NLG(16)492. DATE OF MEETING 29 November Trust Board of Directors Public REPORT FOR

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1 NLG(16)492 DATE OF MEETING 29 November 2016 REPORT FOR Trust Board of Directors Public REPORT FROM Wendy Booth, Director of Performance Assurance & Trust Secretary CONTACT OFFICER Dawn Ojadi, Head of Complaints, Claims & Legal Services SUBJECT Quarter 2 (July - September 2016): Patient Experience: Feedback from Compliments, Complaints and Concerns BACKGROUND DOCUMENT (IF ANY) Monthly Quality Report REPORT PREVIOUSLY CONSIDERED BY & DATE(S) TGAC Meeting 17 November 2016 EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) From this quarters report, the Board are asked to note the following key points: Target for reopened complaints reduced from 20% to 10% Continued improved performance in reducing the number of open complaints HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? N/A HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? N/A ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? N/A IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? N/A ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? N/A WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? N/A WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? N/A THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED N/A ACTION REQUIRED BY THE BOARD The Board is asked to note the contents of the Quarterly Compliments, Complaints, Concerns and Comments Report

2 Directorate of Performance Assurance Patient Experience: Feedback from Complements, Complaints and Concerns Quarter 2: July September 2016

3 Board Report Patient Feedback Summary Quarter 2, July - September 2016 Contents 1.0 Introduction Board Action Recommendations At a Glance Compliments Complaints Concerns Glossary Appendix 1 Focus on VTE as reported in the Safety Thermometer 10.0 Appendix 2 - Friends and Family Target Table Appendix 3 Data Quality Directorate of Performance Assurance, November 2016 Page 3 of 26

4 1.0 INTRODUCTION This is the second quarterly edition of the Trust s Patient Feedback Report in the newly created format. This report outlines performance against various aspects of patient feedback ranging from compliments and what the Trust can learn from the positive comments received through to feedback outlining where the Trust could improve. These are reported quarterly first to the Trust Governance & Assurance Committee (TGAC) and ultimately to the Trust Board. For the indicators presented, wherever possible data is provided outlining the Trust position for the previous year to allow comparison and trending. 2.0 BOARD ACTION The Board is asked to: Review the performance against the range of indicators included within the report. 3.0 RECOMMENDATIONS There are no new recommendations contained within this report. Directorate of Performance Assurance, November 2016 Page 4 of 26

5 4.0 At a Glance Directorate of Performance Assurance, November 2016 Page 5 of 26

6 This Section 5.0 COMPLIMENTS 5.1 Compliments quantitative trending 5.2 Compliments service users own words 5.3 Update on work to capture Directorate of Performance Assurance, November 2016 Page 6 of 26

7 5.0 COMPLIMENTS 5.1 Compliments quantitative trending over time Key points - context: Compliments are verbal or written expressions of praise, admiration or congratulations sent of a person s own volition and are recorded on Datix, circulated to the appropriate staff and management of the trust and included in this report. Thank you cards or gifts received by individuals, wards or departments, responses to surveys, or praise contained in response to sought after comments are not classed as compliments for recording purposes. There are many sources of feedback received into the trust these come via cards, family and friends tests and more commonly social media. Feedback of this kind is responded to, logged and recorded onto Datix, this is then distributed to the relevant directorates for distribution. The PR and Communication team liaise closely with the Complaints team to enable this feedback to be diluted throughout the trust for complimentary purposes or service improvement. Key points performance: Most recent compliments trending information is from Quarter , July to September. During the quarter 123 compliments were received. The following graph provides a breakdown of compliments received per month over the last year Compliments Received: Trust Wide Compliments received into the trust Compliments by Method and Hospital DPOWH GDH SGH Total Contact Us Enquiry Form Facebook Grimsby Telegraph Letter NHS Choices In person Scunthorpe Telegraph Telephone Totals: The chart above provides a breakdown of Quarter 2 s Compliments and what method they were received into the trust. Directorate of Performance Assurance, November 2016 Page 7 of 26

8 Comments: There have been a total of 414 compliments received over the last year. From the above data we can see that there has been an increase in the number of compliments received this quarter (123) in comparison to the previous quarter (87) Complaints by Method and Hospital ALL DPOWH GDH SGH Total Contact Us Enquiry Form Customer Service Comment Card Facebook Grimsby Telegraph Letter NHS Choices In person Telephone Totals: Directorate of Performance Assurance, November 2016 Page 8 of 26

9 5.2 Compliments in service users own words Key points context: The receipt of compliments to a department or ward has an uplifting effect on the areas workforce. This positive recognition of the hard work and devotion of Trust staff is always gratefully received and celebrated. Work is underway to provide a more accurate picture of compliments and feedback received in the Trust which will then feed into work streams around learning lessons. Key points in service users own words: Diana, Princess of Wales Hospital, Grimsby: Women s & Children s Team: Young girl brought to Rainforest Ward by ambulance accompanied by her mum. Every single person on the ward was kind, considerate and took the time when very busy to reassure both mum and daughter. They were kept up to date and when they could expect to be seen by the doctor. Everyone was kind and caring and the daughter who had been very distressed and not eating asked for beans on toast and this was provided even though it was not on the menu. A tablet was brought so that the young patient could watch Peppa Pig. When see by the doctor she was brilliant and took the proper time to make the patient feel reassured and they did not feel they had wasted anybody s time. Accident & Emergency: Patient says he had to attend the A&E department via his GP surgery and wanted to say what a fantastic service he received from them. In particular, from the young male doctor who was extremely thorough and explained everything in detail and what was to come next. The doctor was extremely polite and made the patient feel confident with the diagnosis and follow up recommendations. Scunthorpe General Hospital, SGH: General Surgery: Patient says everyone involved in his care on ward 25 were not only professional and proficient but very caring throughout his stay. Patient also noticed that this applied to all other patients on the ward. The patient would like to think that his feedback will not only serve as a major thank you to all concerned but will also be captured and used in some way when reporting of nursing care which is provided on the front line. Outpatients Patient complimenting the outpatient staff who tried to keep the waiting areas cool during a very hot day by bringing electric fans. Although the wait in outpatients was long the staff kept patients updated and directed to the water foundation if needed. A volunteer did a fantastic job running around and taking patients to different areas and kept them in good spirits despite the heat. The patient feels that the staff and volunteers should be recognised as they were working very hard to keep the Breast Care, DPoW: Everybody dealt with me with the utmost kindness, understanding and dignity when I attended the Pink Rose Suite. Obstetrics/Maternity, DPOW: I would like to compliment and send a huge thank you to the midwifery team on Jasmine Ward who safely delivered my baby boy. Before coming into hospital I had heard a few horror stories, however my midwife was amazing and went about and beyond to meet my needs. My midwife listened to what I wanted in my labour and encouraged me rather than instructed me. I could tell my midwife loved her job. Endoscopy, SGH: I would like to thank all the Endoscopy staff for their care and attention at my recent visit. A particular thanks to Miss Kaur, Andrea and Steven for their patience and compassion especially when I became distressed during the procedure. Trauma & Orthopaedics, GDH: I would like to thank Mr Edwards and his team in Orthopaedics for my excellent care. Directorate of Performance Assurance, November 2016 Page 9 of 26

10 patients updated, to get them seen as soon as possible and tried to make them comfortable. Goole District Hospital, GDH General Medicine: Patient was very complimentary about all the staff on ward 3 during her stay. 5.3: Compliments: Work is underway to provide a more accurate picture of compliments and feedback received in the Trust which will then feed into work streams around learning lessons. The plan is to share the lessons between Compliments, Complaints, Concerns, Friends and Family Tests and Patient experience. The Inclusion of the menu card surveys will also be incorporated going forward. Directorate of Performance Assurance, November 2016 Page 10 of 26

11 This Section 6.0 COMPLAINTS 6.1 Quantitative trending of complaints 6.2 Complaints per total patient contacts 6.3 Monthly performance with timescales 6.4 Remedial Action 6.5 Parliamentary & Health Service Ombudsmen (PHSO) involvements 6.6 PHSO & NED Reviews 6.7 Compensation Tracker Directorate of Performance Assurance, November 2016 Page 11 of 26

12 6.0 COMPLAINTS 6.1 Quantitative trending of complaints Key points context: A complaint is a matter which the complainant wishes to be registered and investigated in accordance with the Local Authority Social Services and NHS Complaints (England) Regulations A complaint may be written or oral and will be investigated by senior staff and a full response will be provided. In order to understand performance with complaints, the following chart provides trends over time for agreed indicators, specifically the number of new, closed and total, or net open, complaints. These indicators are defined, for clarity, in the glossary. Key points performance as at Oct 2016: The following chart illustrates performance against these indicators since April Data Source: DATIX, Performance Assurance Team Comments: The above chart illustrates the continued significant progress made in reducing the net open number of complaints. Directorate of Performance Assurance, November 2016 Page 12 of 26

13 Re-opened complaints TARGET: Re-opened complaints to not exceed 10% of total closed complaints Key points Context: The criteria for classifying a complaint as a re-opened complaint is as follows: If the complainant is dissatisfied with the final response and has requested further clarity or a discussion around the complaint. If the complainant requests a further meeting from receiving a response to seek resolution. If the complainant requires more clarity or further questions are raised from the response. In order to set a useful target for this area, the context of historic performance is needed to be considered. Since May 2014, the number of reopened complaints had been on average 12 per month which exceeded the target being aimed for a 50% reduction, equating to no more than 2.5 per month. The number of closed complaints had continued to rise and, as a significant proportion of these related to older complaints which made up the backlog, it was expected that a proportion of those complaints closed would have always been re-opened, as a result of the complainant requiring further assurance. To set a numerically based reduction was therefore deemed unrealistic. Instead of a numerical target, a proportional or a percentage target would seem more realistic. From Quarter 2, the percentage target has been reduced form 20% to 10% Key points Performance: The following chart illustrates the percentage of re-opened complaints compared with the number closed. Data Source: DATIX, Performance Assurance Team Comments: The percentage of re-opened complaints is below the 10% target at 7.7%. The above chart illustrates both the percentage re-opened and the numerical equivalent. Both illustrate a downward trend therefore demonstrating a reduction in the numbers of complaints being re-opened. This would imply that complainant s satisfaction in their complaint handling/response has improved. Directorate of Performance Assurance, November 2016 Page 13 of 26

14 It is worth noting that in an attempt to improve complainants satisfaction and improve their feeling of assurance, at the end of each response letter, the complainant is offered the opportunity of a meeting to discuss the findings. More and more complainants are taking up this opportunity and this has an impact on the numbers of reopened complaints reported in this section of the monthly quality report. To test out complainant s satisfaction of this process, the Trust also uses service user satisfaction surveys to help gauge performance from a different perspective. 6.2 Complaints per total patient contacts Key points Context: In order to understand complaints and the context in which they are made it is important to understand the context of total numbers of complaints compared with the total number of patient contacts each month. The following chart illustrates the total number of new complaints each month, compared with the number of patient contacts within the same month. Data Source: DATIX, Performance Assurance Team Comments: The above chart illustrates performance since October 2014, unlike the earlier chart illustrating performance with new, closed and net open. Since 2014, the number of new complaints has remained static with no discernible trends. The number of total patient contacts has shown a slight reduction over this period. There does not appear to be any significant correlation between the number of new complaints and the total number of patient contacts. A factor behind this may be that some complainants do not immediately contact the Trust, thereby resulting in a new complaint being received in a subsequent month. Recommendation: It is recommended that this analysis not be included in future reports. Directorate of Performance Assurance, November 2016 Page 14 of 26

15 6.3 Monthly performance with timescales Key points Context: The Trust s contract with commissioners stipulates a target of 95% of complaints being responded to within the timescales agreed with the complainant. The following table illustrates that the Trust has routinely met this target. July 2015 Aug 2015 Sept 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 April 2016 May 2016 June 2016 July 2016 Aug 2016 Sept % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100 % 100 % 100% Comments: In some cases, the original timescale needs to be-negotiated due to delays in obtaining statements, locating health records or the complainant requests further time to provide further details or concerns therefore the above summary of performance reflects in some cases where complaint timescales have been re-negotiated. Whilst re-negotiated timescales are employed in some instances where the nature of the complaint and the necessary investigative work are likely to exceed the original negotiated timescale, such decisions are only taken following internal challenge with the Trust s Complaint s Manager, and every effort is therefore invested to meet timescales agreed initially. To aid timely response to patient complaints, the central team have process mapped the various stages and have understood from this typical process bottlenecks. As a result of this work time has been invested to streamline the process through effective escalation at the earliest opportunity. To provide an overview of the reasons for renegotiating complaints, Complaints renegotiated by Reason for delay July - Sept 16 Data Source: DATIX, Performance Assurance Team Administration problems 2 Awaiting complainant response 1 Awaiting meeting date confirmation - Complainant 1 Awaiting outcome of meeting details 1 Complex complaint 5 Staff Annual Leave 4 Awaiting first information 5 Awaiting comments from other Division involved 1 Awaiting Management Approval 2 Awaiting further information from nursing staff 1 Awaiting further information from Consultant 3 Awaiting departmental information 1 Totals: 27 Comments: The Complaints Policy has been amended to include a more streamline process mapping for escalating any elevating any blockages. The team will be working with operational groups to further develop efficient processes. The amended Complaints Policy can be found on the intranet. Directorate of Performance Assurance, November 2016 Page 15 of 26

16 New strategy for responding to complaints within timescales: As previously referred to within the monthly quality report, benchmarking work has been undertaken with other organisations and the Trust has also benefited from a recent internal audit into the complaints handling processes in place. As a result of these pieces of work, the Trust is currently moving to a revised complaint handling timescale. The introduction of defined timescales has been introduced and is currently being embedded into the Complaints team. The triaging of complaints is based on the estimated level of investigation required with each level of categorisation having a defined timescale for response which reflects the complexity of the complaint. Complaints fall into the following 3 categories when triaged: Category 1 single issue or single group. Final response or meeting completed within 30 working days Category 2 - multiple issues with group. Final response or meeting completed within 45 working days Category 3 multiple issues with multiple groups. Final response or meeting within 60 working days Data relating to these categories will be provided in future reports to enable the trust to be assured and confident that the team are working to a reduced number of working days to respond to complainants in an effective and efficient manner. The impact of implementing these timescales and categories will be monitored through the quarterly analysis report. The benefits for the trust and for complainants will be identified through the improved complaint handling and timescales in turning complaints around for a speedy resolution. In readiness for this change in the complaints handling processes, the Trust s central complaints team is actively working to streamline the process with operational groups to minimise delays in handling of complaints. The central team are also working with operational teams to ensure resulting action plans following complaints have greater ownership at group level. Directorate of Performance Assurance, November 2016 Page 16 of 26

17 6.4 Remedial action taken as a result of complaints closed in Quarter 2 Key points context: Where remedial action is identified, an action plan, which records timescales and responsibilities, will be prepared by the complaint handler and agreed with the relevant Operational Group. These action plans are co-ordinated, distributed and monitored within the Complaints Team. On the closure of the complaint or no later than 3 months after closure of the complaint the actions should be confirmed completed, this will be monitored regularly by the Operational Group until fully implemented. Examples of remedial action taken during the quarter are provided below. Complaint: Patient concerned regarding ophthalmology problems following field and vision test in the outpatient clinic. In the clinic the consultant mentioned that a cataract had been removed from the right eye. Patient was not aware he had cataracts and said he had no cataracts removed previously. On examination the patient was asked who had diagnosed Glaucoma and the patient advised that this was a doctor at this hospital who he had seen five years earlier. Consultant could not confirm Glaucoma and diagnosed ocular hypertension. Patient had been using prescribed eye drops for Glaucoma for the past five years. Patient very concerned and worried that had been wrongly diagnosed and treated for five years. Remedial Action: Complaints meeting held with consultant, complainant and complaints team and patient s medical records were reviewed. The diagnosis of ocular hypertension or OH was confirmed with patient. Complainant reassured that no physical harm or damage to the eye and an apology was given. It was agreed that the details of this complaint would be used anonymously for training purposes for staff and that the consultant would speak directly with the doctor concerned. Complaint: Complainant had previously broken a bone in foot and was provided with a back cast and given a follow up appointment for review. Seventeen days later complainant collapsed at work and was unresponsive for a short period of time. Patient attended A&E department and was given an ECG. Patient was advised that blood pressure was high, blood sugars were low and pulse rate was fast. Complainant advised that they had just fainted and nothing else. Complainant not happy with doctor s attitude. Complainant was discharged from A&E but returned five days later as breathing had become progressively worse. Whilst in A&E, the complainant was provided with oxygen and a suspected blood clot on the lungs was diagnosed. This diagnosis was confirmed following a CT scan and a heart scan confirmed that the right side of the heart was enlarged with fluid around it. The complainant remained in hospital for eight days with a diagnosis of pulmonary embolism. Remedial Action: A meeting was held and an apology provided and a statement obtained from the junior doctor who initially saw the complainant in A&E. It was clear that the junior doctor had not obtained enough clinical information upon presentation, as loss of consciousness was not documented although pulmonary embolism was clearly considered on review of the documentation by the consultant when complainant represented in A&E. Consultant in Emergency Medicine will ensure that in future junior doctor training PE recognition will be incorporated. Directorate of Performance Assurance, November 2016 Page 17 of 26

18 6.5 Parliamentary & Health Service Ombudsman (PHSO) involvements Key points Context: The Parliamentary & Health Service Ombudsmen (PHSO) was set up by Parliament to help individuals and the public when concerns are raised with regard to NHS care that those involved do not feel have been resolved. The PHSO look into complaints where someone believes there has been an injustice or hardship because an organisation has not acted properly or fairly or has given a poor service and not put things right. ( The PHSO is independent of the NHS and of government. Any complaint accepted by the PHSO must already have been considered at local resolution. If an investigation takes place the PHSO may uphold the complaint in full or in part and will provide a report of the reasons for their decision. The PHSO may make recommendations for example an apology, an explanation, improvement in practices and if appropriate financial redress. It is worth noting that due to the emotive nature of complaints, some complainants will feel that the Trust s response has not been adequately handled, therefore may request the PHSO s involvement. The PHSO s involvement, however, should not be interpreted, in isolation, as a marker that the Trust s complaint handling procedures have been inadequate. The PHSO will investigate the case specifics and make a judgement whether to uphold the complainants concerns or not. The Trust works to fully support the PHSO s office in their work. The PHSO report entitled Key points Performance: During Quarter 2 there was 2 complaint that was partially and 1 not upheld by the PHSO. The following chart illustrates the performance since 2013 with complaints that have been referred to the PHSO Awaiting PHSO Upheld Partially upheld Not upheld No further action Total Data Source: DATIX, Performance Assurance Team Directorate of Performance Assurance, November 2016 Page 18 of 26

19 Comments: The above chart illustrates that during 2016 only 4 complaints referred to the PHSO have been completed to date. Four further referrals are awaiting PHSO involvement. There have been no findings against complaint handling in the last quarter. 6.6 Parliamentary & Health Service Ombudsman (PHSO) and NED Reviews Complaints which have been reviewed by the Parliamentary and Health Service Ombudsman which have been upheld or partially upheld will routinely have a NED review (Non-Executive Director) concluded to explore further learning lessons or remedial action to take place. The NED review includes inclusion of operational / clinical staff throughout the Trust along with the complaints facilitator to ensure the internal independent review is concluded adequately and appropriately. The outcome of the NED Reviews are provided to the operational group for consideration and monitored regularly by the operational group until fully implemented. Operational Groups are responsible for the service improvement and audit of action taken to address any lessons that need to be learnt. Learning from the NED reviews is shared as widely as possible within the Trust and where any changes in service provision made as a result of a concern or complaint, where appropriate will be fed back to complainants. The complaints team have arranged and concluded 13 NED Reviews and have provided summaries of the outcome of the meeting to all operational groups for their dissemination. Further work on the NED Reviews and learning of lessons will be included in future reports to enable further analysis to be concluded in relation to trends and themes. Out of the 13 NED reviews the following themes and trends have been identified. o o o o o Lack of / poor communication Discharge planning skills that need to be revisited Communication around End of Life with Family and relatives Record keeping not reaching the record keeping standards / conflicting information Staff attitude requiring remedial training Directorate of Performance Assurance, November 2016 Page 19 of 26

20 6.8 Compensation Please find below the compensation tracker for Quarter 2 Compensation request received Q2 July to Sept 2015 Q3 Oct to Dec 2015 Q4 Jan to Mar 2016 Q1 - April to Jun 2016 Q2 July to Sept Directorate of Performance Assurance, November 2016 Page 20 of 26

21 This Section 7.0 CONCERNS 7.1 Key points - Context 7.2 Concerns per total patient contact 7.3 Pals / Directorate performance data timescales 7.4 Remedial Action taken 9.0 Appendix 1 Focus on VTE as reported in the Safety Thermometer 1 Directorate of Performance Assurance, November 2016 Page 21 of 26

22 .0CONCERNS 7.1 Key points Context: A concern is a matter which an individual wishes to be considered on an informal basis. It is expected that the majority of concerns raised will be dealt with by the complaints process. All staff are expected, on a routine and daily basis, to deal with patients concerns as presented to them. Wherever possible, staff are encouraged to achieve speedy resolution of the concern by either resolving it personally or establishing a dialogue between the complainant and the relevant personnel within operational areas. The objective will be a speedy, informal resolution of the concern without recourse to correspondence/formal procedure. If made to and dealt with by front line staff a record of the concern should then be made by either entering it into the informal complaint book for the department/ward/area or informing the PALS team who will then record this on the Trust s database (Datix) Key points performance as at the October 2016: The following chart illustrates the number of concerns received in Quarter 2 has slightly decreased since the precious quarter (588 compared to 621) Data Source: DATIX, Performance Assurance Team 7.2 Concerns per total patient contacts Key points context: In order to understand concerns and the context in which they are made it is important to understand the context of the total numbers of concerns compared with the total number of patient contacts each month. The following chart illustrates the total number of new concerns each month, compared with the number of patient contacts within the same month. Directorate of Performance Assurance, November 2016 Page 22 of 26

23 Nunber of Concerns compared with total patient contacts NLAG total concerts vs total patient contacts ,000 44,000 42,000 40,000 38, ,000 0 Oct Nov Dec Jan Feb Mar Apr Ma y- 15 Jun -15 Jul- 15 Aug Sep Oct Nov Dec Jan Feb Mar Apr Ma y- 16 Jun -16 Jul- 16 Aug Sep New Concerns Pt Contacts 44,1 41,4 39,8 41,0 40,1 44,1 41,0 38,3 44,4 43,5 37,8 42,0 43,0 41,8 40,0 39,7 42,3 41,1 39,2 40, ,3 41, ,000 Data Source: DATIX, Performance Assurance Team Comments: The above chart illustrates patient contact since October Pals / Directorate performance data with timescales Key points Context: The Trusts contract with commissioners stipulates a target of concerns being responded to within 3-5 working days. The following data/tables below illustrates the performance of the Directorates and the further work and education from the Complaints/PALs team required to support and guide the groups through ensuring these timescales are met. The table below shows the number of PALs concerns received since August This table breaks down the figures by month and also identifies the original and exceeded timescales. Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 PALs concerns received PALs concerns closed within 5 working days PALs concerns closed over 5 working days The below 3 tables shows the figures for Quarter 2 split down by month and group. July 2016 table shows the number of pals concerns closed within agreed timescales and the amount of overdue concerns split by directorate: Jul-16 Clinical Support Services C&TS Chief Nurse Quality Assurance Diagnostics Facilities Finance Medical Dir Medicine Org Dev Path Performance Strategy S&CC W&C Total closed within 5 working days = 50% 4% (4/113) 6% (7/113) 0% 0% 0% 1% (1/113) 1% (1/113) 0% 38% (43/113) 0% 1% (1/113) 0% 0% 38% (43/113) 11% (13/113) 100% closed over 5 working days = 50% 2% (2/114) 2% (2/114) 1% (1/114) 0% 0% 6% (7/114) 1% (1/114) 0% 42% (48/114) 0% 0% 0% 0% 35% (40/114) 11% (13/114) 100% August 2016 table shows the number of pals concerns closed within agreed timescales and the amount of overdue concerns split by directorate: Aug-16 Clinical Support Services C&TS Chief Nurse Quality Assurance Diagnostics Facilities Finance Medical Dir Medicine Org Dev Path Performance Strategy S&CC W&C Total closed within 5 working days = 70% 4% (5/115) 7% (8/115) 1% (1/115) 0% 0% 4% (5/115) 2% (2/115) 2% (2/115) 38% (44/115) 0% 0% 0% 0% 34% (39/115) 8% (9/115) 100% closed over 5 working days - 49 = 30% 6% (3/49) 2% (1/49) 0% 0% 0% 0% 2% (1/49) 0% 60% (29/49) 0% 0% 0% 2% (1/49) 22% (11/49) 6% (3/49) 100% September 2016 table shows the number of pals concerns closed within agreed timescales and the amount of overdue concerns split by directorate: Directorate of Performance Assurance, November 2016 Page 23 of 26

24 Sep-16 Clinical Support Services C&TS Chief Nurse Quality Assurance Diagnostics Facilities Finance Medical Dir Medicine Org Dev Path Performance Strategy S&CC W&C Total closed within 5 working days = 60% 10% (12/120) 4% (5/120) 1% (1/120) 0% 0% 6% (7/120) 0% 0% 45% (54/120) 0% 1% (1/120) 0% 0% 28% (34/120) 5% (6/120) 100% closed over 5 working days - 80 = 40% 1% (1/80) 3% (2/80) 0% 0% 0% 1% (1/80) 0% 0% 44% (35/80) 0% 0% 0% 0% 46% (37/80) 5% (4/80) 100% Comments: To aid timely responses by the groups the PALs team currently prompt groups at day 3 of the concerns resolution. This is escalated accordingly to groups if this does not meet the 5 working day timeframe. This process through effective escalation at the earliest opportunity provides a more effective and efficient service to the Trusts complainants. Where it is apparent that some PALs concerns require additional time allocated for resolution the Directorates are encouraged to communicate this information to the complainant at the earliest opportunity and keep PALs updated to ensure this is monitored accordingly. The Complaints / PALs team also provide additional support when it is identified when Directorates have an influx of concerns or if handlers have numerous concerns open at one time. Support is provided by the Clinical Lead in Complaints to help alleviate pressures on groups to ensure these are dealt with in a timely manner. 7.4 Remedial action taken as a result of concerns closed in Quarter 2 Key points context: Where remedial action is identified during the resolution of a PALs Concern this is documented on the Datix system along with any lessons to be learnt and the final outcome of the closed concern which is agreed only when the resolution is provided to the complainant. Examples of remedial action taken during quarter 2 are provided below. Concern: Patient complained via her MP that she had been asked to provide a copy of her entitlement to NHS services even though she had always lived in the UK. Remedial Action: The Income & Overseas Co-ordinator responded by letter to the MP and provided an explanation quoting from the Overseas Visitor Hospital Charging Regulations 2015 and also apologised for the confusion. Concern: Patient concerned her inpatient admission notes were not available during her outpatient clinic appointment. Remedial Action: Handler contacted patient with an explanation. Patient s main notes went missing and a temporary record was made available for her outpatient appointment. Handler confirmed with patient that her main notes had subsequently been found and the documentation contained in the temporary record had been merged into the main record. Concern: Patient concerned that her name was not on the waiting list for an ophthalmology procedure. Remedial Action: Handler rang patient to discuss. Subsequently patient was given an appointment for pre-assessment prior to surgery and also a date for the ophthalmology procedure. Directorate of Performance Assurance, November 2016 Page 24 of 26

25 Concern: Patient was concerned that although she attended for her ophthalmology appointment at 9.50 am she was not seen in clinic until The nursing staff had not informed the patients about the reason for the long delay. Remedial Action: Handler contacted the patient to provide an explanation for the long delay in clinic and also to apologise for the wait. 0 Appendix 1 Focus on VTE as reported in the Safety Thermometer Appendix 2 - Friends and Family Target Table 11.0 Appendix 3 Data Quality.0 Appendix 3 Data Quality Directorate of Performance Assurance, November 2016 Page 25 of 26

26 This Section 8.0 Glossary Safety Thermometer 10.0 Appendix 2 - Friends and Family Target Table Appendix 3 Data Quality.0 Appendix 38.0 Glossary Benchmark Peer Group: Calderdale and Huddersfield NHS Foundation Trust, Chesterfield & North Derbyshire Royal Hospital NHS Trust, Countess of Chester NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Trust, North Cumbria University Hospitals NHS Trust, North Tees & Hartlepool NHS Trust, Rotherham NHS Foundation Trust, Royal Bolton Hospital NHS Foundation Trust, The Pennine Acute Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Trust Complaints: The NHS Complaints Regulations (England) 2009 require that an offer to discuss the complaint with the complainant is made on receipt of all complaints; the discussion to include the response period (the period within which the investigation is likely to be completed and when the response is likely to be sent to the complainant). The requirement is to investigate the complaint in an appropriate manner, to resolve it speedily and efficiently and to keep the complainant informed as to progress. The response should be within 6 months or a longer period if agreed with the complainant before the expiry of that period. The Complaints Regulations permit extensions to the agreed timescale where this becomes necessary and in agreement with the complainant. The Trust (as outlined within the Policy for the Management of Complaints) expects that any delay to the agreed response time is communicated to the complainant, the reasons explained and an extension agreed. In respect of monitoring, the Regulations require (amongst other points) that the Trust maintain a record of the response periods and any amendment of that period and whether the response was sent to the complainant within the period or any amendment of that period. KEY DEFINITIONS TO INTERPRET COMPLAINTS DATA: Glossary NEW: The number of new complaints received in a month regardless of whether or not they were resolved within that month. CLOSED: The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale. NET OPEN: The total number of complaints currently open; includes new complaints and those unresolved from previous month(s). This includes open on hold. This includes re-opened complaints. RE-OPENED: Complaints that have been resolved which for any number of reasons require further review. Control Limits: indicate the range of plausible variation within a process. They provide an additional tool for detecting special cause variation. A stable process will operate within the range set by the upper and lower control limits which are determined mathematically (3 standard deviations above and below the mean). These consist of an upper control limit, a lower control limit and a mean (average). Friends and Family Test Methodology: The Trust introduced the new friends and family test in April 2014, when it was launched across the country. Within 48 hours of receiving care or treatment as an inpatient or visitor to A&E, patients are given the opportunity to answer the following question: How likely are you to recommend our ward/a&e department to friends and family if they needed similar care or treatment? Service users are then asked to answer how likely or unlikely along a six-point scale they would answer the above question. There is also an opportunity to elaborate on the reasons for their answer and all feedback will be encouraged whether positive or negative. Positive feedback defined as the percentage of patients/service users answering extremely likely and likely For more information regarding the Friends & Family Test, please follow this link to the NHS England site: Patient Experience: This Trust has set the goal of being the hospital of choice for our local patients. Being the hospital of choice is a far different thing than being the hospital of convenience, proximity or default. We measure patient experience using methodologies employed by the NHS National Patient Experience Survey against two key indicators to help us determine that our hospitals are the ones our patients would choose if the practical factors were removed. The Trust uses The Menu Card Survey which asks five questions relating to patient experience and is attached to inpatients menu cards. It measures the patients experience in real time. The questions asked are all derived from questions that feature in all National Patient Surveys. The scores depicted in the graphs reflect an absolute figure generated by this methodology (in short high score is good, 100% would be the maximum achievable score). Directorate of Performance Assurance, November 2016 Page 26 of 26