Annual Complaints Report For the Period 1st April 2014 31st March 2015 1
Contents Page 1 Introduction 3 2 Definitions 4 3 Activity and Performance 5 4 Listening, Learning, Reviewing, Improving 12 5 Priorities for 20-14/15 14 6 Conclusion 16 Appendix A Corporate Objectives 2015/16 17 2
1. Introduction This report summarises complaints activity and performance at Tameside Hospital NHS Foundation Trust (THFT) for the year 1 st April 2014 to 31 st March 2015. The report also highlights improvements to services that have been implemented as a direct result of complaints and outlines plans for the next 12 months. The Keogh Report (2013) highlighted a number of failings across NHS Trusts and made a number of important recommendations to ensure an accessible and responsive complaints process. These recommendations included more detailed Board level scrutiny of actions taken as a result of complaints; better support for complainants throughout the complaints process; publicising the complaints process more widely; and more detailed scrutiny of NHS complaints processes by the Care Quality Commission (CQC). We welcomed these recommendations and, in response have made significant improvements within our Trust with regards to how our complaints process works. These improvements can be seen throughout this report. However we are still on a journey and there is more to do. During the period 1 st April 2014-1 st March 2015 we received 532 formal complaints and responded to a further 2408 informal concerns or complaints which were out of time or did not meet the NHS reports criteria. The number of complaints and concerns received accounts for less than 0.67% of the number of patient contacts, which totalled over 433,163 during the reporting period. We have continued to welcome, listen to and act on all aspects of patient feedback. There are a number of posters advising how to raise concerns, not only on the Wards but at the entrances to the hospital. We have complaints leaflets in public areas and an easy to read version for people who less literate. Ward staff are encouraged to try and resolve complaints at ward level, where this is not possible they can direct patients/families to the PALS and Complaints Team. An Advice Desk at the entrance to the Hartshead Building and offers support and advice which includes directing any complaints to the relevant department if needed. There is a full page on our website where complainants are directed to advice on how to make or resolve complaints and information as how to do this. An internet complaints form can be submitted by email. A dedicated email address and telephone number is available and training has been provided to staff in supervisory roles to promote the service across the Trust. The team have recognised the benefit from having a log of all areas where literature on complaints is provided on the main Trust Site and has a monthly walk around of these areas to ensure that the information is visible and readily available. The priorities for the complaints service for 2014/15 Progress against last year s priorities is covered throughout the report. The Trust s Corporate Objectives are detailed in appendix A. Our priorities were: Improve response times to ensure patients and families receive a timely response. Review the Trust s complaints policy Improve the support within Clinical divisions to ensure that deadlines are met with regards to complaint responses. Further strengthen our service by providing training for staff who are directly involved in complaints handling. Further strengthen our PALS and Complaints Team with additional staff and support. 3
2. Definitions Throughout this report formal complaints are referred to as complaints and these are managed through the Trust s complaints process. The term concerns is used in relation to informal concerns which are managed and resolved either on the spot, at a local level or complaints which do not meet the criteria of the NHS complaint regulations or are out of time. We record and respond to all concerns and complaints irrespective of how they are presented; whether this is in writing, in person, over the telephone or by email. Complaints made verbally but not successfully resolved within an agreed timescale, and those made in writing or electronically, such as by email, are acknowledged within 3 working days. This will normally be done in writing unless under exceptional circumstances. Acknowledgements to all concerns are sent by a member of the Complaints & PALS Team. For any complaint raising issues that require a more detailed investigation these are managed formally, in accordance to the Trust s Complaints Procedure. All Concerns and Complaints are recorded and managed in the following ways:- Informal Concerns Informal concerns which cannot be resolved locally on the spot are usually managed through our Patient Advice and Liaison Service (PALS) These are usually concerns, queries or requests for information which do not require detailed investigation, but which may require guidance, signposting or information. These issues are recorded and dealt with on the spot either by our PALS & Complaints team or by a relevant member of staff who is able to offer appropriate information. If the matter is not resolved to the enquirer s satisfaction within then the concern is managed as a formal complaint. Some informal concerns are considered to be too significant not to investigate and these are reviewed by a Senior Manager and Senior Nurse and if appropriate are investigated as a complaint would be. Complaints The Trust will investigate a complaint in a manner appropriate to the nature of the issues it raises; we aim to resolve all complaints speedily and efficiently and, during our investigation, keep the complainant informed, as far as reasonably practicable, as to the progress of the investigation and any delays. Each complaint is triaged and graded by a Senior Officer in the Quality & Governance unit or a designated Senior Manager. This helps to determine the level of investigation required and whether any additional actions need to be taken, such as a Serious Incident Review by Root Cause Analysis, or liaison through HM Coroner or involvement of the Trust Safeguarding Team. A timeframe is communicated with the complainant at start of the investigation this is a means of setting a realistic timescale given all the circumstances which may arise the Trust still aims to resolve the majority of complaints in 25 working days though for complex cases this may be 45 working days or more if investigation or Root Cause Analysis is required. We have aligned our complex investigation process to national incident reporting timescales to ensure consistency. Our focus is to provide a quality, thorough open candid investigation and response which sometimes may necessitate a longer time period. We were previously criticised by Keogh (2013) for not doing this. 4
3. Activity & Performance This section provides an overview and a more detailed breakdown of key performance and activity data for 2014/15. It includes the number of complaints received, the number of complaints closed, response times and a breakdown of the subjects most frequently raised in complaints. Plans for improving performance for 2015/16 are detailed in Section 5 of this report. During 2014/15 the Trust has been in Special Measures with new leadership and direction following the Keogh Review (2013). We have implemented and embedded changes to the complaints process to be more responsive to patients concerns. We have in addition been subject to a CQC Chief Inspector of Hospitals inspection with additional public scrutiny and engagement and listening events which identified issues that have been managed through the written complaints process. We have therefore identified complaints which previously went unreported and have responded to an influx of complaints in the periods following regulatory inspection. The Trust has had 7 cases referred to Parliamentary Health Service Ombudsman in 2014/15 compared to 7 in 2013/14. These cases predominately related to care and handling of care occurring in the preceding year s pre Keogh and our improvement journey. In summary, the Ombudsman has requested that the Trust take action in the majority of cases and requested financial redress in three of these. Where cases have been upheld these are summarised later in the report, as are the actions required or taken. 3.1 Overview Table 1: Activity and Performance Data Number of complaints received Number of complaints closed Number of complaints received in writing* Number of concerns received** 2012-13 2013-14 2014-15 403 450 532 35 393 612 403 412 495 1785 2229 2403 Complaints concerning THFT n/a 7 7 reviewed by the PHSO Complaints concerning THFT upheld by the PHSO n/a 2 3 * The number of complaints received in writing is reported to the Department of Health in the annual K041a complaints monitoring return. Whilst the number of complaints reported to the Board increased to 532 from 450, 495 of these complaints were reportable in the Department of Health KO41 report, with the others being concerns and issues we have investigated outside the complaints regulation reporting requirements to ensure candour and rigour. Key points to note from the data are as follows: The data recorded highlights a 9% increase in the number of complaints and concerns combined this year. This is reflective of our post Keogh improvement action to improve our recording and oversight Trust-wide. The number of complaints closed decreased by 7% in 2014/15. The number of complaints concerning this Trust that were reviewed by the PHSO remained consistent with those reported in the 5
previous year. Three complaints were upheld by the PHSO following their investigations. 3.2 Complaints and Concerns Received The graph below shows the number of concerns and complaints received by month during 2014/15. This demonstrates the considerable fluctuations which can occur from month to month: Table 2: Complaints and Concerns Received by Month 3.2.2 Complaints Received by Method A breakdown of the number of complaints received by method is provided below for 2013/14 & 2014/15. Table 3: Breakdown of Formal Complaints Received by Method 2013/14 Telephone 5% Email 34% *The dotted line represents anticipated trend Whilst there are some months where lower or higher activity occurs each year e.g. lower numbers received in December, complaints activity can be unpredictable but can be related to factors such as Trust activity. 2014/15 Letter 60% In Person 1% 3.2.1 Complaints and Concerns Received by Care Group The graph below shows the number of complaints and concerns received during 2014/15 by Directorate. Elective Services and Medicine and Emergency Services received the most complaints and concerns this was to be expected as they are the two biggest divisions within the Trust. The complaints and concerns raised within these divisions accounted for 58% of the overall number received. Table 4: Number of complaints and concerns received by Division 2014/15 The 3 main methods used to raise complaints are email, telephone and letter. Writing a letter continues to be the most popular method used to complain, however the percentage of complaints received by letter has fallen slightly since last year from 60% to 58% An increase can be seen in the number of complaints being made by telephone (5% to 14%). The increase in telephone calls could in 6
part be due to all concerns coming through one telephone number to the PALS & Complaints department now and then being triaged accordingly where historically this was split into two areas (formal/informal). The amount of complainants who are opting to get in touch by e- mail (34% to 27%) has reduced slightly. People complaining in person has remained consistent over the two year period- It was previously noted that sign posting to the PALS & Complaints service in some areas could be improved therefore this figure may be reflective of the assertive work that has taken place regarding this. Table 5: Complaints as a Proportion of our Activity The table below shows the proportion of complaints and concerns received over the last 3 years per 1000 patient contacts: Complaints Recorded Complaints per 1000 Contacts PALS Concerns Received PALS Concerns per 1000 Contacts 2012/1 3 2013/14 2014/15 403 450 532 1.15 0.95 1.11 1785 2229 2404 5.09 4.65 5.06 The increase in our response times has been part of our improvement plan and we have worked hard to make a significant reduction in the backlog of historical complaints in the system. We have also seen a reduction in the number of comeback letters received as a result of improvements made to the way we handle complaints and concerns. The Trust does however recognises that we still need to make further improvements with regards to completing complaints investigations and responding to patients within the initial agreed timeframes. Table 7: Complaint Response Times and Performance Achieved by Month The number of complaints per 1000 contacts received in 2014/15 has increased to 1.11 compared to 0.95 reported in 2013/14. The increase in the number of recorded complaints is apparent, but so also is the in activity in the Trust during the time period covered. Activity overall has increased by 4.6% from 2013/14 3.3 Complaints and Concerns Closed This section provides a breakdown of information relating to complaints completed during 2014/15 3.3.1 Response Times The chart below demonstrates our continued improvement in our response times during 2014/15 which has risen steadily from 43% to our agreed target of 90%. The chart above highlights that from April 2014 there was a focus on responding to and addressing the overdue complaints for which we were previously criticised. During this time we experienced a month when a high number of complaints were closed. The chart below identifies the progress made since the Keogh Report 2013. Table 6 : Responses agreed in timescale 7
Table 8: Ongoing Complaints 3.3.2 Response Times by Care Group It is important to review performance at this level in order to identify areas performing well and any problem areas. A summary and breakdown of performance at Divisional level is provided in table 7. 3.3.3 Response delays - how we are improving this Delays in receiving investigation responses from staff have been a contributory factor to the historic backlog of complaints for which we were previously criticised. The instability in Divisional leadership and management has contributed to this in a period of change. Delayed responses from Medicine & Emergency Service and Elective Services (the 2 areas who receive the highest number of complaints) had been identified as a key area of concern. The commissioning of complaints investigators to support the Divisions has proved successful in addressing the historic backlogs of complaint responses and an improvement in performance is now evident. All formal complaints are seen by the Chief Executive and reviewed by the Chief Executive to ensure scrutiny and challenge. We have also developed a partnership with Weightmans LLP to provide in-house Medico- Legal support and in partnership with them and Hempons we have obtained clinical reviews of clinical care and treatment to get a third party independent perspective. Changes have been made to the way that Complaints and concerns are now logged onto our Ulysses Customer Service Database this has enabled better reporting within the team and divisions. Further work will be undertaken in 2015/16 to look at more ways in which the system can be streamlined. Delays were often caused when a complaint was sent out for investigation but was later found to be too complex to be answered within the 25 days stated. All complaints and concerns are now triaged daily using a standard pro-forma which summarises the nature of the concern, live action taken and the required outcome as well as grading the complaint. This enables a review of Duty of Candour requirements to take place. The initial timescale for investigating is now decided at this point and aligns with the incident process. The triaging process is undertaken by a senior member of the Quality and Governance Team, generally the Director of Quality and Governance, the Head of Assurance and Governance or the Head of Patient Safety. We will continue to monitor our triaging system throughout 2015/16 to ensure that it continues to work effectively and adapts accordingly Training has enabled staff to be clearer about the standard of complaints responses required and the tone in which they need to be written. The culture with regards to the way complaints and complainants are handled has transformed and staff are now more likely to try and resolve minor complaints at ward level. We have now trained over 100 front line supervisory staff and further training will take place throughout the year to ensure that all staff are empowered to manage complaints effectively and timely. 3.3.4 Response Times by Division It is important to review performance at this level in order to identify areas performing well and any problem areas. A summary and breakdown of performance at Divisional level is provided in table 7. 8
Table 9: Response Times by Division Division Division 2014/15 Total Number of Complaints closed Diagnostic & Therapeutic 15 Elective Services 176 Medicine And Emergency Service 273 Women s & Children s 54 changing for 2015/16 so our revised process will reflect this. This concerns raised within this category have been drilled down further in Table 10 with the top 6 most reported categories shown over the three year period. 3.3.6 Compliments The Trust has IN 2014/15 started to record the amount of compliments received. The chart below demonstrates this over a 3 month period (Q 4) The ratio of compliments to complaints as of March 2015 was 7:44 The table above highlights that only one Division managed to achieve the Trust s objective of closing 90% of its complaints within an agreed timescale. It is worth noting however that this division handled the smallest number of complaints within the group. All other divisions were consistent with the amount of complaints closed, each managing approximately 84%. 3.3.5 Themes in Complaints The issues most frequently raised by complainants between April 2014 and March 2015 are illustrated in the chart below; we have used the national K041 complaint themes to categorise these. Table 11: Three Year Comparison of the sub group of All aspects of Clinical Care (Top 7) Table 10: Three Year Comparison of Themes Raised in Complaints (Top 6) The breakdown of the category All Aspects of Clinical Care shows that Medical care and treatment continues to be the most commonly raised concern consistently over the three year period. The most reported 3 subjects have remained the same for the last 3 years. All Aspects of Clinical Care continues to be the most commonly raised subject and continues to increase year on year. This is reflective of the national picture. Nationally the K041 coding is 3.3.6 Key themes raised in concerns The most frequent themes from concerns include: Medical Care & Treatment Cancelled / postponed appointments /operations Discharge arrangements Staff Attitude 9
3.3.7 Outcomes of complaint investigations The outcome of all complaints is recorded as follows: Upheld Partially Upheld Not Upheld Complaints in which the concerns were found to be correct on investigation Complaints in which, on investigation, the main concerns were not found to be correct, however some of the concerns or issues raised by the complainant were found to be correct. Complaints in which the concerns were not found to be correct on investigation. If a complaint is not upheld, we still recognise the validity of the concern to that complainant and we acknowledge that we have failed to meet their expectations. All complaints are reviewed and reported on irrespective of their outcome status. If a complaint is not upheld, there is still an opportunity to learn and review our procedures, for example through understanding the motives and feelings of the complainant. The chart below shows that whilst similar proportions of complaints are split between upheld and not upheld during the period 2014/15 the majority of closed complaints had a reported outcome of Partially Upheld (31%). Outcome codes of closed complaints 2014/15 3.3.8 Complaints Referred to the Parliamentary Health Services Ombudsman (PHSO) We aim to resolve all complaints to the complainants satisfaction by conducting thorough investigations and providing a comprehensive response as well as offering complainants the opportunity to discuss further concerns with us. However, we are not always able to achieve a resolution, which satisfies the complainant. Under the NHS complaints system, complainants dissatisfied with responses received from us have the right to ask the PHSO for an independent review of their case. The right to go to the PHSO is explained to all complainants. When we come to the end of a complaints investigation and we feel that there is nothing further we can do locally to resolve a complaint to the complainant s satisfaction, we will encourage complainants to take their case to the PHSO. Health Watch We promote and reinforce Healthwatch Tameside as our local consumer champion for health & care in Tameside and appropriately signpost to Healthwach Tameside for help with NHS complaints as necessary. NOT UPHELD 18% ONGOING 40% UPHELD 11% PARTIALLY UPHELD 31% 10
PHSO Cases: In their annual report published in October 2014 the PHSO reported that 34 enquiries had been raised with the PHSO about us in 2013/14, 5 of these were accepted for investigation. In the first two quarters of 2014/15 of 19 enquiries 5 were accepted for investigation. This appears to be an increase on the previous year if the trend continues. In 2013/14 this equates to 1.2% of the complaints received by Tameside NHS Foundation Trust. The PHSO report identifies on average 2.2 complaints per 100 written complaints received were investigated, however THFT only received 1.2 in this period. Definitions used to categorise founded/not well founded or upheld Well-founded identified if the Trust provided an apology for the issues raised as part of the complaint response. Partially founded identified where some issues in the complaint were not upheld and no apology required. Not well founded Identified where no apology was necessary or issue refuted. Independent Review From 1 st April 2014 31 st March 2015 there have been 7 requests submitted to the Ombudsman which is comparable to the number requested in 2013/14:- Month request received Ref No. Jul-14 3991 Division Medicine & Emergency Service Dec-14 1141 Women & Children Aug- 2014 Aug- 2014 May 2014 4706 Women & Children 4203 Oct-14 3937 Apr-14 3690 Sep-13 4170 Medicine & Emergency Service 3617 Elective Services Medicine & Emergency Service Medicine & Emergency Service Medicine & Emergency Service Outcome and Actions Partially upheld - relates to a case in 2012 on-going Complaint regarding medical care and treatment on the Medical Assessment Unit On-going - relates to a case in 2003 Complaint regarding antenatal medical care and care during labour Upheld - relates to a case in 2013 recommended payment of 4.178 - Complaint regarding care on Labour ward following birth of baby Upheld - relates to a case in 2012 recommended action plan and payment of 15,000. Complaint regarding medical care and treatment on Ward 45 Upheld - relates to a case in 2011 recommended payment of 350 and action plan Complaint regarding care and treatment on due to complications following appendectomy at another hospital On-going - relates to a case in 2012 complaint regarding medical care and treatment in the Emergency Department On-going - relates to a case in 2011 complaint regarding medical and nursing care on Ward 40 On-going relates to a case in 2012 Complaint regarding medical care and treatment in the Emergency Department Three cases that were referred to the PHSO in 2013 and concluded in 2014 are shown below. Month request received Ref No. Aug-13 3838 Division Medicine & Emergency Service 2013 4132 Elective Service Outcome and Actions Upheld Final report received Feb 2014, recommended action plan and payment of 15,000.00 relating to a case in 2011 Not Upheld Complaint/allegation that a swab was left inside a patient following Colposcopy relating to a case in 2012 11
4. Listening, Reviewing, Learning, Improving 4.1 Complaints Monitoring The complaints process is closely monitored to ensure that all complaints and concerns are handled appropriately. The following process is now in place to ensure a robust system responding to all concerns raised. Triaging of Complaints - Each complaint is triaged using a pro-forma which summarises the nature of the concern, live action taken and the required outcome as well as grading the complaint. The initial timescale for investigating is decided at this point and aligns with the Clinical incident Investigation process, Safeguarding and Coroners requirements (if applicable) and ensures that the level of investigation matches the severity of the incident. The triaging process is undertaken by a senior member of the Quality and Governance Team, generally the Director of Quality and Governance, the Head of Assurance and Governance or the Head of Patient Safety & Risk. A complaints file is maintained to address the issues around the thoroughness of the investigation, timeliness and quality of response as well as addressing the back log of historic cases, Additional resources have been brought into the existing team to act as complaints leads for the Divisions focusing on supporting the more complex cases received for these areas. Processes are now aligned to the Patient Safety team, Safeguarding Team, Mortality review team and Inquest team all of which now sit under one integrated management structure and Directorate. There is a response letter checklist completed by the complaints lead which is then countersigned by the Director before the response letter is submitted for CEO review and sign-off. The Director of Nursing deputises in her absence Complaints are routinely included and discussed at every Board Meeting as they are now incorporated with in the Integrated Quality Account Performance Report and in the Aggregated Learning Summary. In addition any complaints that have been converted to Serious Incidents are also included in the Part 2 Serious Incident update to Trust Board at each meeting. We now have designated groups and Committees with operational responsibility for oversight and monitoring of the complaints process. The Executive Management Team meet on a weekly basis and monitor the number of ongoing complaints and to discuss cases of specific concern if required. The Quality and Governance Committee receive monthly information on Complaints through the Aggregated Learning Report. The Service Quality & Operational Group (SQOG) also receives the Aggregated Learning Report and summaries of all minutes from Divisional Governance meetings. At a Divisional level, governance meetings are held within each Division on a monthly basis and complaints are included as a standard agenda item for these meetings. It is evident that complaints are incorporated on the agenda and discussed within these meetings. There is a Trust wide Learning from Experience group and Patient Experience group where complaints are discussed and reviewed. 4.2 Reviewing and Improving the Complaints Process There have been notable improvements over the last 12 months in the investigation process and quality of responses provided by the Trust to Complainants. The Trust continues to have an active case load and seeks ways in which further improvements could be made to reduce the average length of time taken overall to respond to an individual complaint. In all cases this must be balanced against the requirements of undertaking a comprehensive and transparent investigation and the quality of the response. All cases are triaged and a timescale set at the outset communicated with complainants to reflect 12
the level of complexity and detail of investigation needed consequently, those cases deemed to be complex and requiring RCAs are initially required with 45 days being in keeping with the national and commissioned guidelines for RCA investigations. In 2013 only 30% of PALS concerns were answered within 2 working days compared to 72% in 2015 this has lowered the amount of complaints which are made which required prolonged investigation. There has been a significant reduction in the backlog of historical complaints. We have trained over 100 staff in complaints handling and investigation techniques in order that complaints are answered at ward level where appropriate. As a result the average number of comebacks on response letters has reduced considerably, the Trust recognises however needs to make further improvements on completing complaints investigations and responding to patients within the initial agreed timeframes. The Trust continues to monitor the percentage of complaints responses provided in the agreed timescales. We now have continued focus and assertive work with Clinical Divisions on a continuous basis. Increased number of Divisional Staff Root Cause Analysis trained. Implemented daily caseload monitoring by Head of PALS and Complaints. Complainants are kept informed of any complexities or delays in investigation either through formal written letters, emails or telephone calls. There were 7 key areas where recommendations were given for further improvement of the service, these findings have been actioned and will be used to review our complaints process further to ensure that our standards and Quality continue to grow. 4.3 Complaints Policy Review The Complaints Policy was reviewed during March 2015 and a result a revised version of the complaints policy was approved by the Trust Executive Group. Further development work is planned for 2015/16 which will lead to further revisions regarding any improvements and changes to the complaints management process. 4.4 Investigating trends and identifying issues Reporting arrangements have improved greatly over the last 12 months with greater information available on the types of complaints, trends and analysis of issues. This now enables the Trust to be able to identify any specific themes or increases in complaints at directorate, ward or department level ensuring that they can be acted upon quickly and minimise the risk of any reoccurrence. Examples of complaints and changes / lessons learnt as a result We have shown extensive learning from our complaints and investigations. We have reported on this pathway in our Quality Account which can be accessed via: the Trust website http://www.tamesidehospital.nhs.uk/ and also on NHS Choices. An Independent Complaints Audit by MIAA was undertaken for the 2014/15 period which stated rated the Trust as having Significant Assurances for PALS & Complaints - it highlighted that there had been a vast amount of action taken by the Trust to build a fit for purpose process to handle and respond to complaints as well as improve the patient experience through learning from complaints. 13
5. Priorities for 2015/16 Complaints Process We will continue to review the complaints service throughout 2015/16 and make any necessary changes in line with national recommendations and feedback to ensure that our complaints process remains patient focussed, provides quality responses and that we see an increase in complainant satisfaction. Our key priorities for 2015/16 include: Complaints training We will continue to offer training to staff throughout 2015/16 and build on the success of the training package that was delivered during this reporting period. In the coming 12 months we will: Provide further training to address divisional capacity through increasing the level of RCA training for divisional staff to further strengthen the ability to provide timely and comprehensive responses. Continue with our programme of training sessions on complaints management and investigations targeting staff at Band 6 and above. Implement a robust monitoring system to enable the PALS & Complaints team to follow up and offer formal reporting for nonattendance at any training session or low divisional sign up. This will enable us to ensure that all relevant staff receive this training. Improved Reporting We will continue to improve the quality and accuracy of the data we record throughout 2015/16. The K041 National reporting requirements have changed and as a Trust we will need to ensure that we record our complaints correctly to reflect these changes. The frequency in which the K041 is submitted will now increase from annually to quarterly. On-going emphasis will remain on the importance of reporting consistent and accurate information. The new reporting structure will also require the Trust to identify how many outstanding complaints remain as of the 1 st April. The Quarterly process will include active monitoring of complaints closures to reflect this. Where multiple complaints appear in one episode of care these will now be reported to capture all concerns therefore it is anticipated that our complaints figure will increase during 2015/16 as a result of this change. Future reporting will also include the % of complaints responded to within agreed timescale by divisions. To improve complainant satisfaction with the complaints process Action has been taken over the last 12 months to improve the way in which we respond to our complaints and the overall quality of our investigation and responses. We hope to see continued progress in complainant satisfaction as a result of new processes that have been put in place alongside our training package. We will continue to monitor and develop this throughout 2015/16 From the chart below it is evident that the quality of responses sent out is now greater than those in the 12 months previous with only 18 comebacks in our latest reporting period against our original figure of 43 comebacks in 2013 and 25 in the same period 12 months previous. 14
Being Patient & Carer Focussed and Offering Choice There are a number of posters advising how to raise concerns, not only on the Wards but at the entrances to the hospital we also have complaints leaflets in public areas Ward staff are encouraged to try and resolve complaints at ward level, where this is not possible they can direct patients/families to the PALS and Complaints Department so that they can speak to a member of the team in person. An advice Office is at the entrance to the Hartshead Building and offers support and advice which includes directing any complaints to the department if needed. There is a full page on or website where complainants are directed to a complaints form and leaflet. A An internet complaints form can be submitted by email. A dedicated email address and telephone number is available and Training has been provided to staff in supervisory roles to promote the service across the Trust. 6. Conclusion We remain committed to thoroughly investigating, learning from, and taking action as a result of individual complaints where it is found that standards have fallen below the level we expected and where services could be improved. We undertake detailed and extensive monitoring of all complaints. This ensures that, where questions are raised about the quality of care that we deliver, they can be quickly investigated and responded to. 15
7. Appendix A Corporate Objectives Objective 1. All patients receive harm free care through the delivery of the Trust s Patient Safety Programme Key Outcomes We will continue to build upon and embed the reduction in harm achieved in 2014/15 and we will maintain or exceed the end of year position against key performance metrics. We will participate in the Haelo Patient Safety Programme and ensure external engagement is secured to meet its expressed objectives We will implement and deliver the Trust Safety plan for 2015/16 measuring and monitoring safety objectives across the Trust as submitted to Haelo and the NHSLA. A speciality level range of safety metrics are developed which will drive local quality improvement and measurement. We will develop in partnership with our commissioners and other providers and the local authority a system wide metrics for at least two agreed areas of harm and collate baseline data for these. We will develop a system for anticipating and predicting potential future harm and implement this for at least two of the Patient Safety Patient work streams for 2015/16 2. To improve the quality of patient care through the implementation of the Trust s agreed Quality Strategy. We will achieve the identified pledges and measures as stated in the Trust Quality Strategy and meet key indicators as attributed to each Quality Priority. Each speciality will have developed a suite of Quality metrics which will drive local quality improvement and measurement. The Trusts mortality rates will have improved in line with expected levels. We will further develop our strategy for seven day services and working in partnership with other key organisations. Through delivery of the Workforce and HR/OD Strategy we will ensure delivery our of Health and Wellbeing and organisational development intentions and improve outcomes against our Values and Behaviours. We will review our position against appropriate NICE guidance and Quality standards ensuring these are monitored and prioritised within service delivery We will deliver Advancing Quality (AQ) improvement targets. 3. To improve the patient experience through a personalised, responsive, compassionate and caring approach to the delivery of patient care. There is evidence of an improvement in administration processes which support responsiveness to patients and other service users. This will include: All urgent letters typed and sent within 2 working days. All routine letters typed and sent within 5 working days All areas will have agreed standard operating policies which will ensure that compliance is maintained with these standards We will improve our Friends & Family Test and response rates by a further 5% on the national trajectory for each required FFT speciality published. We will improve our reported Positive patient experience metrics and intend to be in the top 50% of Trusts when benchmarked for each reported FFT speciality. 16
Objective Key Outcomes We will further reduce the number of KO41 complaints per 1000 patient contacts to below 1.15 complaints per 1,000 patient contacts. We will increase in the number of recorded compliments and improve the Compliments to KO41 Complaints ratio by 20% from the Q4 2014/15 baseline. We will continue to undertake First Friday walkrounds to receive feedback on patient and staff experience and see on going improvement in the feedback provided and reported. We will continue to implement our open and transparent culture around the performance of the organisation and our performance against our agreed quality and safety metrics and include examples of improvement and patient stories. We will publish these on the Trust Website in our Open and honest publications monthly We will continue through feedback questionnaires and other systems to understand what our patients and key stakeholders are telling us about the Trust s Quality of service provision and reputation. We will report on this through published performance in the Open and Honest publications and it visibility through the NHS choices star ratings. 4. To foster a continuous quality improvement culture which promotes patient quality, safety, personalised and effective care. There is evidence of a service Transformation Strategy which will focus on improving responsiveness to patients and support the more effective use of resources. The Strategy will support the delivery of: A reduction in DNA rates in Outpatients from 11% to 7.5%. Appointment dates will be agreed in advance with 90% of patients before an appointment is provided. The utilisation of slots in clinics will improve from 73% to 90% All day case and inpatients being offered a choice of date for their treatment. A reduction of cancellations of surgery on the day from 1.1% to 0.8% Redesign across the Heart Disease Pathway in collaboration with health, social care and third sector partners will continue. The outcome being a pathway which delivers safe and effective care. Develop an internal engagement and service improvement programme delivered at Departmental level, which listens to staff and empowers staff to act and along with an implementation plan ensure: There is evidence of employee engagement with the Trust s Transformation agenda evidenced through NHS Staff Survey results aim to be best 20% for staff engagement scores There is continued improvement with staff engagement evidenced through NHS Staff survey results at Trust and Divisional Levels Through the new Appraisal process Board to ward objectives are realised and evidenced evidenced within the Staff Survey results aim for above average/best 20% compared with national average. Continuation of the Leadership Development and coaching programmes to develop a distributed leadership model evidenced through NHS Staff Survey scores best 20% Development of a Learning & Development Strategy for Health Care 17
Objective Key Outcomes Support workers in bands 1-4. Achievement and maintenance of Mandatory Training Compliance 95% Embedding of Trust Values and Behaviours through new Appraisal process. Completion of Appraisals within new Appraisal window and compliance with the 95% target Launch Trust Workforce Health & Wellbeing Policy - Improvement in Attendance levels achievement of Trust target 3.5% Evidence of improvement in the quality and safety of the Trust s service provision through the implementation of the Trust s Quality Strategy, evidenced through improved safety and quality metrics 5. To develop a Strategic Plan which will secure clinical and financial sustainability for the trust in collaboration with its strategic partners, and key stakeholders. There will be evidence of further development of the 7 day services Strategy. To develop a workforce strategy which ensures our workforce requirements support new ways of working, builds skills and capabilities so staff are equipped to deliver community and hospital service delivery To support and encourage team working across boundaries to enable better integration and enhance the working experience of staff so they are able to provide truly integrated services In pursuing our strategy of integrated care, we will collaborate with commissioners, social care, GPs and other healthcare providers to expand patient access to health care, improve care coordination, and achieve the triple aims of improved health outcomes (quality), lower total healthcare costs and increased patient satisfaction. An agreed clinical model for the delivery of an Integrated Care Service, is endorsed by system stakeholders i.e. CCG, LA and the Trust, which is deemed financially and clinically sustainable. An organisational vehicle, for the delivery of an Integrated Care Model, is agreed. Engagement/consultation process is agreed with the Trust s commissioners. There is evidence of a clear acute network plan which secures sustainability for the Trust s future service strategy. There is evidence of an agreed implementation plan for the delivery of Integrated Care and acute service strategy for year 1. An engagement strategy is agreed, for the development of secure partnership relationships, which includes the third sector. 6. To work with our partners, stakeholders and the community to deliver more effective safe, high quality, effective care. To further develop the Governors bi-monthly training programme ensuring alignment with current regulatory requirements and regional and Local Health Economy issues. Enhance membership engagement by implementing a fit for purpose electronic membership engagement platform. 18
Objective Key Outcomes Enhance membership engagement by establishing a quarterly programme of health related seminars beginning with living with diabetes scheduled for 9 May 2015. Plan and deliver 2015 Open Day in September 2015 the theme is Tameside Hospital at the Heart of the Community. Work with CVAT and voluntary groups in the planning and delivery of the open day. Develop links and build relationships with third sector partners. Deliver the Health and Wellbeing programme - Making Every Contact Counts (MECC) in partnership with TMBC Continue to develop an open and transparent culture around the performance of the organisation with respect to the Trust s performance against its agreed quality and safety metrics for example If in Doubt Campaigns, Executive walk rounds, First Friday. To develop an engagement strategy to further enhance relationships within Primary Care; this will be evidenced through increased joint education events, wider use of social media and specific specialty/topic engagement activities/events. 7. To deliver against the required local and national frameworks, and to put in place arrangements to secure economy, efficiency and effectiveness in it use of resources, in order to meet all the requirements of the Trust s operating licence and the commissioners requirements. Compliance with all national and local performance standards is achieved: Delivery of all CQUIN targets Delivery of commissioners agreed contract and quality plans All NICE guidelines are considered and implemented into the Trust Quality Plan Financial and CIP plans are delivered against agreed improvement trajectories Key performance metrics/standards are delivered in accordance with national requirements The Trust s improvement trajectories, for the following standards, are met: o Referral-to-Treatment A&E Stroke Services The Trust s information Quality Assurance Improvement plan is delivered and improvements are secured in performance data in the following areas: Mortality Length-of-stay Readmissions 19