Action Plan 2013 Date Created 6 th October 2014 Plan Owner : Executive Lead Kevin Marsh Operational Lead Katherine Allen (Head of Communications and Patient Experience) Date last updated : (and version no) Draft 1 07.11.14 Core implementation Group :?Katherine Allen, Head of Communications and Patient Experience Bennion, Assistant Director of Nursing Sarah James, Head of Safety and Quality Kevin Marsh, Director of Nursing, Assistant Director of Nursing Next review due by - Group / Committee : Date : Learning from Patient Experience Group Links to key documents Link to Corporate Risk Register Risk ID Initial Risk Score CxL = Target Risk Score CxL = Driver 1. Admission to hospital Patient information and number of cancelled operations Improved National Inpatient Survey score; positive comments via Friends and Reduced number of changes to admission date 1.0 1.1 1.2 Review the provision of regular and updated information given to patients about their condition and/or treatment in A&E. Review the reasons for the number of times there have been changes of admission dates by the hospital particularly where these occur twice or more Ensure specialists are given all the necessary information about Reporting of changes of admission date Understanding of the extent and specificity of this issue Lead Clinician & Senior Nurse Emergency Department Robert Sainsbury, Thomson, 31/12/14
A small number of patients still perceive these to be mixed gender facilities in use Reduction in numbers of reported breaches and improved perception of patients in the National Inpatient Survey 1.3 a patient s condition or illness from the professional who referred the patient Continue to review progress on eliminating mixed gender rooms, bays and bathroom facilities. Environmental layout in some areas Bennion 2. Hospital and ward based experience Levels of noise, cleanliness and food. A significant number of patients rate food Improvement from 2012 to 2013 is continued and improved further. Results at Partnership Forum show continued improvement in cleanliness. Infection control audits evidence that gels are available at all bed spaces. Reduced negative comments about food via Friends and 2.0 2.1 2.2 2.3 Revisit SHUSH campaign. Measure noise levels to ensure that staff are aware of actual levels and can take action where needed Continue to review the cleaning contract for both wards and bathroom facilities ensure that there is a clear line of responsibility for this. Ensure that hand wash gels are visible and available for staff and patients. Ensure that lines of responsibility are clear for monitoring dispensers. Senior Nursing team to test food quality, temperature, timing of Environmental layout on many wards None Bennion and Iain Roy, Director of Facilities Fiona Baker and Jan West Bennion and 30/12/14 30/01/15
as only fair or poor. food arriving and the operation of the catering contract 16% patients reported not receiving help with feeding. 3. Doctors and patient understanding & involvement in decisions Survey results typically show that up to a fifth of the patients do not fully understand answers to questions given by doctors. Some patients report lack of involvement in conversations 4. Involving patients in discussions Some patients would like to be more involved in decisions supported by lack of negative comments in Friends and. supported by lack of negative comments in Friends and. Reduced complaints about understanding of clinical treatment. supported by lack of negative comments in Friends and. 2.4 3.0 3.1 4.0 Look at staff availability and ensure that suitable staff are available when needed. Undertake spot checks to ensure this is happening Further address communication issues between doctors and patients through the training and induction of junior staff; Further ensure that patients are acknowledged and included in all conversations which are around them and their care. Continue to review methods by which staff can involve patients in decisions about their care and treatment. 31/01/15 Thomson Thomson Thomson and Kevin Marsh
made about their care. 5. Explanations and involvement in decisions. 6. Involvement and information about discharge from hospital 12% patient felt excluded from decision 60% patients delayed on discharge reported a delay waiting for medicines Only 66% of patients report receiving written information; 78% report receiving a verbal explanation No patient would report via NIPS that this was not explained. Patient flow group agreed measures to address; score for 2014 is improved; reduced Friends and comments about medicines delay 5.0 6.0 6.1 6.2 Ensure that patients are given as much information and explanations as they want about what the operation would entail, before, during and after, including anaesthesia and its effects. Question prospectively the extent to which patients feel involved in decisions about their discharge from hospital; implement improvement plans to address findings. Review the way in which discharge medication is ordered and delivered to the patient with a view to reducing delays or improving efficiency of the process Review provision and clarity of information that is given to patients about the medication side-effects to watch for and what to do if they are worried Thomsontor Robert Sainsbury and Niall Ferguson
23% patients said their family had received no information 19% of patient report they did not receive this information 11% of patient report not having the opportunity to discuss on-going needs. 7. Information about to complain 59% of patients report not seeing information about how to complain 6.3 6.4 6.5 6.6 7.0 Continue to review how patients are given information about danger signals to watch for after discharge, and review the clarity of that information including what to do if they are concerned or worried Continue to review the extent to which clinical staff provide the patient's family with adequate information about caring for the patient Continue to ensure all patients are given verbal and written information about who to contact if they are worried about their condition or treatment after returning home Ensure hospital staff discuss with patients any on-going needs they may have after leaving hospital. Check each ward and ensure information about how to complain is readily available for patients 30/3/15 Sarah James 31/12/14
Name Bennion Sarah James Fiona Baker Jan West Robert Sainsbury Thomson Niall Ferguson Iain Roy Kevin Marsh Job Title Assistant Director of Nursing (Community) Assistant Director of Nursing (Acute) Head of Patient Safety and Quality. Lead Infection Control Nurse (North) Lead Infection Control Nurse (North) Director of Operations Medical Director Director of Pharmacy Director of Facilities Director of Nursing tracking Complete Green G On plan Blue B Risks slippage Amber A Barriers not achieved Red R