PATIENT EXPERIENCE STRATEGY

Transcription

1 PATIENT EXPERIENCE STRATEGY

2 CONTENTS Section 1: Introduction Executive introduction 3 Review of previous strategy 6 Links to other strategies 8 Engaging with patients, users and carers 9 Key drivers of patient experience: the national picture 10 The NHS England Engagement Ladder 11 Section 2: The Strategy Strand 1: Listening and responding to feedback 13 Strand 2: Patient Partners 15 Strand 3: Accessibility 17 Section 3: Conclusion Delivery and monitoring of the strategy 19 Conclusion 20 Consultation 21 Appendices Appendix 1 Action Plan Patient Experience Strategy Appendix 2 - Action plan summary Patient Experience & Involvement Strategy

3 EXECUTIVE INTRODUCTION The heart of our success as an organisation is the involvement of our patients, their relatives, carers and the community to give them the best experience of care possible. It is enshrined in the NHS Constitution and has become a key indicator of the NHS performance nationally. Patients are the reason why we work for Barking, Havering and Redbridge University Hospitals NHS Trust. We know that a positive experience during care leads to positive clinical outcomes. If a patient feels listened to, involved in their care, respected and cared for they will respond better to medical and nursing interventions and also be better able to manage their own journey through care. The Patient Experience Strategy aims to enable and empower all staff within our Trust to feel able to put the patient experience at the heart of everything we do. The Strategy launches the start of our journey and cultural shift from doing to patients, to working with patients and carers. Our long-term aim is to ensure that patients have a central role in all aspects of care provision, service design and improvement and assurance processes. By doing this, we not only improve outcomes for patients, their relatives and carers, We can improve the outcomes for the Community we serve and we can have a real meaningful impact on the long term Quality and Financial outcomes of our Trust. Matthew Hopkins Chief Executive Follow me on Kathryn Halford Chief Nurse Follow me on 3

4 INTRODUCTION Patient experience has been identified across NHS England as a vital element of patient care, enabling service users to direct us through feedback, involvement and engagement to providing care that is not only clinically outstanding but provides a holistic approach to patient wellbeing whilst they are in our care. Patient s experience of care, clinical effectiveness and patient safety together make the three key components of quality in the NHS. Good care is linked to positive outcomes for the patient and is also associated with high levels of staff satisfaction. Our patients are at the heart of everything that we do, and delivering first-class care is our main priority. We are going to build on existing good practice to design our services around our patients needs, to ensure we provide an exceptional standard of care and experience to all our patients. Our operational plan clearly identifies one of its workstreams as working in partnership. However to do this we will need to further develop our community links and improve engagement so that all our potential patients, carers and existing patients, including those who are vulnerable, are seen as equal partners. We will build on our existing successes and make our services people centred by involving patients in many more of our improvement and redesign projects and use their feedback to continually monitor progress in real time. This will bring about a fundamental cultural change from doing to patients to working with patients. The current model of health and care is unsustainable and this gives us an opportunity to redesign systems that focus on holistic, integrated care and are person centred. There is a strong moral and ethical case for a health system that centres on what matters to individuals and increasing evidence that this approach leads to better outcomes and benefits to patient s, carers and the community. Wendy Matthews- Deputy Chief Nurse /Director of Midwifery, Victoria Wallen- Head of Patient Experience, Rea Blewitt and Angelina Leatherbarrow-Patient Involvement & Experience Facilitators The Patient Partnership Council 4

5 Our vision is to provide outstanding healthcare to our community, delivered with PRIDE and to do this means that we put patients at the top of everything that we do. Patient first is the heart of everything we do. Patient first is our most transformative element. Gary Kaplan, MD, Virginia Mason CEO A Leadership Journey in Health Care: Virginia Mason s Story (CRC Press) 2 5

6 REVIEW OF THE PREVIOUS STRATEGY The Strategy for our Trust set out 10 aims putting Patient Engagement firmly at the forefront of our organisational culture. The strategy took the principles set out in the original 2010 Listening and responding to patient views strategy paper and reinvigorated them, building a more robust framework for improvement. The strategy also took in to account the CQC findings from 2011 investigation in to the quality and care provided at Queen s and King George Hospitals. There have been a number of successes during the three year period covered by the Patient Experience Strategy. We now plan to take those successes and build even further, to put this strategy in to the heart of the organisation and fully commit to a culture and behaviour within our Trust which will establish us a leader in delivering outstanding patient experience. KEY SUCCESSES Friends and Family Test (FFT) - over 71,000 surveys were received by Our Patient Experience team in , enabling our Trust to see top line patient feedback for divisions and wards Our Patient Experience team has developed the patient story tool within our Trust. Patient stories are heard at every corporate welcome in order to drive home the power of patient experiences to all new colleagues. Patient and staff stories are heard at bimonthly Trust Board meetings A new children s Emergency Department at Queen s Hospital created a welcoming, nonthreatening environment for children and young people who need to access emergency care Patient Magnets - symbol magnets introduced to wards to enable easy identification of additional support needs for individual patients Pets as Therapy - we now have weekly visits from PAT dogs Protected meal times all non-urgent interventions are suspended on wards during meal times, allowing patients to eat in peace Listening Events our Patient Experience team leads on a programme of Listening Events across the three boroughs our Trust serves. The issues chosen for focus and discussion at the events are based on the highest numbers of Patient Advice and Liaison Service (PALS) enquiries and formal complaints. Findings were considered by Trust staff and Healthwatch Information boards on wards providing ward information and how to feedback to us Appendix Strategy Action Plan Summary 6

7 Ward information boards Pets as Therapy dogs 'It's good to talk' boards Patient information magnets 7

8 LINKS TO OTHER STRATEGIES / INTIATIVES Our Patient Experience Strategy does not sit in isolation but is intrinsically linked to a core business goal of working in partnership This is because we want to make sure that our workforce from the ward to the board are involved in ensuring people using our services receive high quality care. This work also links to other related strategies, the operational plan and initiatives feeding into our PRIDE values that become part of our everyday working practices. Our vision with patients at the top is underpinned by our PRIDE values and operational plan with the enabling strategies identified in the triangle on page 5. Our Patient Experience Team work in partnership with our clinical divisions, corporate services and our Patient Partners to ensure that there is a cohesive patient journey through our services. We want this to be as easy and stress free as possible, and provide all service users with avenues to talk to us and engage with their care, from first contact to after care and follow on services. We will work towards making sure that we engage with people as patients who also live and work in our communities so that our first contact is increasing with people outside of the hospital. This means that the Trust will increasingly be a community resource, assisting patients who need care and enabling people to become part of a healthier community and our workforce. Information Management and Technology Strategy Communication and Engagement Strategy Organisation Developement Strategy Equality and Diversity System (EDS2) Nutrition and Hydration Strategy Patient Experience End of Life Care Strategy Dementia Care Strategy Quality and Safety Strategy Nursing Midwifery and AHP Strategy Infection and Prevention Control Strategy 8

9 ENGAGING WITH PATIENTS, USERS AND CARERS Our Patient Experience Team will produce an annual engagement calendar. This will set out the range of initiatives throughout the year where the staff in the Divisions and departments can speak to our service users about the care they have received and the expectations they have of our Trust as we continue to develop our patient experience activities. We also link up with partner service providers to establish opportunities to share engagement platforms to reach the most diverse and vulnerable groups in our communities NHS Choices Engagement events Mystery Shopper Volunteers Friends and Family Test Patient Champions How we engage with our patients, users and carers Patient Stories Complaints User groups within divisions Comment Cards Patient Advice and Liaison Service (PALS) Patient Partnership Council Listening Events 9

10 KEY DRIVERS OF PATIENT EXPERIENCE KEY DRIVERS OF PATIENT EXPERIENCE - THE NATIONAL PICTURE NHS England Five Year Forward View (October 2014) 3 described the ambition of the NHS to introduce a transformational approach to healthcare, and that patient experience plans must include ambitions to: reduce poor experience of inpatient care assess the quality of care experienced by vulnerable groups of patients, and how and where experiences will be improved for those patients demonstrate improvements from Friends and Family Test (FFT), complaints and other feedback deliver all the NHS Constitution patient rights and commitments increase transparency of patient outcomes data to promote choice over where and how patients receive care. The White Paper, Equity and Excellence: Liberating the NHS (Department of Health 2010) 4 highlights the central aim of putting patients and the public first, to offer greater choice and control. This includes shared decision making, underpinned by the principle nothing about me without me. The National Institute for Health and Clinical Excellence (NICE) Quality Standards for patient experience in adult services (February 2012) 5 and service user experience in adult mental health (December 2011) 6. All major policy drivers make it clear that we must carry on embedding good practice in all that we do. The national policy drivers have informed our Trust s approach and listed below is a brief description of key messages: High Quality Care for All (Dept. of Health, 2008) 7 confirms quality as the organising principle behind everything that we do The NHS Constitution (2009) 8 makes clear the public s right to be involved in the decision about the planning and delivery of local services. This will help the NHS to demonstrate that it is responding to the views and experiences of local people The Operating Framework for the NHS in England (Dept. of Health 2011) 9 sets out the case for commissioners and providers to work together to improve the experience of patients, carers and the public NHS Outcomes Framework (Dept. of Health, 2015) 10 Domain 4 ensuring people have a positive experience of care Quality Accounts include progress on measures in CQUIN schemes The Health and Social Care Act (2008) 11 set up the Care Quality Commission (CQC) and made it a requirement to look at people s needs and experiences of care The Accessible Information Standard (2015) 12 aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand with support so they can communicate effectively with health and social care services NICE guideline: Community Engagement (March 2016) 13 improving health and wellbeing and reducing health inequalities March 2016 NHS England (2015) 14 The Ladder of Engagement 10

11 NHS ENGLAND ENGAGEMENT LADDER One of the fundamental areas of the Patient Experience Strategy is the cultural shift of doing to to working with our patients. The engagement ladder is a model from NHS England that is used widely which articulates the journey of patient engagement. It clearly shows the steps where staff can map their services against with a clear journey along the ladder and partner with people using our services. Devolving Placing decision making in the hands of the community and individuals. For example. Personal health budgets or a community development approach Collaborating working in partnership with the communities and patients in each aspect of the decision, including the development of an alternatives and identification of the preferred solutions Involving Woking directly with the communities and patients to ensure that concerns and aspirations are consistently understood and considered. For example, partnership boards, reference groups and service users participating in policy groups. Consulting obtaining community and individual feedback on analysis, alternatives and or decisions. For example, surveys, door knocking, citizens panels and focus groups Informing Providing communities and individuals with balanced and objective information to assist them in understanding problems, alternatives, opportunities, solutions. For example, websites, newsletters and press releases 11

12 THE STRATEGY The three-stranded approach below aims to facilitate a positive patient experience, making the cultural shift from doing to to working with patients and people using services. Contained within each strand are five pledges and each pledge will have clearly defined measurable outcomes to ensure that we are making a difference. We plan to map each outcome against the Darzi Quality framework, asking ourselves if the pledge particularly leads to safer, more effective care or improved patient experience. We want our strategy for improving patient experience to be memorable to patients and staff alike, and believe that having a simple, effective model will help. We will listen and respond to feedback We will ensure that we involve our Patient Partners We will improve information and accessibility Cultural shift 12

13 STRAND 1: WE WILL LISTEN AND RESPOND TO FEEDBACK Listening and responding to user and carer s feedback is essential to improving patient experience. This feedback comes from a variety of ways in both real time and through national surveys. Responding and acting on this feedback in a timely way will bring about change to improve patient experience. Pledge 1 Increase the uptake of Patient Experience Surveys We will encourage more service users to give us feedback by improving and creating new ways of talking to us. We will continue to make changes based on the feedback and improve the positive experience score. Pledge 2 Tell us your story so we can improve We will provide patients with the opportunity to talk about their experiences both positive and negative, through the Tell us Your Story program. We will build on the positive areas and demonstrate improvements where we have failed our patients. Pledge 3 Pledge 4 Pledge 5 More personalised responsive PALS The Patient Advice and Liaison Service (PALS) will provide easily accessible, individually tailored support for patients, carers and family members to personalise care and provide timely response to any enquiries and concerns. Introduce clinicians and staff web pages Individual web pages will be set up so that patients can leave comments, feedback and review care received by individual clinicians. Individualised feedback for staff will provide invaluable areas for celebration and, in some cases, reflection on improvements required. Be outstanding for End of Life Care We will ensure that the family/carers of those patients that are coming to the end of their life are fully consulted and engaged with throughout the final stages of care. Pastoral care and follow up for the bereaved where it s appropriate. 13

14 WE WILL KNOW IT S WORKING WHEN There is a Patient Experience dashboard in place with steadily improving FFT response rates. Increase the positive recommendation for maternity: 99%, inpatients: 97%, outpatients: 97% All divisions have an accessible library of patient stories which are regularly used for training, and available online for staff. The Patient Story is added to divisional induction programs. Divisions can demonstrate improvements by making patient-centeredness business as usual, sharing these patient stories and partnerships There is a reduction in complaints and serious incidents and these are key metrics in the Divisions as well as clear examples of learning from incidents Ensure that care and services are based on user feedback The PALS team are responding to 95% of concerns within 10 days in year one and are providing a personalised service 150 eligible clinical staff are signed up to clinicians webpages in year one Families feedback to us that they were consulted and included in the final stages of care through the bereavement questionnaire 80% of bereaved families will be given a single point of access to address any concerns they have 88% of death certificates are issued within 48 hours. We have good equalities data giving us an understanding of those using our services, so we can map service gaps, respond to any concerns and make sure that everyone is accessing high quality services 14

15 STRAND 2: WE WILL ENSURE THAT WE INVOLVE OUR PATIENT PARTNERS Engaging and co-consulting with our patient partners on all aspects of pathways and service design starts to create a fundamental change in the way we deliver care through The Pride Way. A cultural shift is created from doing to patients to working with patients. Pledge 1 Pledge 2 Pledge 3 Pledge 4 Patient Partnership Council We will form a Patient Partnership Council to ensure that Patient Partners have a voice in our Trust. Hello, my name is In order to drive a culture change where staff recognise the value of first impressions and are happy to be identified and engaged with, we will implement a set of minimum standards for initial contact for all staff in our Trust. Patients are central to all we do We will empower patients to have a voice and take an active role in shaping services for the future, by supporting divisions in their recruitment of Patient Partners to be actively involved in activities within each clinical division and corporate are. Increase the number of volunteers We will grow the number of volunteers across our Trust through engagement events and promotion in our hospitals, online and through social media. Continue to review how volunteers provide added value to the patient experience during their care. Pledge 5 Introduce what matters to me Provide an opportunity for patients to discuss personal priorities for their clinical needs and also ensure that their social/personal needs are also taken in to consideration when planning their care package. 15

16 WE WILL KNOW IT S WORKING WHEN We have a full Patient Partnership Council (PPC) with agreed terms of reference and an annual work plan in place. PPC is able to demonstrate its impact on patient experience All staff are briefed and receive clear guidelines for minimum standards for introductions. Training sessions are added to BEST and 100 % of all staff have received an e-learning briefing by end of year one All divisions can demonstrate that they have patient partners regularly engaged with work stream planning, user group activity and divisional life The number of volunteers working in our Trust increases year on year to 600 active volunteers by end of year three Feedback demonstrates that patients feel confident that their personal circumstances have been listened to and taken in to consideration as far as possible. This will be reflected in an improvement in the National Inpatient Survey. Positive responses to the question Were you involved as much as you wanted to be in decisions about your care and treatment? improving from 70% to 90% by end of year one. 16

17 STRAND 3: WE WILL IMPROVE INFORMATION AND ACCESSIBILITY Many of our patients have difficulty in accessing our services and we aim to provide people who have a disability, impairment or sensory loss with information that they can easily read or understand, and ensure that the facilities and environment take into consideration patient s needs. Pledge 1 Improve adherence to Accessible Information Standard We will ensure that we provide clear information for our patients and their families, to help them understand their treatment and care journey through the hospital. Pledge 2 Improve accessibility for blind and visually impaired service users We will review and improve access for our blind and visually impaired service users, ensuring easy access to vital services to meet individual needs. Pledge 3 Achieve the Deaf Charter Mark We will review and improve access for our deaf and hearing impaired service users ensuring easy access to vital services to meet individual needs. Pledge 4 Improve services for patients with dementia and their carers Our Patient Experience team will continue to work with the dementia care team on elements of the Dementia Strategy. The creation of a dementia-friendly area at Queen s Hospital. Designed in partnership with people with dementia, their carers and relevant partner agencies. Pledge 5 Improve journey and facilities for users with disabilities Service users with disabilities or a learning difficulty are supported in their journey through care. Patients feel empowered to easily and confidently access the services they need. Facilities are improved e.g. adult changing facilities. 17

18 WE WILL KNOW IT S WORKING WHEN Patients have clear information available to them there is an improvement from 78% to 90% by year 3 Blind awareness training programme is developed on BEST and all divisions have named staff who have received it 95% of all patients with a learning disability will have a patient passport Service users with additional accessibility needs tell us that they are able to access services with ease and confidence, and that they feel we are meeting their needs We have achieved the outcomes of the Equality and Delivery System particulary the goal of improved patient access and experience taking into account the particular needs of our vulnerable community groups. Lost appointments are reduced by 25% in year one, 30% in year two and 50% in year three Barking, Havering and Redbridge University Hospitals Trust is recognised by the Dementia Action Alliance as a Dementia Friendly Trust Adult changing facilities are in place at King George and Queen s hospitals RAD Quality Mark Our Trust meets Accessible Information Gold Standard We are recognised externally for improving patient experience. 18

19 DELIVERY AND MONITORING OF THE STRATEGY The strategy will be a publicly available document so our patients, their families and carers will be able to hold us to account. It links into the Quality Account We will use the pledges in this strategy document to populate an action plan for our Trust that will focus on SMART, clearly defined outcomes. These outcomes will aim to put our quality management approach, The PRIDE Way, at the heart of this. The work plan will be a public document so we can be transparent and open in demonstrating our commitment to delivering our targets. The strategy will be launched to all Trust staff through briefing sessions and our intranet. There will be ongoing opportunities for staff and patients to feedback and update us on the Patient Experience Strategy to ensure it continues to be relevant to the needs of our service users. The PRIDE Way The PRIDE Way puts patients at the top of everything we do and as it becomes totally integrated within our culture, patient experience will inevitably improve. However there are a series of key performance indicators that ensure we remain on target to achieve what we have set out to do. The associated action plan will be regularly monitored. Key groups and committees responsible for delivering this strategy: Our Trust s Quality Governance Steering Group (QGSG) is responsible on behalf of our Trust Executive Committee and ultimately the Quality Assurance Group and Trust Board, for monitoring the delivery of this strategy. The Board Assurance Framework will also be able to demonstrate the success of the strategy Our Trust s Patient Experience and Engagement Group is responsible for the delivery of this strategy. It reports directly to the Quality Governance Steering Group, and includes patient representation. Key Groups for Providing Oversight The Quality Assurance Committee of the Trust Board is responsible for ensuring that delivery of the strategy is on track with final oversight from the Trust Board. The divisions and corporate care groups each monitor local delivery of patient experience targets through their own boards and governance groups, and report progress via their QGSG reports and performance meetings. 19

20 A number of sub groups are established, which report to this group on specific work streams. These include: Patient Partnership Council Nutrition Advisory Group Sub groups reporting into Patient Experience Group End of Life Care Advisory Committee Dementia Steering Group Learning Disabilities Working Group Updates are also received at the group. These include: Voluntary Service Mental Capacity Act and Deprivation of Liberty Updates received at Patient Experience Group Mixed sex accommodation Bereavement survey Pastoral and Spiritual Services Divisional updates 20

21 CONCLUSION Successful implementation of the strategy will enable the following outcomes More than 97% of inpatients would make a positive recommendation about our Trust to friends and relatives. Service planning and delivery within divisions is able to demonstrate active engagement with patients and show positive action in response to views and feedback. Early detection of poor performance enables our Trust to take action and avoid subsequent poor care. Trust compliance with CQC Essential Standards for Safety and Quality. A reduction in the number of formal complaints received by our Trust. 21

22 CONSULTATION We shared our strategy through all stages, from its first draft to being finalised. This was to ensure we were getting real time feedback from our service users, our partner organisations and community groups. We want to make sure our strategy for involving patients and improving their experiences whilst our care is relevant to the people that should benefit the most from the pledges we are making. Havering Sight Action AGM Havering College Listening Event Visitors to Queen s Hospital Visitors to King George Hospital Equality and Diversity Standard volunteer consultation group HealthWatch All three feeder borough HealthWatch organisations Patient Partnership Council Havering Carers event at the YMCA Public Consultation at King George Hospital as part of Fab Change Day Redbridge Overview Scrutiny Committee Redbridge Concern For Mental Health 22

23 REFERENCES 1 Barking Havering & Redbridge University Hospitals Operational Plan (February 2017) 2 A Leadership Journey in Health Care: Virginia Mason s Story (August 2015) 3 NHS England Five Year Forward View (NHS England October 2014) 4 The 2008 Darzi NHS Next Stage Review (Department of Health 2008c) 5 Equity and Excellence: Liberating the NHS (Department of Health 2010) 6 Quality Standards for patient experience in adult services (National Institute for Health and Clinical Excellence February 2012) 7 Quality Standards Service user experience in adult mental health services (National Institute for Health and Clinical Excellence December 2011) 8 High Quality Care for All (Department of Health 2008) 9 The NHS Constitution (NHS England 2009) 10 The Operating Framework for the NHS in England (Department of Health 2011) 11 NHS Outcomes Framework (Department of Health 2015) 12 The Health and Social Care Act (Department of Health 2008) 13 The Accessible Information Standard (NHS England 2015) 14 Community Engagement - improving health and wellbeing and reducing health inequalities (National Institute for Health and Care Excellence March 2016) 15 The Ladder of Engagement (NHS England 2015) 16 The Equality and Delivery System EDS2 (NHS England 2013) 23

24 We will listen and respond to feedback APPENDIX ONE: STRATEGY ACTION PLAN Strand 1 Action Lead Year 1,2,3 RAG There is a Patient Experience dashboard in place Head of Patient Experience April Year 1 Our patient survey shows divisional targets for Divisional Triumvirate March completion are being met and an increase in positive Year 3 recommendation to maternity: 99%, inpatients: 97%, outpatients: 97%, A&E: 95% - placing our Trust in the top 10 organisations nationally There is a reduction in complaints and serious incidents and these are key metrics in the Divisions as well as clear examples of learning from incidents Complaints Manager Deputy Chief Nurse Quality and Safety April Year 2 Ensure that care and services are based on user feedback Divisional Triumvirate June Year 1 The PALS team are responding to 95% of concerns within 10 days in year one and are providing a personalised Head of Patient Experience June Year 1 service 150 eligible clinical staff are signed up to clinicians Medical Lead for Patient March webpages in year one Families feedback to us that they were consulted and included in the final stages of care through the bereavement questionnaire 80% of bereaved families will be given a single point of access to address any concerns they have, increasing to 95% by year 3 88% of death certificates are issued within 48 hours, increasing to 90% in year 3 Patient Experience Team and OD team have combined robust metrics for equality data. Experience End of Life Care Team Year 1 March Year 2 Bereavement Team June Year 1 March Year 3 Bereavement Team MarchYear 1, OD and Patient Experience Team March Year 3 March Year 1 24

25 We will ensure that we involve our patient partners Strand 2 Action Lead Timeframe Y 1,2,3 We have a full Patient Partnership Council (PPC) with Head of Patient Experience April agreed terms of reference and an annual work plan in Year 1 place. PPC is able to demonstrate its impact on patient experience All staff are briefed and receive clear guidelines for minimum standards for introductions. Training sessions are added to BEST and 100 % of all staff have received an e-learning briefing by end of year one All divisions can demonstrate that they have patient partners regularly engaged with work stream planning, user group activity and divisional life The number of volunteers working in our Trust increases year on year to 600 active volunteers by end of year three Feedback demonstrates that patients feel confident that their personal circumstances have been listened to and taken in to consideration as far as possible. This will be reflected in an improvement in the National Inpatient Survey. Positive responses to the question Were you involved as much as you wanted to be in decisions about your care and treatment? improving from 70% to 90% by end of year one. Associate Director Education and Training Divisional Triumvirate Volunteer Services Manager Divisional Triumvirate March Year 1 March Year 3 March Year 3 March Year 1 RAG 25

26 We will improve information and accessibility Strand 3 Action Lead Timeframe Y 1,2,3 All divisions have named staff who have completed deaf Divisional Nursing Teams March awareness training, available on BEST Year 2 Blind awareness training programme is developed on BEST and all divisions have named staff who have received it 95% of all patients with a learning disability will have a patient passport Service users with additional accessibility needs tell us that they are able to access services with ease and confidence, and that they feel we are meeting their needs Lost appointments are reduced by 25% in year one, 30% in year two and 50% in year three Barking, Havering and Redbridge University Hospitals Trust is recognised by the Dementia Action Alliance as a Dementia Friendly Trust Adult disability changing facilities are in place at King George and Queen s hospitals RAD Quality Mark is achieved for both Queen s and King George Hospitals Our Trust meets Accessible Information Gold Standard We are recognised externally for improving patient experience We have achieved our Equality and Delivery System (EDS2) Patient Experience Team Learning Disabilities Liaison Nurse Learning Disabilities Liaison Nurse Head of Outpatients Dementia Team Learning Disabilities Liaison Nurse March Year 2 June Year 3 March Year 3 March Year 3 March Year 2 March Year 2 Head of Patient Experience March Year 3 Deputy Chief Nurse Patient June Experience Year 2 Head of Patient Experience March Year 3 Head of Inclusion March Year 2 RAG 26

27 APPENDIX TWO : STRATEGY WORKPLAN SUMMARY The Patient Experience & Involvement Strategy was accompanied by an action plan detailing the ten strategic aims that were set out in the strategy document. Below is a summary of the progress against each of the aims. The action plan was last updated in February 2015 STRATEGIC AIM 1 Communication & First Impressions The Trust will continue to develop staff guidance on the importance of customer care and excellent communication skills. 1.2 The Trust will consult, engage and discuss its work with groups such as Local Involvement Networks (LINks), Local Authority Health Overview & Scrutiny Committees (OSC), and work with regulators, national patient organisations and other external stakeholders and user representatives. This work will include consultation and campaigns for specific areas of service development. STRATEGIC AIM 2 Cleanliness & the Environment 2.1 The Trust aims to achieve a score of good or excellent in all categories and across all Trust sites for the annual Patient Environment Action Team (PEAT) assessment. PROGRESS A comprehensive cultural change programme was developed and implemented to support the mission, vision, values and behaviours agreed by the Board in The principles of the programme are being integrated into existing programmes and incorporated into newly commissioned programmes. In 2013 the Board and Executive Team developed a behavioural acronym of P.R.I.D.E - Passion, Responsibility, Innovation, Drive and Empowerment, to represent the behaviours we, as an organisation, need to practice to deliver our Vision, Mission and Values for our patients, service users and staff. Since 2013 PRIDE workshops have been delivered to 800 key managers and influencers, and rolled out to all staff. Programme of work to engage with key stakeholders has been embedded. Regular meetings are held with Healthwatch groups, politicians, IPEG and Redbridge OSC. A monthly electronic stakeholder newsletter is sent out to hundreds of local stakeholders. Annual public meetings continue. PROGRESS PLACE assessments are separate from other systems such as Health Watch s Enter and View assessments of the Care Quality Commission s survey and monitoring processes. These assessments are annual snapshots that provide hospitals with a clear picture of how their environment is seen by those using it and how they can improve it. These assessments are carried out by people who use the hospital - patients, relatives, carers, visitors or advocated and are supported by hospital staff. A Quality of Care programme is carried out weekly and 27

28 2.2 Close contract monitoring will be used to ensure the provision of clean facilities that meet and maintain the National Standards for Hospital cleanliness. The involvement of senior level staff aims to foster a culture where the Hospital environment is everybody s responsibility. 2.3 Roles and responsibilities for cleaning will be clarified through the development of a ward/department Service Level Agreements (SLA). 2.4 The Trust will work in partnership with the Local Involvement Networks (LINks) and Patient User Groups to identify and implement areas for improvement. STRATEGIC AIM 3 Infection, Prevention & Control 3.1 The Trust will maintain its Registration against the Hygiene Code. 3.2 A comprehensive Trust Infection Control Strategy will be developed and implemented Trust wide. 3.3 Trust stretch targets will be set internally for the reduction in the number of healthcare associated infections to facilitate incremental improvements over and above those expected by external monitoring bodies. 3.4 An annual Infection Control report will be made available to the public to demonstrate public transparency. includes an audit of the environment monthly. If any areas of concern are highlighted this is escalated accordingly - ward issues to the Senior Sister, cleaning issues to the Senior Sister and Sodexo, and repairs to Works Department. Quality of Care programme is carried out weekly and includes audit of the environment monthly. If any areas of concern are highlighted then this is escalated to appropriate staff. Matrons also link with Sodexo environment audits within their own areas. The Cleaning Matters initiative has been rolled out at both Queens and King George Hospital, the aim of this is to support the operational needs of the wards with improved communication. The Operational Service Plans for both hospitals has also been completed. IPC Team undertakes environment audits which are reported to Senior Sisters, Clinical Governance officers, Matrons and Service Managers, including Estates department, Sodexo (at Queen s hospital) and House-keeping staff (at KGH) to comply with to rectify shortfalls. An action plan is produced by Senior sisters/charge Nurses as necessary. Trust Meetings with LINks are held quarterly. In attendance are the Trust s CEO, Director / Deputy Director of Nursing. BHRUT s Improving Experience Group (IPEG) has patient users as members. LD patients/carers are members of the Trust s LD Group. PROGRESS QoC: Monitored weekly by local matrons in relation to safety checklist compliance and reported monthly across the Trust. Areas of non-compliance followed up with wards and Matrons. IPC Annual Plan is in place and reviewed at the Infection Prevention & Control Committee. Further information on this and other policies are available on the Intranet. Targets have been set by the cluster and the Trust actively monitors these. Review meetings of any ward outbreak of infections take place. Information reported to the Infection Prevention & Control Committee. Annual report signed off at Trust Board. 28

29 3.5 The Trust will maintain an infection control Risk Register to enable close monitoring of any infection control or prevention issues that require specific targeting. 3.6 Infection control training needs will be reviewed annually to ensure that appropriate training is given to staff that is commensurate with their roles and responsibilities. STRATEGIC AIM 4 Essence of Care / Fundamentals of Care 4.1 The Trust will ensure that the delivery of patient care will be at the highest possible standard and meet the 10 point Dignity Challenge. 4.2 The Trust will ensure that all patients have same sex accommodation in line with National (DH, 2010) and Trust Policy. 4.3 The Productive Ward & Productive Theatre programme will be rolled out across the Trust. 4.4 The Synbiotix system will be rolled out across the organisation Updated and reported to the Infection Prevention & Control Committee. The annual plan for education has been approved by the Infection Prevention & Control Team who reviews compliance every 6 months. In place. PROGRESS A Privacy & Dignity Leaflet has been produced, and is available on the Trust internet site. Quality of Care audits which are focussed on the fundamentals of care, are carried out weekly. Any issues are raised immediately with the nurse in charge. Results are monitored and discussed and any recurring issues or themes are addressed. Quality, Effectiveness & Safety Trigger Tool (QUESTT), which identifies the potential for deteriorating standards in the quality of care delivered by a team in a defined area has been implemented and is conducted monthly by a Senior Sister/Charge Nurse. Pressure Ulcers & Falls are considered at SI Panels, chaired by the Deputy Directors of Nursing. Breaches are monitored and reported to the Trust Board monthly. Audits monitoring quality are carried out weekly across the Trust as part of the quality of care programme. All wards are participating in the Productive Ward programme. Sustainability was recognised nationally as an issue, so the Trust created a programme which focused on a theme per month based on the productive ward modules. This programme has concluded. The Productive Theatre programme started in January 2011 and progressed through the foundation modules. The initiative is no longer in progress, although the changes made are embedded. The Synbiotix system will form an overarching monitoring programme which will involve daily monitoring, which will form part of the Ward to Board process. 29

30 4.5 Essence of Care Benchmarks will be rolled out across the organisation. STRATEGIC AIM 5 Patient & Public Involvement, Engagement & Feedback 5.1 The organisation will support staff in recognising and overcoming patient access barriers for people with communication, physical and/or sensory impairment by the delivery of translating and interpreting services and access to other support options such as large print documents, Braille, hearing loops or signing. Following implementation of the Synbiotix system, an audit tool will be devised using the Essence of Care benchmarks to enable ward staff to monitor and improve clinical care in their wards/departments. Staff information on intranet. PROGRESS Details of how to access interpreting services displayed on wards. Easy-read leaflets have been produced, and are available on the Intranet. 3-way interpreting telephones on wards. Laminated signs to indicate sensory impairments on all wards. Deaf Awareness Training available for all staff. Development of a deaf awareness top tips video which is on the Trust intranet and website. Also developed into a top tips poster which is displayed in common staff areas. Interpreting service available within the Trust. Trust signage has been reviewed and changed. 5.2 The Trust will work with nominated leads to develop strategies that will improve the capacity for communities, users, carers, and in particular, those groups who are seldom heard to participate in service planning and delivery initiatives. 5.3 BHRUT will maintain effective links with partner organisations to improve seamless care in the local health community, to share learning and assist the spread of good practice. Participation in the Local Improvement Networks (LINks), Local Authority Health Overview & Scrutiny Committees, The IPC Team has produced pictorial and colourful isolation door signage for improved communication and guidance. The QH site has been completed. The KGH site is currently underway (as at 16 Jan 2015). Patient representatives attend the Trust s IPEG, LD Group. Deputy Chief Nurse attends Overview & Scrutiny Meetings. Regular meetings are held with LINks/Overview & Scrutiny Committee members. Director/Deputy Director of Nursing members of Local Borough Safeguarding Children & Adult Boards. 30

31 Partnership Boards etc, will be a vital part of achieving this aim. 4 The Trust will maximise and consolidate the effectiveness of Trust volunteers. Volunteers are interviewed and placed in a department where they would be most suited to the role. Volunteers are required to attend Trust Induction prior to commencement. Local inductions undertaken by the department where the volunteer is placed. Volunteers receive ongoing training in the department relevant to their role. Volunteers help in various departments, for example wards, outpatient clinics, information desks, welcomers, befrienders/hospital visitors, chaplaincy and cancer services. The duties vary and may involve making refreshments for patients, directing and escorting patients, answering enquiries, running errands for the staff or helping with admin duties. On-going work by volunteers includes: Visiting wards with low response rates for patient surveys. Volunteers assist patients with filling out surveys, taking the responsibility off staff. Furthermore, there are posters which are updated every month with the latest patient feedback data for each ward which volunteers deliver and install in staff rooms. 5.5 The Trust will ensure that public and patient involvement elements from action plans arising from Local and National patient surveys, NHS Choices, service reviews or accreditation visits are developed, implemented, monitored and reported upon. National Inpatient Survey results & actions monitored at the Trust s Quality & Safety Committee. Complaints, PALS, NHS Choices, and Comment Card results reported in a quarterly Patient Experience Report which is discussed at the Trust s Quality & Safety Committee. Results of Patient Experience Questionnaires (including FFT) completed by patients prior to discharge are analysed and sent to wards/departments weekly. The FFT results are displayed on FFT Boards on the Ward/Department. Action plans in place. Patients are asked to complete a patient experience questionnaire on the day of discharge. This incorporates the National Friends & Family Test. (FFT) question. Following an analysis of completed questionnaires, the results are circulated electronically to all clinical areas. FFT is completed in Adult Inpatients, A&E, Maternity, Day Surgery Units and Paediatrics and OPD. The Trust has introduced the patient survey in the most commonly requested top 10 languages, a braille version and easy read versions. Complaints, PALS, enquiries, NHS Choices information triangulated and included in a bi-monthly Patient Experience Report which is present at the Trust s Quality & Safety Committee. 31

32 STRATEGIC AIM 6 Patient Information 6.1 A comprehensive range of high quality information and materials will be made available locally to patients in a variety of formats, free at the point of delivery. The Trust will also make arrangements to ensure provision of suitable information for black and ethnic minority groups and people with hearing, sight, speech and learning disabilities. 6.2 Clinical staff will ensure that patients and carers are able to discuss information in a private environment, with the support needed to cope with its emotional impact. STRATEGIC AIM 7 Spiritual & Pastoral Care 7.1 Patients and their carers will be offered access to different forms of spiritual support, appropriate to their needs through the services offered by the Trust s Chaplaincy Team and access to Prayer Rooms catering for different faiths. 7.2 Patients will be given opportunities for their spiritual needs to be assessed at various points in the patient pathway, ensuring that spiritual elements of illness are taken into account. 7.3 Spiritual care for patients and their carers will be developed to become an integral part of the Trust s care and will be open to similar levels of scrutiny and supervision as other aspects of non-physical care. The PROGRESS Information centres are available in the foyers of both Queen s and King George Hospitals and regularly replenished. EIDO leaflets have been promoted to staff, together with awareness of the Trust s patient information policy, together with Clinical Governance who hold the contract for EIDO. Patient information for a wide variety of conditions and needs is available via the Information Centres. The Trust s new website has full integration with nationallyapproved information via NHS Choices. This means that high quality information on virtually all medical conditions and aimed at all groups is available via our new website, side-byside with information on services. Users/Carers for LD are members of the Trust s Learning Disability Group. Easy read leaflets for Complaints & PALS are available. Quiet areas are used as and when necessary. PROGRESS There is a multi-faith prayer room; St Luke s chapel and KGH Multi Faith prayer room which are open 24/7. The Trust uses Volunteers who are Muslim, Sikh and Jewish. They can be contacted via the Chaplaincy Department. Chaplaincy Volunteers support the Trust s Chaplaincy team and conduct ward rounds to speak to patients and their families. The Chaplaincy Department continues to offer training to all staff around spiritual assessments. Chaplains take part on the mandatory training for HCA s, RN and Dr s. Spiritual & Pastoral Care Training has taken place in Critical Care areas both at Queen s and King George Hospitals. Currently the Spiritual & Pastoral Department are using their own in-house patient tracking system. Figures for number of patient episodes, staff support, number of call outs, description of work, and multi-faith data are provided monthly to management. Quarterly figures are included in the Trust s Patient Experience Report. 32

33 Chaplaincy Team will develop mechanisms for monitoring and reporting on the use of their service. STRATEGIC AIM 8 Services for Families & Carers 8.1 Family members and carers needs will be assessed, acknowledged and addressed as a routine part of the nursing and medical assessment processes. Family members and carers should be offered the opportunity for their needs for support and information to be assessed separately from those of patients. 8.2 Adequate training and education will be provided for staff, relative to their role and responsibility, to ensure they are competent to identify, assess and take appropriate action in relation to the care of vulnerable adults and children. STRATEGIC AIM 9 End of Life Care 9.1 To ensure all relevant clinical staff are aware of the Priorities for Care of the Dying Person as formulated by the Leadership Alliance for the Care of Dying People June Patients will be offered their choice of end of life care. The Trust aims to increase the number of patients who wish to die at home in doing so. STRATEGIC AIM 10 Bereavement Care 10.1 The Trust will comply with the Department of Health s - Advice on Developing Bereavement Services in the NHS. Spiritual & Pastoral Care Annual report is produced. PROGRESS A Quality of Care programme is carried out weekly and includes audit of care as well as gathering qualitative data regarding patients feelings and perceptions on care, privacy and dignity, nutrition, discharge planning. If the patients are unable to partake in this audit then the relatives are encouraged to assist and express their perception of the fields being audited. The inclusion of the Band 6 Sisters have enabled compliance to be maintained through raising their awareness/appreciation of the process. Training Needs Analysis (TNA) & Strategy approved and in place for Safeguarding Adults & Children. Safeguarding training compliance reviewed monthly, and reported at the Safeguarding Children s & Adults Operational Group and Safeguarding Strategic & Assurance Group. Weekly Safeguarding training day held as part of the Trust s Mandatory Training Programme. PROGRESS Two End of Life Care Facilitators are in post and are providing an education programme for implementation of the Individualised End of Life Care Plan. Refer to End of Life Care Advisory Board Action Plan. Refer to End of Life Care Advisory Board Action Plan. PROGRESS Bereavement Policy has been ratified and is on the Trust Internet. Bereavement booklet in place. Usage to be audited via the bereavement questionnaire which has been piloted on Mandarin B ward. 33