Patient Experience Strategy

Patient Experience Strategy 2013 2018 V1.0 May 2013 Graham Nice Chief Nurse Putting excellent community care at the heart of the NHS Page 1 of 26

CONTENTS INTRODUCTION 3 PURPOSE, BACKGROUND AND NATIONAL CONTEXT 3 DEFINITIONS 5 DUTIES 6 STEPS TO IMPROVE PATIENT AND SERVICE USER EXPERIENCE 7 USING PATIENT AND SERVICE USER EXPERIENCE TO IMPROVE SERVICES: THE FIVE STAGES 8 Stage 1. Capturing the Patient Experience 9 Stage 2. Analysing The Information 11 Stage 3. Making Improvements 13 Stage 4. Measuring The Change 15 Stage 5. Feeding Back What We Have Done 16 WORKING WITH PARTNERS 17 CONSULTATION, APPROVAL, RATIFICATION AND REVIEW 17 EQUALITY AND ANALYSIS 18 TRAINING, DISSEMINATION AND IMPLEMENTATION 18 DOCUMENT CONTROL AND ARCHIVING 19 REFERENCES 19 APPENDIX A: IMPLEMENTATION PLAN 20 Page 2 of 26

Introduction Sussex Community NHS Trust (SCT) is the main provider of community healthcare across Brighton & Hove and West Sussex. The Trust was formed in 2010 through the integration of South Downs Health NHS Trust and West Sussex Health, resulting in an organisation with more than 4,000 staff. SCT provides essential assessment, diagnostics, treatment and care to over 8,000 people a day. The Trust s vision is to put: Excellent community care at the heart of the NHS. The Trust has three strategic objectives: Support people to stay well and care for people who are not well or injured Sustain and improve our financial strength To have high quality services led and delivered by excellent staff informed by public and wider stakeholder engagement The experiences of patients and service users and their families are extremely important to SCT. Patient and service user experience is critical to both individual patients and their families and goes beyond the health outcomes of care. This strategy sets out to identify the key objectives over a 3 year period to use and improve patient and service user experience within SCT. This strategy covers all services provided by Sussex Community NHS Trust. Purpose, Background and National Context The purpose of this strategy is to: Set out the organisation s vision and values in relation to patient and service user experience Develop a culture that places quality of care at the heart of our services In October 2011 the NHS National Quality Board defined patient and service user experience as: A patient s direct experience of specific aspects of treatment or care. Based on this definition, on 21st February 2012 the Department of Health launched the NHS Patient Experience Framework which serves to outline the key elements of patient and service user experience: Page 3 of 26

Respect for patient-centred values, preferences, and expressed needs, including: cultural issues; the dignity, privacy and independence of patients and service users; an awareness of quality-of-life issues; and shared decision making Coordination and integration of care across the health and social care system Information, communication, and education on clinical status, progress, prognosis, and processes of care in order to facilitate autonomy, self-care and health promotion Physical comfort including pain management, help with activities of daily living, and clean and comfortable surroundings Emotional support and alleviation of fear and anxiety about such issues as clinical status, prognosis, and the impact of illness on patients, their families and their finances Welcoming the involvement of family and friends, on whom patients and service users rely, in decision-making and demonstrating awareness and accommodation of their needs as care-givers Transition and continuity as regards information that will help patients care for themselves away from a clinical setting, and coordination, planning, and support to ease transitions Access to care with attention for example, to time spent waiting for admission or time between admission and placement in a room in an inpatient setting, and waiting time for an appointment or visit in the outpatient, primary care or social care setting. The SCT Patient Experience Strategy is based on these values. In addition, it serves to support a number of other core national frameworks, standards and recommendations including: Annual Quality Account Care Quality Commission Essential Standards of Quality and Safety Mid Staffordshire NHS Foundation Trust Public Enquiry 2013 Monitor Quality Governance Framework NHS Litigation Authority Risk Management Standards NHS Operating Framework National Institute for Health and Clinical Excellence (NICE) Quality Standards / Guidance on patient experience NHS Outcomes Framework 2012/13 Page 4 of 26

Definitions Care Quality Commission (CQC) Commissioning for Quality and Innovation (CQUIN) Independent regulator of health an social care provider in England and Wales A framework for payment that enables commissioners to reward excellence. Friends and Family Test Healthwatch Monitor Parliamentary Health Service Ombudsman Patient A single question, How likely are you to recommend our [ward / A&E department] to friends and family if they needed similar care or treatment?, introduced by the Department of Health (DoH) to create a simple, comparable test which, when combined with follow-up questions, provides a mechanism to identify poor performance and encourage staff to make improvements where services do not live up to the expectations of our patients (DoH, 2012) Independent consumer champion for health and social care in England Authorises and regulates NHS Foundation Trusts Considers complaints from members of the public who feel a public body, such as the NHS, has not acted properly or fairly. For the purpose of this document, the term patient is used to include loved ones, carers, family and friends Patient experience A patient s direct experience of specific aspects of treatment or care. Patient experience feedback Information received from patients, through a variety of mechanisms, that is used to design and improve services Primary Care Trust (PCT) The commissioning body for health services. Service User People who use health and social care services as patients Carers, parents and guardians Organisations and communities that represent the interests of people who use health and social care services Members of the public and communities who are potential users of health services and social care interventions. Page 5 of 26

Staff The term service user also takes account of the rich diversity of people in our society whether defined by age, colour, race, ethnicity or nationality, religion, disability, gender or sexual orientation, and may have different needs and concerns. Definition taken from Health Service Executive, 2011 All staff, whether substantive or temporary, employed by the Trust or working for the Trust through a 3 rd party contract, volunteers, trainees or secondees. Duties STAFF Responsible, appropriate to job role, for ensuring that patients are provided with clear verbal and written information. Responsible for ensuring that patients are given the opportunity to ask about benefits, risks and alternative options for treatment through open, honest and sensitive conversation. TRUST BOARD Responsible for ensuring it receives and acts appropriately on information about the areas of public concern and assuring itself that consultation with patients and service users, relatives, carers and the public has taken place before decisions on service planning are made. CHIEF EXECUTIVE Ultimately responsible for ensuring that there are effective systems and processes in place for capturing and using patient and service user feedback and patient and service user experience. CHIEF NURSE As lead executive accountable for patient and service user experience, responsible for the effective delivery of this strategy. EXECUTIVE DIRECTOR OF OPERATIONS Responsible for ensuring that services act on patient and service user feedback and patient and service user experience to improve the quality of services delivered. DIRECTOR OF HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT Responsible for ensuring that improving patient and service user experience is reflected in the Trust s appraisal system. CALDICOTT GUARDIAN (IN SCT THIS IS THE MEDICAL DIRECTOR) Responsible for ensuring that all patient identifiable information is managed in accordance with the Caldicott principles. COMPLAINTS AND ASSURANCE LEAD Page 6 of 26

Responsible for ensuring an effective and efficient PALS and complaints service. Responsible for providing complaints, PALS and compliment data relating to patient and service user experience and outcomes. PATIENT EXPERIENCE SUB COMMITTEE Ensure SCT engages with patients and carers from diverse backgrounds in a meaningful way to help plan, deliver and improve our services. HEADS OF SERVICE / STRATEGIC BUSINESS UNIT LEADS Responsible for ensuring that the views of patients, relatives, carers and the public are considered in all service development plans in a timely and effective manner. Responsible for ensuring the results of feedback influence service changes and the results are fed back to patients and service users. Steps To Improve Patient and Service User Experience SCT understands that the patient is the most important person and the reason for the existence of the Trust. Therefore we are committed to providing a consistently high standard of service which meets the needs of the local population and is truly patient-centred. We consider the patient, their families and carers to be the expert by experience as they hold a unique vantage point as knowledgeable witnesses in the delivery of care. As a Trust we need to be proactively seeking patient feedback will help us deliver services and enable us to continually develop, learn and improve. SCT strives exceed the standards set out by Care Quality Commission in their Essential Standards for Quality and Safety. These standards are outcome focused and have a clear set of statements around what people who use services should experience. By collecting meaningful patient and service user experience information we can assure ourselves we are complaint with the expected standards, and where we are not we can take active steps to become compliant. Measuring patient experience, not just patient satisfaction, is essential. Collecting information in itself has no value; it is how the information is used to transform services which matters and this comes from the experiences of people using those services. This strategy has been designed using three basic steps. Each of these have been applied to a series of stages (outlined in the next section). These steps involve exploring: Page 7 of 26

Using Patient and Service User Experience to Improve Services: The Five Stages SCT has identified five key stages in the use of patient experience information: 1. Capturing the experience Obtaining information from patients and service users on their experience(s) of using SCT services 2. Analysing the information Looking at what the information is telling us, good or bad; looking for trends, looking for where improvements are required, and looking for examples of great practice we can share across the organisation 3. Improving the services Making changes that should have a positive impact on patient care 4. Measuring the change Assessing the impact of the changes made to ensure they have made a positive difference. 5. Feeding back what we have done Telling you what we have done, and the impact of what we have done. Each of these stages flow in a constant cycle of quality improvement: Page 8 of 26

Stage 1. Capturing the Patient Experience A. Where are we now? The current situation. The Trust already uses a number of methods to collect patient and service user experience information these include: Complaints feedback Friends and Family Test (pilot) PALS enquiries Patient Experience Sub Committee Patient and service user surveys Compliments Web based feedback forms Verbal feedback during assurance reviews B. Where do we want to be? Our objectives. OBJECTIVE 1: Build on existing work to further develop robust systems and processes for gaining both quantitative and qualitative feedback from patients, their families and carers. In order to achieve the best possible picture of its services, SCT will build on its existing feedback collection mechanisms. This means gathering quality information on a regular basis about how people feel about our services, including roll-out of the Friends and Family Test. In order to make improvements we need to capture both quantitative and qualitative information. Quantitative information includes collecting statistical information, such as the number of complaints or compliments and qualitative information is about capturing people s perceptions, opinions and reasons for their experience. As information technology improves we will look at using increasingly varied and innovative ways to capture patient and service user experience such as: Page 9 of 26

Touch Screen Tablet Surveys SMS Surveys On-Line forums Social Media To gain robust qualitative information we need to be proactively asking people what it is like to use our services and where they feel any issues and problems may lie. To improve the way we do this we will be exploring how we can develop this area looking at options such as: Public Meetings Comment Cards Telephone Surveys Use Of PALS Contacts Focus Groups In addition to these direct methods, the Trust has a body of information already in place through its own quality and safety systems and this information will also be used to identify areas of excellence and areas requiring improvement. These other sources of data include: External regulator such as the Care Quality Commission Reviews of Compliance, Patient Environment Action Team assessments etc Feedback from the Parliamentary Health Service Ombudsman Incidents and Serious Incidents National surveys and reports Annual staff survey C. How are we going to get there? Our plan. Development and implementation of a system and process to collect consistent, high quality patient and service user experience information. Development of a more robust approach to collecting, sharing and using feedback from websites such as NHS Choices, Patient Opinion, IWantGreatCare and the friends and family test. Page 10 of 26

Development and implementation of systems and processes for collection, analysis and use of patient stories - where an individual patient, or carer, describes their experience of healthcare in their own words Development of a protocol and quality assurance process for surveys and questionnaires developed and used within the Trust. Development of patient drop in sessions for patients and relatives to share their views and experiences of services. Stage 2. Analysing The Information A. Where are we now? The current situation. Our current incident, complaints, claims, Patient Liaison and Advice Service (PALS) and patient and service user survey data gives us information on individual patient s experience, when things have gone wrong or were not as the patient, or their family and carers had expected. This information provides a useful resource for supporting services to learn from patient and service users experiences. Concerns and complaints are often dealt with at a local service level and have resulted in local improvements and developments. Learning and improvements need to be effectively analysed and shared wider across the organisation to ensure there is no repetition of the same negative experience. In addition sharing of good practice and compliments can support to aid developments across the organisation. On a regular basis quality reports are produced for services and for Board assurance using the data collected. Each of the different aspects e.g. incidents or complaints are analysed and reported on but results from patient surveys, complaints, PALS contacts and incidents could be analysed further and against each other. This triangulated view will help identify Trust wide themes and trends to inform both targeted service developments and Trustwide improvements. Complaints received provide not only an opportunity to put things right where they have gone wrong but also to learn important lessons and develop new approaches to improve our services. The way in which we deal with complaints can improve the experience of users - where complaints are not handled so well this could make it worse. B. Where do we want to be? Our objectives. Page 11 of 26

OBJECTIVE 2: Develop more robust analysis of complaints, claims, PALS enquiries and compliments to inform both service specific and Trust wide improvements. OBJECTIVE 3: Build on existing work to further develop a triangulated and robust system and process for gaining both quantitative and qualitative feedback from patients, their families and carers, from all available information sources. Information captured will be analysed both within the service to which the data relates and across larger organisational areas to identify what it is really telling us about the quality and safety of the services we provide as well as the trends and themes such as: Common issues arising across a number of different services Common issues arising within a specific service A specific service receiving significantly better / worse results than others A specific service showing particularly exceptional performance C. How are we going to get there? Our plan. Develop systems for the triangulation of different types of data to identify where there are common issues arising. Development of a robust system to review information collected from all aspects of patient and service user experience to identify themes, trends and learning A review of the quality of our response to complaints and PALS enquiries including systems, processes, human interactions and written communications Collation and disseminating of learning from complaints, claims, incidents and PALS enquiries. Development of a standardised process for handling informal complaints Active promotion the PALS services to users of Trust services and the wider population Development of strategic action plans to address common themes raised in complaints, claims, incidents and PALS enquiries. Page 12 of 26

Stage 3. Making Improvements A. Where are we now? The current situation. Services within SCT vary in terms of levels of service development in response to patient and service user experience information. Equally some services and individuals are more active in promoting their developments and improvements than others. The actions, words and behaviours of SCTs senior management team set the tone of the organisation and influence how staff and managers feel about the Trust which in turn has an impact on how they behave towards each other and towards patients and their families. Executive and Non-Executive Directors undertake visits to services, invite patients to tell their stories at the Trust Board and participate in assurance reviews, which includes interviewing patients and service users about their experience of Trust services. The Chief Executive personally reviews and signs all complaint responses. The Chief Executive also sends out a weekly e-bulletin informing staff of developments, improvements and future organisational direction. Staff also receive a Quality Focus newsletter which includes examples of identified learning from incidents, complaints and the management of risk. B. Where do we want to be? Our objectives. OBJECTIVE 4: Every service within the Trust will use patient experience to gain insight and identify opportunities for improvement. It is important that all services within SCT see that they contribute either directly or indirectly towards a positive patient and service user experience, even back office services such as Human Resources, Finance and Estates. Each area needs to reflect on the feedback received from patients, their families and carers to identify opportunities for improvement. OBJECTIVE 5: Every service within the Trust will, having identified opportunities for improvement, implement at least one patient experience improvement project annually. We recognise the importance of responding and acting upon issues and concerns raised by patients and their families and carers as soon as possible. Page 13 of 26

Where possible immediate remedial action will be taken locally to respond to issues of concern to rectify the situation to the satisfaction of those involved. Once the immediate problem is resolved it is essential that we learn from situation and use the information to make improvements that will impact on patient and service users experiences in the future. Individual services will use local user feedback to identify opportunities and plan for local service improvements. OBJECTIVE 6: The Service Experience team will lead a Trust wide support campaign to support services in making improvements where themes are identified SCT plans to develop a campaign style approach to improve the experiences of patients, their families and carers in relation to the NHS Patient Experience Framework: Respect for patient-centred values, preferences, and expressed needs, Coordination and integration of care Information, communication, and education Physical comfort Emotional support Welcoming the involvement of family and friends Transition and continuity Access to care OBJECTIVE 7: The Trust Board will continue to take an active leadership role in advocating improvements in experiences of patients in receipt of SCT services. Learning and improvements will be reported to the Quality Committee and Patient Experience Sub Committee on a regular basis. Ongoing embedment of a Trust wide a culture where all services and individuals understand their impact on the patient and service user experience C. How are we going to get there? Our plan. Ensuring we actively learn from the outcome of complaints and incident investigations Consistent identification of specific actions that need to be undertaken to make improvements Supporting services to gather robust patient and service user experience feedback using a range of methods Page 14 of 26

Enabling our teams to take action to rectify issues of concern in a timely manner, immediately wherever possible Ensuring that local services take action based on the feedback from patients, their families and carers to make improvements and developments that positively impact on patient and service user experience Development of a process to ensure that services share their improvements in order to influence Trust-wide developments. Development of clear Trust wide messages and communications to support and improve patient and service user experience. Design of a focussed plan to support our campaign on the identified themes for improvements in patient and service user experience. Development of the existing Executive and Non Executive Directors walkabouts in services to explicitly and consistently include patient and service user experience questions Ensuring the Board receives regular information about patient and service user experience in a variety of formats including not only statistical information but with a focus on outcomes and improvements Stage 4. Measuring the Change A. Where are we now? The current situation. We measure patient and service users experiences by using existing information collection methods such as complaints and PALS data. We report on our findings in board quality performance reports and in our annual Quality Account. Internal assurance review visits also report on both patient and service user experience and, through follow up reviews, what action(s) has been taken as a result. However, we currently have limited methods in place to report on or measure service developments and improvements where there have been no complaints, incidents or compliments etc, reported or if a service has not been subject to an assurance review. B. Where do we want to be? Our objectives. OBJECTIVE 8: Develop a robust system to audit and measure improvements made as a direct result of patient experience information. It is essential that we regularly audit changes made to our services in response to patient and service user experience information to ensure the Page 15 of 26

change really does make a difference. We will also continually review the way we capture information to ensure it is fit for purpose and responds to patient and service user s preferences. C. How are we going to get there? Our plan. Development of an audit tool to ensure services are focussing on improvements based on patient experiences Development of robust system to report and share developments trust wide Continual review of the way we capture information to ensure it responds to patient and service user s preferences Stage 5. Feeding Back What We Have Done It is essential for patients and service users to know that the time and effort they spend providing us with information on their experience of our services is valued and used. Processes already in place for dealing with specific queries (eg PALS and complaints processes) provide direct feedback on individual issues. B. Where do we want to be? Our objectives. OBJECTIVE 9: Develop systems and processes to provide feedback to patients and other stakeholders on changes made both service specific and Trust-wide. Patients, their families and carers feel more confident in services when they can see they have been listened to. By providing feedback to patients, their families, carers and other stakeholders about how we have used patient and service user experiences to improve services, not only are we closing the loop, we are also celebrating our joint successes and encouraging future involvement. C. How are we going to get there? Our plan. Providing feedback to patients, their families and carers on a regular basis. Development of appropriate publicity on the key improvements we make to deliver messages to the wider community Provide a patient and service user experience emphasis in Trust publications such as the annual report, annual Quality Account, Quality Focus, Trust Talk and on the Website. Page 16 of 26

Working With Partners HEALTHWATCH SCT has established strong links with local patient and service user groups including Healthwatch. Healthwatch is a new independent consumer champion created to gather and represent the views of the public. Healthwatch England was launched in October 2012 and from April 2013 local Healthwatch organisations will be in place. We will continue to develop these relationships to ensure the views and opinions of patients and service users are taken into account when developments are being planned to improve patient and service user experience. SCT PATIENT EXPERIENCE SUB-COMMITTEE The Patient Experience Sub-Committee reports into the Executive Leadership Team and its membership includes patient representatives, the Trust Equality and Diversity Lead, the Head of Marketing, Communication and Intelligence and a Non-Executive Director. The group reports into the Executive Leadership Team and has links with external patient and service user groups. The Patient Experience Sub-Committee will take a lead role in the implementation of this strategy and associated activities. DEVELOPING PATIENT AND SERVICE USER INVOLVEMENT The Trust will continue to build on its existing relationship with local Healthwatch networks and aims to establish a strong working relationship with Seldom Heard from Groups, Focus Groups and public meetings. DEVELOPING STAFF INVOLVEMENT It is essential that all members of staff, clinical or non-clinical, understand the role they have in making a difference to the experience of our patients and service users. Every patient interaction should demonstrate the highest possible standards of care and should actively reflect the values in the NHS Patient Experience Framework. Consultation, Approval, Ratification and Review The following groups and individuals have been involved in the development of this strategy: Patient Experience Sub-Committee inc Healthwatch representatives) Chief Nurse The Patient Experience Sub-Committee will approve this strategy. The Chief Nurse will ratify this strategy. This strategy will be reviewed every 2 years by the Patient Experience Sub Committee. Page 17 of 26

Equality and Analysis The Trust aims to design and implement services, policies & other procedural documents and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. Under the Equality Act 2010, policy or other procedural document authors have a statutory duty to give due regard to issues of race, disability, gender (including transgender), religion or belief, age, sexual orientation and human rights when developing their policy or other procedural document. This means that policy or other procedural document authors have to assess the potential for their document to discriminate on any of these grounds. Alternatively, the impact of the policy or other procedural document on these groups might be positive or the same for everyone. This strategy has been equality impact assessed and a copy is available on request. Training, Dissemination and Implementation TRAINING SCT is committed to equipping staff with the necessary skills required to undertake their roles competently and confidently. In turn, staff must take responsibility for developing these skills and participating in the lifelong learning process. There may be a requirement to undertake some workshop activities with Trust staff on the implementation of various aspects of this strategy. DISSEMINATION This strategy will be publicised and published on the internal staff intranet, the Pulse and also be published on the Trusts website. Copies of this strategy will be sent to key partners and stakeholders. Managers will be responsible for ensuring their teams are aware of this strategy as all staff, clinical and non clinical have a role in improving patient and service user experience. The Trust offers translations of all essential leaflets for patients in all major languages, plus Braille, easy read, large print and audio formats. Non-compliance with strategies, policies and procedural documents can affect patient safety, SCT s compliance with the Care Quality Commission (CQC) regulations, NHS Litigation Authority standards, and audits or inspections carried out by internal and external auditors. Compliance with Trust strategies, policies and other procedural documents is a contractual condition of SCT employment. Page 18 of 26

IMPLEMENTATION This strategy will have an associated implementation plan. Monitoring of compliance against the implementation plan associated with this strategy will be undertaken via the Patient Experience Sub Committee, which feeds into the Quality Committee. Document Control and Archiving The Trust s Policies & Projects Coordinator will keep and maintain a Trust s Policy & other Procedural Documents Register by setting out the name of the responsible service area, author, date of last review and date of next review and will alert the relevant owner/author. Authors are responsible for ensuring the responsible Director is kept up to date on the review status of their policies and other procedural documents. References Quality Account Toolkit (Department of Health, 2010) Care Quality Commission Essential Standards of Quality and Safety (Care Quality Commission, 2010) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry Robert Francis QC (TSO, 2013) Monitor Quality Governance Framework (Monitor, 2010) NHS Friends and Family Test Implementation Guidance (Department of Health, 2012) NHS Litigation Authority Risk Management Standards NHS Operating Framework 2012-13 (Department of Health, 2011) NICE Guidance CG138: Patient Experience in Adult Services: Improving the Experience of Care for People who Use Adult NHS Services (NICE, 2012) NICE Quality Standard 15: Patient Experience in Adult NHS Services (NICE, 2012) NHS Outcomes Framework 2012/13 Page 19 of 26

Appendix A: Implementation Plan Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 OBJECTIVE 1: Build on existing work to further develop robust systems and processes for gaining both quantitative and qualitative feedback from patients, their families and carers Research electronic /real time systems options available for data collection and create a project initiation document. Development and implementation of an ongoing process to collect qualitative and present information. Implementation of electronic/real time system for data collection Implementation of process Review and refresh system. Review process Development of a more robust approach to collecting, sharing and using feedback from websites such as NHS Choices, Patient Opinion, and IWantGreatCare Implementation of process Review process Implementation of the friends and family test in inpatient wards, urgent treatment centres and minor injury units Audit of implementation success, review of process and technology used Review process Page 20 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 Development and implementation of systems and processes for collection, analysis and use of patient stories. Roll out and implement Implementation of process Review process Develop a protocol and quality assurance process for surveys and questionnaires developed within the Trust. Roll out, provide briefings to services and implement Review process Develop a patient drop in service for sessions for patients and relatives to share their views and experiences of services. Pilot drop in sessions and review Implement changes and review OBJECTIVE 2: Develop more robust analysis of complaints, claims, PALS enquiries and compliments to inform service Trust wide improvements. Review of the quality of our response to complaints, including systems, processes, human interactions and written communications Devise and action plan to improve processes and systems and implement Review, amend and implement further developments Establish an implement a system for the collation and Review system Page 21 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 disseminating of learning from complaints, claims, incidents and PALS enquiries. Development of a standardised process for handling informal complaints Review system Commence active promotion the PALS services to patients and families across the Trust Continue promotion of PALS service and measure success Continue to promote PALS service and monitor success Development of strategic action plans to address common themes raised in complaints, claims, incidents and PALS enquiries. Appraise existing action plan and review and update OBJECTIVE 3: Build on existing work to further develop a triangulated and robust system and process for gaining both quantitative and qualitative feedback from patients, their families and carers, from all available Develop and implement systems for triangulation of different types of data against each other to identify where there are common issues arising. Review system and monitor progress Page 22 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 information sources. Development and implementation of a robust system to review information collected from all aspects patient experiences to identify themes, trends and learning. Review system and monitor progress OBJECTIVE 4: Every service within the Trust will use patient experience to gain insight and identify opportunities for improvement. Development of Trust wide a culture where all services understand their impact on the patient and service user experience Continuation of development of Trust wide a culture where all services understand their impact on the patient and service user experience Test and challenge the trust wide culture. Audit existing patient and service user experience information within Trust and ensure that all services are undertaking appropriate activity and are identifying opportunities. All services to produce action plans on their results and highlight how they will continue to identify opportunities. Review system and success. OBJECTIVE 5: Every service within the Trust will, having identified opportunities for improvement, implement at least one patient and service user experience improvement project annually. Monitor compliance with the learning lessons policy in order for The Trust to ensure that it actively learns from the outcome of complaints and incident investigations Identification of specific actions that need to be taken to make improvements Review processes to ensure that local services take action based on the feedback from patients, their families and carers to make improvements and developments that positively impact on patient and service user experience Page 23 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 Support services to gather robust patient and service user experience feedback using a range of methods Review support provided and plan for further input where required Enable teams to take action to rectify issues of concern, immediately wherever possible Review and provide additional support where required. Development and implementation of a process to ensure that services share their improvements in order to influence Trust wide developments. Review effectiveness and amend where required Development and implementation of clear Trust wide messages to support and improve patient and service user experience. Review effectiveness and amend where required OBJECTIVE 6: The Service Experience team will lead a Trust wide support campaign to support services in making improvements where themes are identified. Design a 2 year focus plan to support our campaign on the identified themes for improvements in patient and service user experience. Implement year one of plan and review success Implement year two of the plan and review success Page 24 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 OBJECTIVE 7: The Trust Board will continue to take an active leadership role in advocating improvements in experiences of patients in receipt of SCT services. Review assurance review documentation to ensure that those reviews accompanied by Trust Board members have a patient and service user experience focus. Development of the existing Executive and Non Executive Directors walkabouts in services to explicitly include patient and service user experience using reviewed documentation Review and amend documentation Review how the Board receives regular information about patient and service user experience in a variety of formats, not just high level quantitative information and agree format. Implement new format for reporting to the Board. Review and amend OBJECTIVE 8: Develop a robust system to audit and measure improvements made in patient and service user experience. Development and implementation of an audit tool to ensure services are focussing on improvements based on patient and service user experiences. Review and amend Development and implementation of robust system to report and share developments trust wide. Review and amend Continual review of the way Page 25 of 26

Objective Year One 2013/2014 Year Two 2014/2015 Years 3-5 2015-2018 Continual review of the way we capture information to ensure it responds to patient s preferences information is captured OBJECTIVE 9: Develop systems and processes to provide feedback to patients and other stakeholders on changes made both service specific and Trust-wide Develop a proposal for a process to provide feedback to patients, their families and carers on a regular basis including use of appropriate publicity on the key improvements we make to deliver messages to the wider community Agree and implement proposal Review and amend Provide a patient and service user experience emphasis in Trust publications such as the annual report, annual Quality Account, Quality Focus, Trust Talk and on the Website. Review and amend Review and amend Page 26 of 26