Asking about the patient experience in theatre, an aspect not covered elsewhere. Trust wide Trust wide General Patient Looking at the patient experience in clinics Experience In Clinic and setting benchmark for future actions City Road Moorfields Ocular Oncology Service: Patient Asking about the practical and emotional support provided by the ocular oncology City Road Experience service Moorfields Adnexal Asking about the practical and emotional City Road 8

9 Oncology Service Why patients Choose MEH A&E Patient experience in the nurse led retinal injection service Pharmacy Information support provided by the Adnexal oncology service Joint survey with commissioners to identify why patients attend City Road A&E Asking if patients are happy with the nurse led service Asking about the quality and provision of medication information provided from trust clinics and pharmacies. City Road City Road Trust wide 3.4 Patient engagement During 2015/16 the Patient Experience Committee worked on developing a comprehensive draft patient engagement strategy (see 6.2). This was informed not only by the patient representatives on the committee but also from the discussions held with around 30 patients and carers attending the annual general meeting in 2015 and telephone conversations with patients about what they felt the public could contribute to the running of the trust, the barriers to involvement and what they would require (training, support, expenses such as transport or child care, etc.). Other focus groups were arranged as part of the trust s external auditor s review of how well led the organisation is with reflections about our strategy, the way we record data and information and our systems and processes. Another was held as part of the part of the preparation of Moorfields Quality Account, reviewing the report and helping to identify key priorities for the trust. A further focus group was held to look at the patient perspective of the MR Service at Bedford and what improvement might be made. Again, an action plan was created and is being implemented. 3.5 Patient Advice and Liaison Service (PALS), Complaints and social media feedback The PALS and Complaints service reports to the Patient Experience Committee as PALS enquiries are possibly one of the most useful indicators of patient satisfaction. The feedback has been reported on more comprehensively in the 2016 Compliments and Complaints Board report, though the themes of appointment management, communication and staff attitude were notable causes of patient frustration. 4.0 Assurance sought by the Patient Experience Committee on trust improvement activities Over the year 2015/16, the PEC sought assurance that patient experience improvement projects and action plans were continuing and effective and project leads and action plan authors we invited to the PEC to discuss progress The Moorfields Way Throughout 2015/16 the Moorfields Way moved from gathering information and ideas to developing a framework of commitments, to communicating its ideas to staff and patients through meetings, clinical governance sessions, and online promotion and information, to the introduction of its more practical aspects. 9

10 The introduction of an appraisal system based around the tenets of the Moorfields Way was introduced and undertaken by many staff prior to the CQC visit in May. Recruitment interviewers can use a bank of questions designed to identify the desired qualities of a candidate that are reflective of the Moorfields Way and based around the commitments of excellence, inclusivity, caring and organisation. Supervisor and front line staff training, again focused around the Moorfields Way, was commenced to support staff in promoting the Moorfields Way behaviours in their staff. 4.2 Telecommunication Project The NetCall telecommunication project continued throughout 2015/16 allowing for a detailed monitoring of the number and speed at which telephone calls are responded to, as well allowing managers to listen in and judge the quality of interactions between staff and callers. Though the results around the number of calls answered and the speed with which they are answered is mixed, this is against a background of increasing call volumes over the year and difficulty with staff coverage in some areas. The question of whether to establish an appointment booking centre (to receive all appointment enquiries) and whether to roll the function out to other areas of the trust will be decided in 2016/ Transport Committee The transport committee meets on a three monthly basis and reports to the patient experience committee. It consists of nurses managers, estates, PALS and representatives of Patient Services, the trusts main transport provider. Each complaint, incident and PALS enquiry is discussed and ways of preventing a re-occurrence identified. This has resulted in a dramatic fall in the number of both PALS enquires and complaints over that past two years. One example of a change made, in response to the number of patients claiming that their transport had not arrived, was an A5 card posted through the letter box if there is no response from the driver knocking or calling, saying they called and including the MEH transport helpdesk number to re-organise the collection of the patient. 4.4 Visual Awareness training Though the role of the Patient Experience Committee is primarily one of oversight and advice, it does identify areas where the patient experience might be enhanced and ask that work be undertaken to meet that need. One example is the provision of visual awareness training, beyond what is provided at induction. The learning and development team produced a DVD, involving patients and staff, to convey the perspective of visually impaired patients. This was produced and viewing it is now part of all staff s mandatory compliance. The need for further face to face training for specific groups of staff is still being assessed. 5.0 Patient Experience Committee: Themes for 2016/17 Trust activity designed to improve the patient experience that the committee will ask to be advised on or will involve it include: 5.1 Accessible Information Standard (AIS) The Accessible Information Standard (the project group of which reports to the PEC) is an NHS England requirement that all organisations providing NHS or adult social care are required to implement. The standard requires a specific and consistent approach to identifying, recording, flagging, sharing and meeting the information and communication needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. 10

11 It is designed to ensure that people who have a disability or sensory loss receive information they can access and understand, whether this be large print formats, braille, , or with professional communication support should they need it, for example from a British Sign Language interpreter. Whereas most of our patients communication needs can currently be met on individual basis and upon request, the challenge for Moorfields is to identify their needs ahead of time, establish processes where needs can be automatically met (e.g. the automatic ing of letters from PAS and OpenEyes), develop clear processes for staff should a patient require audio, braille, easy read letter or information and ensuring that seldom heard groups such as those with a learning disability or dementia are catered for. The role of the PEC will be to ensure that this major piece of work is managed in to place, that momentum is maintained and that mile stones are achieved. 5.2 Patient Engagement During 2015/16 the Patient Experience committee developed a Patient Engagement proposal for the trust. The aim is to further engage, involve and listen to people from all backgrounds who are direct users of, or have an interest in, our services and by extension, allow them to have a direct effect on how they receive care at Moorfields. The key objectives are: To demonstrate that central to the Moorfields ethos is the idea that regardless of the context or setting, patients and their carers are the focus of the services we deliver. To demonstrate through specific programmes and evidence of success, that as a trust we are engaging patients and the public in helping us gain a deeper understanding of the patient experience and that we engage closely with them as partners in any change undertaken. To be able to demonstrate that there is a commitment from our staff, at all levels, to play their part and participate in this process. The activities outlined in the proposal include: Patient Panels for services / satellite /project sites to review and contribute to service performance or change. Committee membership (with the absence of a patient representative requiring justification). An In Your Shoes event for patients, families and carers of seldom heard and minority groups e.g. learning disability, dementia, deafblind, Children etc. Patient information readers group. Patient Story Programme to the board, clinical governance and service meetings Observation of care programmes such as the Institute for Innovation s 15 Step Challenge Mystery patients, reporting in depth through interviews and written feedback, their experiences of being a patient at Moorfields Involvement in policy review Membership of interview panels for all levels of staff Online forum Supporting the Vanguard project in creating models of patient involvement for new and existing satellite sites 5.3 Communication / Editorial Committee The oversight of patient information, patient and GP letters, information screen and website content etc. has fallen in the past to the Editorial Committee. It is envisaged that in 2016/17 11

12 this will be encapsulated within a wider Communications agenda closely related to the AIS. The Patient Experience Committee will take a role in ensuring again, that the work is appropriate to and meets the needs of patients. 5.4 Transformation Board The creation of the Transformation Board in 2016, overseeing change within a surgical, outpatient and emergency care pathways, may have implications for how Patient Experience Committee functions and defines its role going forward with its membership becoming more patient dominant yet retaining its overseeing role of the programmes outlines above as well as that of the transformation activities being led by the Service Improvement and Sustainability project. 5.5 Vanguard Project The Patient Experience Committee may be invited to support the work of the patient engagement work stream of the Vanguard satellite project. This would include supporting the team in identifying existing areas of patient engagement within the trust as well as working with, and learning from them to develop models where patients can become actively involved in service change and planning. TPW/PEAR/7/16 12

13 Appendix 1 Moorfields Eye Hospital NHS Foundation Trust Patient Experience Committee Terms of Reference Definition To provide strategic oversight of patient experience programs undertaken across the trust and to ensure they meet expected milestones. Role The role of this committee will be to support the trust board in providing oversight and scrutiny of the assessment, promotion and delivery of an improving patient experience at Moorfields. It will ensure that the patient voice is heard and championed at an organisational level and will set the vision and agenda for the patient experience at the trust in partnership with our service users. The Patient Experience Committee will focus on the delivery of the Quality and Safety plan, driving improvements at an organizational level ensuring that service change is being led and delivered by the directorate management teams and supporting management teams in how they achieve this. Service change will be led by patient feedback, both qualitative and quantative, with clear and realistic performance objectives and the informed experiential effectiveness of improvements through the inclusion in the membership of patient representatives and clinical staff. Chaired by an executive director responsible for the patient experience, the Patient Experience Committee, whilst offering leadership, support and guidance to the directorate management teams will make clear what is expected of them in terms of their own individual and collective responsibilities toward the delivery the patient experience agenda at Moorfields. The committee will meet on a quarterly basis and consider aspects of activity, oversight; review and reporting that demonstrate how the patient experience is improving across the trust through: Agreeing to identify patient experience strategy for Moorfields Eye Hospital NHS Foundation Trust, and ensure that it aligns with and meets the objectives set out by the Trust Board. To ensure compliance with the patient experience components of the CQC core standards and ensure that the pledges set out in the NHS Constitution are realized. Ensuring that patient experience work is undertaken across the Trust and that it will deliver the patient experience strategy within identified responsibilities and timescales. 13

14 Providing a specific forum for patient reported experience measures to be identified and monitored and where performance is less than requisite, to identify why this is and how the directorate management teams are addressing any shortfall. Membership The committee will be chaired by an executive director of the trust board and the chief operating officer will act as a link between the committee and the directorate management teams. The membership will consist of: Director of Nursing and Allied Health Professions (Chair) Chief Operating Officer (Vice Chair) Senior Clinician City Road Outpatient and Surgical Services Matron Patient Representation Patient Experience Manager A representative from each directorate Reporting Board oversight and scrutiny will be led by the Quality and Safety committee which will have one meeting a year dedicated to the patient experience. Scope of activity To support the directorate management teams in addressing issues relating to the patient experience at the trust. To assess and monitor the delivery of the patient experience elements of the quality and safety plan. To gain assurance that the trust is compliant with its statuary requirements in relation to the patient experience. To assess how the patient experience agenda is incorporated into the human resources function of the trust. To assess how the executive promotes a culture of positive patient experience throughout the trust to ensure the patient s voice is embedded into service and delivery. To provide an annual report summerising the activity of the trust in relation to the patient experience at Moorfields, making recommendations for the board to consider. The committee with meet four times a year and consider any proposed changes to these terms of reference at one of these meetings. ATTENDANCE AT MEETINGS The Committee must be quorate for each meeting to proceed, and for a membership of 14, the requirement is for at least 50% of the total membership to be present, excluding the Chair or their Deputy, who must also be present. Attendance of membership will be scrutinised annually. 14