The Royal Marsden NHS Foundation Trust

Transcription

1 Customer Service Excellence The Royal Marsden NHS Foundation Trust Successful 21 December / Page 1 of 25

2 Assessment Summary Overview Overall Self-assessment Overall outcome Successful 10RP2 The Royal Marsden evidenced improvement across all Criteria. It continues to develop its insight, continues to be very strong in engagement and consultation and continues to record very high levels of customer satisfaction. Customer focus is still led from the top and 2010 feedback on patient privacy and dignity warrants a new Compliance Plus in Element The Trust continues to value staff input to its customer focus ethos. Chargeable services are well-publicised and the organisation always checks that patients receive and understand all its information, interaction methods are continually monitored and improvements made accordingly and clear lines of accountability are set down for arrangements with its partners. The Trust generally meets its operational standards and publishes data on this. Customer satisfaction remains very high on promises delivered and planned outcomes achieved. The complaints procedure was reviewed in 2010 and remains effective in driving improvement although it needs to publicise these effectively to fully comply with Element It showed its customer service outcomes are timely and of high quality, it responds promptly to those making contact, explains delays and takes action on them. The organisation now monitors performance against all customer service standards, shows it generally meets them and publicises data. 11RP3 In the last year RMH has demonstrated improvement across all Criteria. It has improved its Customer Insight, widened its customer focus culture, improved its information, learned from benchmarking and Best Practice, and showed how it is regarded very highly, nationally and locally, for its quality of customer service. The organisation cleared the Partial Compliance in the last report under Element 4.3.4, has maintained Compliance Plus in all reviewed elements and has demonstrated Compliance Plus in two additional Elements, and Further evidence is needed under Elements and RP1 You have continued to demonstrate improvements across all Criteria during the last year. With action taken to clear previous Partial Compliances in Elements and you are now fully compliant with the Standard. With the strengthening of existing initiatives and development of new ones you demonstrated Compliance Plus in four new Elements: 2.1.1, 3.3.1, and : Customer Insight Criterion 1 self-assessment Criterion 1 outcome Successful 10RP2 The organisation has used its insight to seek detailed patient feedback, determined to better support patients with learning difficulties and appointed a Clinical Research Fellow in Psychosexual Practice to identify and help appropriate patients to maintain Compliance Plus in It again evidence improvements made through consultation with customers and through its range of survey feedback, and continued to improve customer experiences and journeys. 11RP3 The Trust has continued to engage with disadvantaged groups, showed it reviews all customer engagement mechanisms on an ongoing basis, as with PCAG, and asked survey questions on all key drivers and on specific subjects generated from its customer insight. 12RP1 You showed how you have continued to collect information for your customer identification and also continued to warrant Compliance Plus with regards to your effective engagement and consultation, including your Board, PCAG and a range of committees, groups and surveys. You are now operating monthly 'Real Time Surveys' to gather more up to date and effective feedback on inpatient satisfaction and you showed your performance against challenging and stretching targets for customer satisfaction continues to improve. 2: The Culture of the Organisation Criterion 2 self-assessment Criterion 2 outcome Successful 15418/ Page 2 of 25

3 11RP3 Its Customer Service Policy and standards remain in place and evidence showed staff are continually encouraged to promote its customer service culture. Although the Trust has the required mechanisms in place to set and monitor targets on Customer Focus within its performance management system, further evidence is needed in Element RP1 With your stronger evidence of your corporate commitment to putting customers at the heart of service delivery including how your Chief Executive, Chief Nurse, Directors, Consultants and Governing Body support this you now demonstrate Compliance Plus in Element Feedback shows that all customers feel they are treated fairly by your staff and you demonstrated your ongoing commitment to delivering customer focussed services through your recruitment, training and development of staff. You provided evidence of your performance management process guidance and completed performance appraisal forms that show you prioritise customer focus at all levels, clearing the Partial Compliance in Element Evidence and verbal feedback to the assessor showed that staff insight and experience is incorporated into internal processes, policy development and service planning. 3: Information and Access Criterion 3 self-assessment Criterion 3 outcome Successful 11RP3 The degree of improvement in improving verbal, documented and web-based information now warrants Best Practice in and evidence shows information updating customers remains accurate. The Trust continues to improve facilities when finances permit and customer feedback confirms they find them clean, comfortable and confidence building. It continually extends its community interaction and the extent of worldwide take-up on Cancer advice and information now warrants Best Practice in Element RP1 You continue to develop effective information that customers need and value and present it in ways that meet their needs and preferences. Improvements to the ways patients, carers and families can access your services now demonstrates Compliance Plus in and your ongoing commitment and endeavours to develop partnerships, including the ICR, GPs and for the offsite production of chemotherapy, to benefit cancer patients, continues to warrant Compliance Plus in Element : Delivery Criterion 4 self-assessment Criterion 4 outcome Successful 11RP3 RMH again involved stakeholders in standards reviews and used benchmarking feedback to improve services. It continues to use best practice within and outside the Trust to improve services and publishes them locally and nationally. Staff continue to be trained in complaints handling and staff confirmed they remain empowered to address them. Successful complainants are asked if they are satisfied with outcomes. 12RP1 A wide range of operational standards for the treatment and care of cancer patients remains in place and you continue to agree at the outset what customers can expect from your services. Your detailed Action Plans, as to address problems with your waiting times, and speed of action to address such dips, now demonstrate Compliance Plus in Element and, similarly, the extent to which you use formal and informal complaints to generate improvements warrants Compliance Plus in : Timeliness and Quality of Service Criterion 5 self-assessment Criterion 5 outcome Successful 15418/ Page 3 of 25

4 11RP3 RMH's effectiveness at identifying and dealing with customer needs at first contact still warrants Best Practice in and it continues to share information to enhance the service to patients, whenever practicable, and updates customers on progress and care plans on an ongoing basis. Although the Trust compares well with others regarding the quality of customer care, additional evidence is needed in Element to show it also compares well with regards to the timeliness of customer service. 12RP1 You showed you operate standards for the timeliness of response and quality of customer services on an ongoing basis and you continue to monitor your performance against them. You also showed that you take action when problems arise, as with keeping appointments. You provided evidence that your performance with regards to the timeliness, as well as quality, of customer services compares well with other organisations, clearing the previous Partial Compliance in Element / Page 4 of 25

5 1: Customer Insight 1.1: Customer Identification 1.1.2: We have developed customer insight about our customer groups to better understand their needs and preferences. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 10:02: SW London Cancer Network patient survey 2009 Assessor Acceptance: Yes This survey of patients across SW London Cancer network shows where patients are diagnosed and highlights differences in responses between patients with different tumour types. 10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes The Trust asks subsets of its patient population for their views, for example patients being treated with radiotherapy. Once the needs and preferences of patients are known improvements are made to services to reflect them. 10:04: National inpatient survey, 2009, Chelsea results Assessor Acceptance: Yes An annual patient survey is run by a contractor to Care Quality Commission guidelines. The results can be reported against characteristics of the Trust's patient population including age, gender, ethnicity, ward or hospital site as here. 10:05: Clinical audit programme 2009/10 Assessor Acceptance: Yes The Trust runs a comprehensive clinical audit programme which is based upon the clinical units. Each unit is responsible for identifying its own audits. These audits provide an insight into patients with particular tumour types for example experience of specific support groups. 10:06: New ambulatory care centre, Chelsea Assessor Acceptance: Yes The new medical day unit in Chelsea has been designed around the needs of its patients. Improvements based on the experience of patients using the old unit include provision of electronic entertainment systems to help pass the time while the infusions are given. 10:57: Cancer Survivorship Programme, colorectal cancer case study Assessor Acceptance: Yes Process mapping identified when colorectal cancer patients should be approached to join the programme (p2). It was also discovered that not all patients wish to discuss their concerns (p4) / Page 5 of 25

6 : We have developed customer insight about our customer groups T08 You have developed a range of focus groups to obtain the views and insight into different tumour patients, and include those for teenagers and for younger children. This was evidenced through the work carried out with gynaecological, lung and prostate patients and through surveys to ascertain needs on, for example, a geographical basis. You also carry out a range of surveys, operate the Viewpoint comment system and hold one-to-one discussions with patients. 09RP1 Add EvSUR24 and IG7. Evidence shows your insight has led to consideration of palliative care patients, the relatives of people with cancer and those who suffer psychological effects after cancer treatment. 10RP2 A range of focussed initiatives, such as for Colorectal Cancer patients, Day Care patients, and Radiotherapy patients, and analyses of survey feedback, such as by tumour type, demonstrate your ongoing developments in customer insight, : to better understand their needs and preferences. T08 The depth of your customer insight has enabled you to understand and respond to their needs and preferences. These have included the adaptation of treatments, reduction in travelling, provision of less-invasive surgery and reductions in hospital stay durations. 09RP1 In addition to previous year initiatives you have enhanced 'End of Life Care'; are designing 'Care for children whose parents have cancer'; and provide 'Support around issues affecting sexuality, sensuality and intimacy following disease and treatment'. This demonstrates Compliance Plus in this Element. 10RP2 The Trust's aims continue to include to better understand patient needs and preferences and in the past year you have opened the new Ambulatory Care Centre in Chelsea, designed the new Sutton Children and Young People's facility and identified a preference for Radiotherapy appointments between 9.00 and These ongoing initiatives continue to demonstrate Compliance Plus / Page 6 of 25

7 1.2: Engagement and Consultation 1.2.1: We have a strategy for engaging and involving customers using a range of methods appropriate to the needs of identified customer groups. Applicant Self Assessment: Compliance to Standard: New Evidence Compliance Plus 12:03: Patient and Carer Advisory Group - community service workshop Assessor Acceptance: Yes The Patient and Carer Advisory Group held a workshop in June 2012 to identify how it could recruit members and represent patients receiving care from Sutton and Merton Community Services, following its merger with the Royal Marsden. 12:06: Foundation Trust Membership recruitment, engagement and involvement strategy Assessor Acceptance: Yes Includes greater emphasis on making the Foundation Trust membership more representative of the communities served, especially young people and black and minority ethnic groups. The Council of Governors has a patient experience sub-group; lay Governors work to improve patient experience (12:87). 12:07: Compliments, complaints and feedback section of Trust website Assessor Acceptance: Yes The Trust website lists many ways that patients and their families can feed back to the Trust including on-line feedback forms, writing a review at NHS Choices and joining a patient/carer group. 12:08: Website - suggestions for research Assessor Acceptance: Yes Trust website users are asked to complete an on-line form to suggest ideas for future cancer research. 12:09: Patient and Carer Advisory Group notes, July 2012 Assessor Acceptance: Yes PCAG, with patients and carers as members, reflects the views of patients to the Trust. At this meeting a patient survey (52/12) and the Listening Post comment collection scheme (55/12) are reported as well as feedback from a member who sits on Trust Equality and Diversity Committee (55/12). 12:10: National outpatient survey 2011, action plan Assessor Acceptance: Yes An example of an action plan that is developed to remedy shortfalls identified by patients in a survey / Page 7 of 25

8 : We have a strategy for engaging and involving customers T08 Your comprehensive consultation strategy remains in place and is supported throughout the Trust and includes the Clinical Audit Committee (CAC) and the Membership Council. 09RP1 The Consultation Strategy is still in place and operates on a continuous basis. 12RP1 Your Foundation Trust Membership recruitment drive, internet developments and engagement and involvement strategy initiatives demonstrate your continued compliance here : using a range of methods T08 You have continued to consult using a range of methods including through the Patient and Carer Advisory Groups, the Viewpoint comments scheme, the Listening Post monthly forum, s and complaints. 09RP1 Your range of methods includes: meetings, surveys, (now also monthly by ward), and Focus Groups (as for patients with pancreatic or hepatobiliary cancers), Listening Post sessions, and more Viewpoint stations are programmed at the Chelsea site. This range of methods represents Compliance Plus here. 12RP1 Your range of methods remains in place for engaging with patients, carers and relatives across all sites, and additions such as use of the internet and the PCAG Workshop held in June 2012 show you continue to warrant Compliance Plus in this Element : appropriate to the needs of identified customer groups. T08 The Trust encourages lay representatives, patients and carers to become involved in consultation and comprise over 50% of the Councillors on the Membership Council, which acts as the Board of Governors. In-patients and outpatients take part in focus groups to cover all ages and the Viewpoint comments scheme is available throughout the hospital. Complaints and s can be used by discharged patients. 09RP1 All methods take account of patients' and carers' needs, such as the range and scheduling of meetings, carrying out of surveys and PALS advisors attending at patients' bedside. This was confirmed by group and Council members who spoke with the assessor during the visit. 12RP1Your methods of engagement continue to be appropriate to the needs of identified customer groups, taking account of such aspects as gender, accessibility, disability, age, ethnic groups and geography. You survey Outpatients and Inpatients, and the latter by Ward and Cancer Group / Page 8 of 25

9 1.3: Customer Satisfaction 1.3.5: We have made positive changes to services as a result of analysing customer experience, including improved customer journeys. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes Improvements are listed (p5) following a survey of patients receiving radiotherapy including work around appointment times and target for start of treatment. 10:13: RM Magazine, summer 2010 Assessor Acceptance: Yes After a review of pharmacy services (p14), involving patient surveys, a number of new initiatives are being introduced to improve access including home delivery of drugs and pharmaceutical services closer to clinical areas. A new haemato-oncology unit also offers improved patient experience (p10). 10:14: RM Magazine, autumn 2010 Assessor Acceptance: Yes A new larger, better appointed medical day unit has opened in Chelsea (p18). It has been designed around the experience of patients using the previous unit. Each chair has more space and its own entertainment centre. There is a refreshment bar and an area dedicated to fast track quick infusion. 10:19: Board minutes, September 2010 Assessor Acceptance: Yes The Trust is in the process of deciding whether to take over running Sutton and Merton community services. The key reason for taking on these services is to ensure continuity of care for patients with long-term conditions including cancer (p6) and a safe and speedy discharge to community services. 10:20: Open access follow-up project Assessor Acceptance: Yes The Trust is moving away from routine follow up for breast cancer patients to a system where the patient is supported to take control of their own follow up. This will improve patient experience. Patients have been involved in taking this project forward. 10:59: Board Minutes, April 2010 Assessor Acceptance: Yes After reviewing patient experience of current services the Trust is introducing Cyberknife robotic radiotherapy and considering managing Sutton and Merton community services to respectively improve patient choice and cut waiting times (p10) and improve patient pathways (p6) / Page 9 of 25

10 : We have made positive changes to services as a result of analysing customer experience, T08 Positive changes to services in the last year include the 're-assessment of prostate cancer treatment at early diagnosis' for men and 're-assessment of the number and size of radiotherapy treatments to women with early breast cancer'. 09RP1 Add EvPEER4 Positive changes in the past year include: 'End of Life Care', treatments for prostate cancer, and measures arising out of the Gynaecology Tumour Working Group. 10RP2 Customer experience drives changes to the Trust's services on an ongoing basis : including improved customer journeys. T08 You continually implement change to improve customer journeys. In the past year you have opened the Rapid Diagnostic and Assessment Centre (RDAC) on the Chelsea site, usually providing screening, tests and results on the same day. You have opened a new Chemotherapy Unit at Kingston Hospital and you review radiotherapy pathways on an ongoing basis. I consider these initiatives warrant Compliance Plus. 09RP1 Add EvSUR21 and EvNHSSUR19. Further developments intended to improve customer journeys, including Telephone Counselling, Ambulatory Service review, and the Operating Theatre suite design (observed), continue to demonstrate Compliance Plus in this element. 10RP2 Improvements include the consideration of customer journeys, which in the last year include the Open Access Follow Up project for breast cancer patients, taking over the running of Sutton Community Services and home delivery of drugs / Page 10 of 25

11 2: The Culture of the Organisation 2.1: Leadership, Policy and Culture 2.1.1: There is corporate commitment to putting the customer at the heart of service delivery and leaders in our organisation actively support this and advocate for customers. Applicant Self Assessment: Compliance to Standard: New Evidence Compliance Plus 12:18: Quality Account 2011/12 Assessor Acceptance: Yes The Trust Chief Executive makes the statement: 'The quality of patient and family care is at the centre of everything we do at The Royal Marsden'. A corporate objective for 2012/13 is to 'Improve patient experience' (p4). 12:19: Board minutes, March 2012 Assessor Acceptance: Yes The Chief Nurse highlighted to other Board members a patient survey, where 100% of patients had described patient transport as excellent and an improvement in chemotherapy waiting times (p5; item 21/12). 12:20: Quality, Assurance and Risk Committee minutes, December 2011 Assessor Acceptance: Yes The importance that directors place on service delivery is shown by the decision to discuss complaints about unsatisfactory customer service and remedy at this meeting of a Board sub-committee (p2; item 87/11). 12:21: Integrated Governance and Risk Management Committee (IGRM) minutes, October 2012 Assessor Acceptance: Yes The Trust actively recruits patients and carers as members of key committees and projects throughout the Trust giving them the power to influence service delivery. The support that Trust leaders give to this empowerment is demonstrated here (p2; 302/12). The patient group reports to IGRM (12:88). 12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes Governors and Board Directors actively advocate on behalf of patients and promote the central position of patients in the work of the Trust egs section 14.1, p8, September 2012 minutes and section 8, p6, May 2012 minutes. 12:83: RM Magazine Spring 2012 Assessor Acceptance: Yes One of the Trust's Governors describes his aims for the next year to include "to increase engagement with carers who can offer many insights to improve standards and the patient experience" (p28) / Page 11 of 25

12 : There is corporate commitment to putting the customer at the heart of service delivery T08 The corporate commitment to putting patients and carers at the heart of service delivery is set down in 'What you can expect from the RMH'. 09RP1 Your corporate commitment is well-documented and re-stated on an annual and ongoing basis by your Board. 12RP1 Your Quality Account includes the statement 'The quality of patient and family care is at the centre of everything we do at the Royal Marsden' and amongst your Trust Objectives is 'To improve patient experience' : and leaders in our organisation actively support this and advocate for customers. 09RP1 Leaders, including your Chairman, Board and Chief Executive, actively support customer care on an ongoing basis, and annually in Reports. All leaders seek ways to lead on this and advocate for customers as a team and individually. The Chief Nurse has become involved through the PCAG to drive 'Support around issues affecting sexuality, sensuality and intimacy following disease and treatment' for cancer patients. 12RP1 The Trust Chief Executive sets down your ongoing commitment in your Quality Account as your 'Statement' and it is one of your fundamental 'Trust Objectives'. This has been strengthened further by your Chief Nurse, Directors, Governors, 'Quality, Assurance and Risk Committee' and your 'Integrated Governance and Risk Management Committee'. The level of commitment and support that leaders in your organisation demonstrate warrants Compliance Plus in this Element / Page 12 of 25

13 2.1.5: We protect customers privacy both in face-to-face discussions and in the transfer and storage of customer information. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 10:26: Information Governance and Medical Records Committee report Assessor Acceptance: Yes A committee has responsibility for ensuring that best practice in information governance is followed to protect the confidentiality of patient records and other information. The Trust scored 71% against the national information toolkit in 2010, which was second highest amongst London acute Trusts. 10:27: Patient privacy and dignity policy Assessor Acceptance: Yes Sets out the principles for protecting the privacy of patients. Each year the policy is reviewed to ensure it is consistent with current best practice. 10:28: Information management and technology security policy Assessor Acceptance: Yes Outlines the security arrangements of information, information systems, software applications, networks, user devices, the physical environment and information management staff. This is one of a series of policies about information governance. 10:29: Mandatory information governance training Assessor Acceptance: Yes All staff are required to undertake information governance training. This is a requirement of the national information governance toolkit. 10:30: Data protection leaflet Assessor Acceptance: Yes Literature reminding staff of their responsibilities around data protection. POL11: Confidentiality policy Assessor Acceptance: Yes Procedures to ensure the confidentiality of patient information and data protection : We protect customers privacy both in face-to-face discussions T08 Trust policies set down the commitment to protect patients' privacy and the latest survey results show 95% of patients (well above the national average of 88%) felt given enough privacy (Ev ANRPT3). This was confirmed by patients who spoke with the assessor. 10RP2 Add Ev 10:4. Your Trust policies and procedures remain in place to ensure privacy is protected in face-to-face discussions and all survey feedback shows it still happens. Customer satisfaction with regards to this is so high (97/98%) you demonstrate Compliance Plus in this Element : and in the transfer and storage of customer information. T08 The Trust's Data Protection Policy and Confidential Policy ensure the privacy of customers is protected with regards to the transfer and storage of customer information. 10RP2 The same evidence shows that you continue to comply with regards to the transfer and storage of patient information / Page 13 of 25

14 2.2: Staff Professionalism and Attitude 2.2.2: Our staff are polite and friendly to customers and have an understanding of customer needs. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes 100% of patients surveyed found reception staff in the radiotherapy department courteous and polite (p2; question 9). 10:32: National outpatient survey, 2009 Assessor Acceptance: Yes Over 93% of patients asked in the national outpatient survey (p93) said they were treated with respect and dignity whilst visiting the Trust's outpatient department. 10:34: Putting people first - training outline Assessor Acceptance: Yes Training for staff about how to provide excellent customer service including identifying the skills needed to understand service user expectations. 10:35: Staff NVQ customer care testimonial Assessor Acceptance: Yes A statement by a member of staff which shows an understanding of customer needs corroborated by testimonials from customers. 10:73: Essence of Care initiative Assessor Acceptance: Yes Action plans to improve basic care have been coordinated by the Essence of Care Steering Group. They cover privacy and dignity benchmarking, protected mealtimes and spiritual needs. A patient is a member of the steering group. COMP10: Thank you cards/letters Assessor Acceptance: Yes Patients and their families write over 800 letters of praise to the Trust a year. Often the letters identify individual staff for particular thanks / Page 14 of 25

15 : Our staff are polite and friendly to customers In addition to Induction training the Trust's commitment is set down in the Patient Privacy/Dignity Policy. Survey results show that staff are polite and this was confirmed during the assessor's visit. - The Inpatient Survey 2004 showed that 93.3% of respondents said they were always treated with respect and dignity. T08 Patient feedback during 2007/8 shows that staff follow Trust policies in being polite and friendly to patients/carers/families. All people the assessor spoke with during the visit agreed that staff are polite and friendly. 09RP1 Add EvNHSSUR19 Inpatient Survey results show that patients and carers find staff polite and friendly. 10RP2 Your commitment and mechanisms, including internal training and NVQ courses, remain in place to encourage staff to be polite and friendly to customers. Patient feedback across the Trust and within discrete services, such as Radiotherapy (100% satisfaction), shows that this continues to happen : and have an understanding of customer needs. T08 Patient feedback also confirms that staff at all levels have an understanding of customer needs. You continually strengthen this through training provision, such as your 'Enhancing Customer Experience'. I consider the Trust demonstrates Compliance Plus in this element. 09RP1 Add EvNHSSUR19 The Inpatient Survey results also show people feel that staff have an understanding of patient and carer needs. This was supported by patients and carers spoken with during the visit who praised staff so highly that it warrants Compliance Plus in this Element. 10RP2 Your evidence also shows that customers believe staff continue to have an understanding of their needs and you continue to demon strate Compliance Plus here / Page 15 of 25

16 3: Information and Access 3.2: Quality of Information 3.2.3: We have improved the range, content and quality of verbal, published and web based information we provide to ensure it is relevant and meets the needs of customers. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 11:31: Information for patients - provision and production policy Assessor Acceptance: Yes Describes the review, audit and evaluation of information materials as well as their production to ensure patients receive information of the highest quality. The policy is reviewed and signed off by PCAG when revised (eg January 2011; evidence 11:36). 11:32: Information standard accreditation Assessor Acceptance: Yes The Trust is working towards having all the patient information it produces accredited against the Information standard. When first accredited the Standard only applied to one series of booklets, at the second assessment further literature was accredited. All will be covered by :33: Patient information database Assessor Acceptance: Yes Examples of entries in the patient information database, showing review schedule and patient comments included in revisions. 11:34: Your guide to support, practical help and complementary therapies Assessor Acceptance: Yes The guide, Directory Plus, was originally published with a questionnaire at the back. The feedback from this questionnaire and patient group members was used to compile the revised version: Your guide to support, practical help and complementary therapies. 11:35: PCAG notes March 2011 Assessor Acceptance: Yes Patients, carers and members of the public are consulted in the production and review of patient literature. In this case (item 20/1, p1) the leaflet 'Being open' was presented to the patient group for comment and sign off. 11:37: PCAG review of draft patient literature Assessor Acceptance: Yes The Patient and Carer Advisory Group reviews draft patient literature to ensure content is clear, relevant and meets the needs of patients of the Trust. For example the smoking cessation and family psychology service leaflets / Page 16 of 25

17 : We have improved the range, content and quality of verbal, SV06 You launched your new website to meet patients', carers and the public's needs. Trust produced or revised 115 patient information leaflets and two new booklets ('Cancer of the Prostate' and 'Clinical Trials'). Ev 308N. SV07 Patient and Carers Advisory Group minutes confirm you improved information regarding 'charges for telephone calls using hospital equipment'. T08 The Information for Patients Policy sets down how staff should communicate with customers and you continually compare the levels of verbal information given by doctors to what patients want, to demonstrate continuous improvement. 11RP3 Your monitoring of patient feedback on clinical and administrative information continues through surveys and questionnaires and improvements are evaluated. Your presentations to GP conferences continue to develop and improve : published T08 You endeavour to improve published information by seeking feedback from patients, their families and potential patients. As a result of feedback regarding the Clinical Governance Annual Report extra information on pastoral care has been added to subsequent issues. Last year 15 leaflets/booklets were revised and an Information Sheet has been changed to clarify how 'blood sample' and 'genetic influences' relate to DNA. 11RP3 You continue to improve published information on an ongoing basis, as evidenced through 'Being Open' and 'Your Guide to Support, Practical Help and Complementary Strategies'. You are now a Certified Member under The Information Standard and demonstrate Best Practice in this Element : and web based information we provide to ensure it is relevant and meets the needs of customers. T08 In the last year you have added prominent links to your home page, such as for GP referrals, services offered and using clearer, less NHS-centric language. You have created a simplified comments/complaints/compliments area, incorporating a feedback form. 11RP3 You also continually improve your web based information in line with customer feedback, as demonstrated in the Patient Information Database and addition of PCAG minutes / Page 17 of 25

18 3.3: Access 3.3.1: We make our services easily accessible to all customers through provision of a range of alternative channels. Applicant Self Assessment: Compliance to Standard: New Evidence Compliance Plus 12:39: Trust's website Assessor Acceptance: Yes Lists the Trust's telephone and fax numbers and address as well as information about clinical units. There is a facility to contact the Trust by . 12:40: Your guide to the Royal Marsden Assessor Acceptance: Yes Has tel numbers, maps of each site and public transport info. The Trust has a contract with a telephone interpreting service. Hearing loops, amplifiers for earpieces and hearing aid compatible phones are available. PALS is a service able to support patients in accessing services. 12:51: Teenagers' social network Assessor Acceptance: Yes The Trust has set up a social network site for its young patients where information can be disseminated and the patients can socialise with their peers. 12:48: Texting protocol for neuro-oncology Assessor Acceptance: Yes A system for patients to contact their specialist neuro-oncolgy nurse through texting is being set up in response to patients' request. Patients can also reach the nurse by and telephone. 12:52: Open access following end of treatment for breast cancer patients Assessor Acceptance: Yes Under the new open access system patients attend for a mammogram once a year, but no other appointments are booked. The patient can return to see the clinical team at any time. Most patients prefer this rather than attend unnecessary routine appointments. The service review is also described. 12:53: Centre for Personalised Care Assessor Acceptance: Yes Following a review of services a Centre for Personalised Care is to be built to deliver treatments in new ways, to more actively support patients returning to their work and home life and provide for currently unmet needs of patients : We make our services easily accessible to all customers through provision of a range of alternative channels. The Trust is accessible by phone, fax, letter, and personal visit. Treatment requires personal attendance and patient transport is available. There is a 'drop-in' service. SV A shuttle bus has been set up between sites. 09RP1 You make services easily available through delivery across three sites and accommodate private patients as well as NHS. Contact can be made by phone, fax, letter, and via the website, as well as personal visit. Psychological Therapy advice is now available by phone and you have launched a new online course on 'Malignant mesothelioma'. 12RP1 All your previous channels for gaining access to services remain in place and you now offer texting, 'Outreach' services, 'Open access arrangements following end of treatment for breast cancer patients' and you are in the early stages of setting up Teenage Social Network arrangements. You now warrant Compliance Plus in this Element / Page 18 of 25

19 3.4: Co-operative working with other providers, partners and communities 3.4.1: We have made arrangements with other providers and partners to offer and supply co-ordinated services, and these arrangements have demonstrable benefits for our customers Applicant Self Assessment: Compliance to Standard: New Evidence Compliance Plus 12:54: Non-emergency patient transport survey Assessor Acceptance: Yes The users of the non-emergency patient transport service provided by a partner have been surveyed. Questions include one asking for an overall rating of experience of the service. 12:55: PCAG meeting notes, September 2012 Assessor Acceptance: Yes The organisation of cancer service pathways in London is being revised to improve care (p2, 63/12). London performs less well than the rest of England. The London Cancer Alliance will cover half of the capital and consist of 17 Trusts. The new arrangements will improve outcomes for patients. 12:56: Complaint patient transport Assessor Acceptance: Yes This response to a complaint made about the service provided by the Trust's non-emergency patient transport partner led to improvements to the service with extra failsafes introduced to prevent bookings being missed. 12:57: Coordinate my Care Assessor Acceptance: Yes This new initiative ensures that out-of-hours doctors, nurses and emergency services have important information about the medical condition and personal wishes of patients nearing the end of their lives. Patients are reassured that their wishes will be met for their end-of-life care. 12:58: Off site production of chemotherapy Assessor Acceptance: Yes The contract for off-site production of chemotherapy includes, key performance indicators, turnaround and pre-ordering targets, monitoring and monthly meetings, guarantees and complaints arrangements. Having production off site, delays for patients have reduced due to less pressure on the pharmacy. 12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes Five of seven below average findings in the national cancer patient survey (p5, item 8, September minutes) relate to the patient's experience with their GP and primary care. The Trust is working with these partners to improve the pathway / Page 19 of 25

20 : We have made arrangements with other providers and partners to offer and supply co-ordinated services, Arrangements made with many partners to provide a co-ordinated service. Include the Institute of Cancer Research, SWLCN, the contract with the Primary Care Trust, Social Services, cleaning contractor, GPs and District Nurses. 09RP1 The Trust has made more arrangements in the past year with other providers and partners to offer and supply co-ordinated services. Partners who spoke with the assessor related how professional you are to deal with, how the partnerships are valued and about the effectiveness from their point of view. 12RP1 You showed you continually seek partnerships to improve services to patients. Recent additions include: the London Cancer Alliance; 'Co-ordinate my Care'; off-site production of chemotherapy; and enhanced liaison with GPs : and these arrangements have demonstrable benefits for our customers 09RP1 You seek new partnerships on an ongoing basis to benefit cancer patients. Recently you have extended the cleaning contract due to its success, set up a joint palliative care service with the Royal Brampton Foundation Trust, made joint appointments of Gastroenterologist and Consultant Radiologist with the Chelsea and Westminster Hospital and with the Institute of Cancer Research and GlaxoSmithKline to enable funding to help Inflammatory Breast Cancer sufferers. This demonstrates Compliance Plus. 12RP1 All partnerships are entered into to benefit patients, as evidenced through: improving experiences and outcomes for patients across London; improving end-of-life care; reduced waiting times for chemotherapy; and improvements to pathways between Primary Care and GPs. You continue to demonstrate Compliance Plus here / Page 20 of 25

21 3.4.3: We interact within wider communities and we can demonstrate the ways in which we support those communities. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 11:05: Presentations to minority ethnic groups Assessor Acceptance: Yes Beyond the direct service it provides to patients referred to it for treatment the Trust presents to community groups that are disproportionately affected by cancer, encouraging them to attend screening eg people with learning disabilities and here minority ethnic groups. 11:44: Special leave procedure Assessor Acceptance: Yes Staff are supported by the Trust to volunteer for work in the wider community (p7-8). 11:62: Christmas Fayre, Sutton Assessor Acceptance: Yes The Trust is organising a 2011 Christmas Fayre at its Sutton site and is actively inviting local residents and its neighbours to attend. 11:63: Worldwide access to cancer information section of Trust website Assessor Acceptance: Yes 92,128 visits to the cancer information section of the website came from 171 countries/territories between October 2010 and November This is beyond the direct service the Trust provides for its patients. There were 64,861 visits from UK 882 cities/towns in the same period. 11:89: Student placements and school talks Assessor Acceptance: Yes Work experience is arranged for students and staff give lessons/talk to schools. COMM3: Parking form for local residents, Sutton Assessor Acceptance: Yes Local residents can apply for a permit to park on the Sutton hospital site : We interact within wider communities and we can demonstrate the ways in which we support those communities. SV07 The positive effect of initiatives was further evidenced through the Hospital Garden transformed by Blue Peter (Ev 329) and by the operation and popularity of Radio Marsden (Ev 330). - Trust has been involved with the community for many years, as evidenced by 40th Summer Fair in Sutton, staff giving talks to Rotary Clubs and schools, and its annual 'celebrate a Life' event. T08 You have continued to be involved in the wider community, as with the Belmont Community Ward Panel and Chelsea Fire Service. 11RP3 You continue to interact with communities around the Trust sites, including through school presentations and work experience, links with ethnic groups and art promotions, and your Special Leave procedure remains in place. The extent of countrywide and worldwide 'take up' in accessing the Cancer information on your website, evaluated through 'hits', now demonstrate Best Practice in this Element / Page 21 of 25

22 4: Delivery 4.3: Deal effectively with problems 4.3.1: We identify any dips in performance against our standards and explain these to customers, together with action we are taking to put things right and prevent further recurrence. Applicant Self Assessment: Compliance to Standard: New Evidence Compliance Plus 12:64: Major incident plan Assessor Acceptance: Yes Describes the procedures to keep patients and relatives informed, including an emergency helpline (p12), in the event of a major incident. 12:65: Integrated Governance Monitoring Report, July-September 2012 Assessor Acceptance: Yes Actions to remedy shortfalls identified by the patient frequent feedback survey include improved information about waits in the medical day unit (p15). Actions in response to complaints (pp90-95) and incidents (97-100) are also included. The report is a public document widely available. 12:39: Trust's website Assessor Acceptance: Yes Actions in response to complaints and comments are available on the Trust's website as are the annual Quality Account and quarterly Integrated Governance and Risk Management reports which include performance monitoring data. 12:66: Outpatient waiting time improvement action plan Assessor Acceptance: Yes Long waits for outpatients are being addressed by a comprehensive action plan. 12:67: Integrated Governance and Risk Management Committee minutes, July 2012 Assessor Acceptance: Yes This committee which includes patient members, discusses action plans (p2) and receives reports about inspections (p2) and other performance info eg about cleanliness (p2), complaints (p2) and recommendations following incident investigations (pp3-4). The minutes are available on request. 12:68: Request for PCAG volunteers to join Trust outpatient and RDAC project group Assessor Acceptance: Yes Patient and carers are part of project groups that work to improve performance, in this case, for the outpatient departments and Rapid Diagnostic and Assessment Centres. Improvements in informing patients, reducing 'did-not-attends' and controlling over running are a few of the aims / Page 22 of 25

23 : We identify any dips in performance against our standards Dips in performance are identified immediately through ongoing monitoring of performance and 'complaints'. SV07 You identify dips on an ongoing basis, as with 'in-clinic chemotherapy waiting times'. 09RP1 The Trust continues to identify any dips on an ongoing basis, such as on theatre usage. 12RP1 Mechanisms, such as your Major Incident Plan, complaints procedure, 'frequent feedback surveys', and ongoing monitoring, such as for 'Outpatients Waiting Times', show how you identify dips in performance, : and explain these to customers, Quarterly Monitoring Reports show dips and are made available to the public on notice boards. These were observed by the assessor. Performance reports explain dips, as with 'Discharge delays' and 'Medication Incidents'. SV06 You also explain dips in performance through letters, notices and in the annual Reports, as with patients not seeing the same doctor at every visit. SV07 Explanations on in-clinic chemotherapy waiting times were given to the Clinical Governance Executive, Patient and Carer Advisory Group and patients. 09RP1 You continue to explain dips to customers through groups, such as the PCAG, the Board, noticeboards and reports. 12RP1 You explain any dips on an ongoing basis, through committees, groups, noticeboards, reports and your quarterly magazine, as you did with regards to waits in the Medical Day Unit : together with action we are taking to put things right and prevent further recurrence. SV07 You also explained action taken. In this case you explained you have changed working methods at Chelsea Medical Day Unit so that patients are given a time for treatment to begin rather than waiting an indeterminate time. 09RP1 You showed you explain action taken to put things right and prevent further recurrence, such as through the review of working methods within operating theatres to improve the percentage usage figures. 12RP1 You continue to communicate action taken, as with: the comprehensive Action Plan to address Outpatient Waiting Times; reduction of Pharmacy Waiting Times; and improving diagnostic processes through the development and building of the Molecular Diagnostics facility in partnership with the Institute of Cancer Research. You demonstrate Compliance Plus in this Element / Page 23 of 25

24 5: Timeliness and Quality of Service 5.2: Timely Outcomes 5.2.2: We identify individual customer needs at the first point of contact with us and ensure that an appropriate person who can address the reason for contact deals with the customer. Applicant Self Assessment: Compliance to Standard: Active Evidence Compliance Plus 11:01: Protocol for supporting people with learning disabilities Assessor Acceptance: Yes Any patients identified with a learning disability prior to contact with the Trust or on admission, will be noted on the electronic patient records system. This will enable all staff to support the patient s specific needs. 11:66: Cultural and religious needs assessment Assessor Acceptance: Yes Patients are asked to complete and bring this assessment form with them when they are admitted to wards so that staff understand their needs and respect and support them appropriately. Clinical Nurse Specialists also assess the holistic needs of patients living with/beyond cancer (11:95). 11:68: Learning disability buddy role requirements Assessor Acceptance: Yes Patients with a learning disability are offered at registration a buddy. The 'buddy' acts as an advocate for the patient and their carer ensuring they receive information in a way they can understand and that their additional needs are met. 11:69: Key worker operational policy Assessor Acceptance: Yes All patients are assigned a key worker on diagnosis. This member of staff coordinates the patient s care and promotes continuity, ensuring the patient knows who to access for information and advice in relation to a cancer diagnosis. 11:70: Unit specific literature Assessor Acceptance: Yes Patients who may have cancer are assessed in the Rapid Diagnostic and Assessment Centre. Individual needs are assessed before surgery in the Admissions and Pre-assessment Unit. 11:92: Key worker audit Assessor Acceptance: Yes The Trust audits the assignment of key workers. 60/60 of patient records audited showed a key worker been provided / Page 24 of 25