Document Title
Patient Experience Strategy
2016/17 – 2020/21
Document Type
Service Application
Version
Name
Rachel Overfield
Louise Mabley
Sue Crabtree
Document Description
Strategy
Trustwide
V5
Lead Author(s)
Job Title
Director of Nursing
Lead for Patient Experience, Volunteering & Self Care
Management programmes
Professional Lead for Palliative, End of Life Care & Patient
Experience
Executive Director / Director / Manager
If you are assured that the correct procedure has been followed for the consultation
of this policy, sign and date below:
Name
Rachel Overfield
Date
Signature
Change History
Version
Date
Comments
Links with External Standards
CQC
Equality & Diversity System
CCG
Key Dates
Ratification Date
Review Date
DATE
1
Executive Summary Sheet
Document Title:
Patient Experience Strategy
Please Tick ()
as appropriate
This is a new document within the Trust
This is a revised Document within the Trust
√
What is the purpose of this document?
The strategy:
 Details the approach to deliver an improved patient experience. It focuses on the need
to provide an excellent patient experience and has considered all the national
guidance.
 Outlines the values in working with patients and the public.
 Outlines how the patient voice will inform the work of the Trust.
 Describes why it is important to engage with patients and the public.
 Defines the accountability structure and proposed measurements of success.
What key Issues does this document explore?





The key ambitions that we have for improvement.
The need for Trust staff to take responsibility for patient experience which will be
evidenced by locally derived data from the national inpatient survey and other
assurance tools.
The continuation of improved experience of patients who access our care resulting in
an increase in the number of patients who would be happy to recommend the Trust.
To collect timely data which is presented in a format that enables front line staff to
understand it and utilise it to improve the patient experience in their area.
To ensure that organisational learning is shared across the divisions to maximise the
impact on patient experience.
Who is this document aimed at?
Trust Staff and Stakeholders/Partners
Patients and the Public
What other policies, guidance and directives should this document be read in
conjunction with?
How and when will this document be reviewed?
This Strategy will be reviewed annually through the Patient Experience Group.
2
CONTRIBUTION LIST
Key individuals involved in developing the document
Name
Rachel Overfield
Designation
Director of Nursing
Circulated to the following for consultation
Name / Committee / Group
Patient Experience Group
Lynda Steele, Interim Head of Governance
Garry Perry, Head of Patient Relations
Shelley Price
Julia Romano
Rosanne Crossey, Head of Business Development and Planning
Daren Fradgley, Director of Strategy and Transformation
Version Control Summary
Significant or Substantive Changes from Previous Version
A new version number will be allocated for every review even if the review brought
about no changes. This will ensure that the process of reviewing the document has
been tracked. The comments on changes should summarise the main areas/reasons
for change.
When a document is reviewed the changes should use the tracking tool in order to
clearly show areas of change for the consultation process.
Version
Date
Comments on Changes
Author
3
WALSALL HEALTHCARE NHS TRUST
PATIENT EXPERIENCE STRATEGY
Content Index
1. FOREWARD
2. DEFINITION OF PATIENT EXPERIENCE
2.1
How to measure Patient Experience
3.
INTRODUCTION
4.
HOW WE CAPTURE PATIENT EXPERIENCE
5. IMPROVEMENT THEMES
5.1
Ambitions
6. PERFORMANCE MONITORING & ASSURANCE
6. EQUALITY IMPACT ASSESSMENT
7.
RISKS AND MITIGATIONS
7. CONCLUSION
8. REVIEWING THIS STRATEGY
Page No:
5
6
7
8
8
10
11
15
17
17
18
18
Appendix 1
Appendix 2
19
20
Key policy, regulatory and legislative documents
Patient Experience Implementation Plan
4
1.
FOREWARD
The Trust’s vision and five stategic objectives depicted below, outline the
organisation’s future direction of travel.
In line with this our vision is becoming your partners for first class integrated care. In
doing so be able to make improvements in our approaches to the care that we
deliver. Patient and carer experience is fundamental to achieving this vision.
Every member of staff is responsible for ensuring that our patients, relatives and
carers have an excellent experience and we aim to ensure that all our staff are
equipped with the essential skills and knowledge to deliver a truly excellent service.
The Trust’s values underpin everything we do and we expect our staff to work to
these values in the delivery of safe, consistent and high quality patient care.
Our innovative ‘For One & All’ programme has defined the promises colleagues have
made to each other and those made to the people they serve.
In the development of this Strategy the national policy and guidelines that have been
considered are contained in Appendix 1.
5
As an integrated care organisation comprising acute and community services we are
fully committed to developing integrated models of care which are designed around
the whole needs of our local population.
Implementation of this Patient Experience Strategy will ensure that the Trust has a
co-ordinated approach to listening to, and learning from, patient feedback and
working together with our patients and carers to continually review and improve our
services.
Staff together with our partners play a key role in improving the experience of the
people that use our services and will continue to work together to make continual
improvements.
This strategy will be publicised and published on the internal staff intranet and also
be published on the Trust’s website. Copies of this strategy will also 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.
Richard Kirby
Chief Executive
2.
Rachel Overfield
Director of Nursing
Amir Khan
Medical Director
DEFINITION OF PATIENT EXPERIENCE
The Department of Health’s definition of patient experience was developed after
extensive research involving patients, the public and NHS staff and appeared in
Building on the Best: Choice, Responsiveness and Equity in the NHS (DH, 2003)
which says:

Patients, families and carers want an NHS that meets not only their physical
needs but emotional needs too; this means:

Having effective treatment in a comfortable, clean and safe environment,
delivered in a calm, reassuring and caring way.

Being talked to and listened to as an equal, being treated with honesty,
respect and dignity.

Patients and carers value their overall experience, as much as clinical
effectiveness and safety.

People with long-term health conditions would like a greater focus on
quality of life and symptom management.

Having efficient processes throughout the care pathway, from initial
appointment through to discharge.

Being treated as a person, not a number, diagnosis or problem.
6

Patients, their families and carers want to feel informed, supported and
listened to, so that they can be more involved with decisions and choices
about their treatment.

Put simply, patients want the NHS to do the following:



Do not harm me.
Make me better.
Be nice to me.
The National Quality Board (NCB) in their paper Improving experiences of care: Our
shared understanding and ambition (2015) describes:

A person’s experience starts from their very first contact with the health and
care system, right through to their last, which may be years after their first
treatment, and can include end-of-life care. ‘Experience’ can be understood in
the following ways:


What the person experiences when they receive care or treatment – for
example, whether they knew who to contact if they had a problem,
whether the nurse explained the procedure to them, and whether the
doctor asked them what name they would like to be called by. The ‘what’
of people’s experiences can be thought of in two ways:

the interactions between the person receiving care and the person
providing that care, for example how a member of staff
communicates with the person (this is known as the ‘relational’
aspects of experience);

the processes that the person is involved in or which affect their
experience, such as booking an appointment (this is known as the
‘functional’ aspects of experience).
How that made them feel – for example, whether they felt treated with
dignity and respect, and whether they felt that the doctor told them about
their diagnosis in a sensitive way.
2.1 How to measure patient experience
‘The Intelligent Board’ (Dr Foster, 2010) measures patient experience using
feedback from patients on ‘what actually happened’ in the course of receiving care or
treatment, both the objective facts and their subjective views of it.
a. The factual element, often statistical, is useful in comparing what people say
they experienced, against what an agreed care pathway or quality standard
says should happen.
b. The opinion element such as compliments, complaints and surveys tell you
how patients felt about their experience and helps to corroborate other quality
measures.
c. Additional measures can also be used that are not derived directly from
patients but on the basis that they relate to things known to matter to patients
and their experience of care, such as single sex wards or waiting times.
7
3.
INTRODUCTION
The purpose of the Patient Experience Strategy is to:

Actively engage with patients and carers encouraging all feedback and
demonstrating genuine learning from listening.

Actively engage with staff to encourage them to make improvements where
services do not live up to the expectations of our patients.

Identify our key focussed themes to improve patient and carer experience
throughout the Trust that have been derived from triangulating our data from
multiple sources.
These themes will be routinely reviewed to ensure we
continue to focus on the most important things to improve or to identify new
issues as they emerge.
4.
HOW WE CAPTURE PATIENT EXPERIENCE
We use a variety of methods and models as outlined below to capture patient
experience and are linked into the Trust’s governance structure.

Patient Experience Group (PEG)
The PEG is chaired by a Director of Nursing and Professional Lead for
Palliative End of Life Care and Patient Experience Vice-Chair. The Group will
be the organisational monitoring group and will be leading the focussed themed
development work.

National Survey Programme
The Trust participates in the national patient experience survey programme
including the annual inpatient survey and ad hoc surveys of outpatients, cancer,
maternity, accident and emergency, children and young people etc.

The Friends and Family Test (FFT)
We aim to offer all patients the opportunity to respond to the FFT question and
to have the opportunity to tell us about anything else we could have done to
improve their experience. Responses to the FFT for inpatients/day cases,
accident and emergency, maternity and outpatients are reported monthly to the
NHS England for publication on their website and NHS Choices website. We
continually monitor the proportion of patients who would/would not
recommend our services and identify key themes from the comments made to
continually improve our services.
Each patient area has performance targets in relation to the FFT. Whilst most
services routinely achieve their target we want to be in a position where they
consistently meet these requirements.

Local patient experience surveys
8
The Trust uses the Envoy Messenger system to capture real-time feedback
from patients. A variety of patient experience surveys are available for patients
to complete, either using handheld devices on the ward, by completing a paper
survey or from home via the Trust’s website or using our unique survey link at
www.walsallhealthcare.nhs.uk/patient-experience.aspx.

NHS Choices, Patient Opinion and Social Media
The NHS Choices and Patient Opinion websites and Facebook and Twitter
provide the Trust with valuable feedback from patients and their
relatives/carers. We always respond promptly to any feedback provided and
encourage people to get in touch with the Trust directly if there are any issues
or concerns that we can help to resolve. All feedback, whether positive or
negative, is shared with the clinical teams.

Patient Experience/Engagement Activities
The ‘In Your Shoes’ Programme offers a genuine opportunity for people to
influence how the Trust delivers healthcare in the future. We want to build on
what we do well and to learn from what we could do better and identify priorities
to focus on to improve patients experience.

Complaints
Patients have the right to make a complaint about any aspect of NHS care,
treatment or services, and this is firmly written into the NHS Constitution.
Complaints and feedback from patients play an increasingly important role in
improving the care of patients in the NHS. Dealing well with complaints and
concerns is an essential part of providing first class, integrated health services.
The Trust Complaints and Concerns Policy describe how the organisation
meets the internal and external requirements for complaints handling. We are
committed to honesty and openness and a willingness to listen to the
complainant, and to understand and work with the patient to rectify the problem.
In addition, there is a commitment to ensuring the user-led vision for raising
concerns and complaints adopted by the Parliamentary and Health Service
Ombudsman is embedded across the organisation, and both quality and
timeliness of responses is the focus.

Patient Stories
Patient Stories provide valuable and essential qualitative evidence of
experience and are embedded in the culture of the Trust. Both Complaints and
Compliments are presented at every Trust Board public meeting.

Strategic Groups
The involvement and engagement of patients, carers and members of the
public has increased as a result of Strategic Groups, including: Members
Forum, Friends & Family A&E Patient Forum, Outpatient Patient Forum,
Podiatry Patient Forum, Pharmacy Patient Forum, Disability Advisory Group
and Community Leaders. We need to increase this form of engagement.

Healthwatch
Healthwatch is an independent consumer champion created to gather and
represent the views of the public. We will continue to develop this relationship
to ensure the views and opinions of patients and service users are taken into
9
account when developments are being planned to improve patient and service
user experience.

Trust Staff
The Trust believes that every member of staff is responsible for ensuring that
our patients, relatives and carers have an excellent experience and we aim to
ensure that all our staff are equipped with the essential skills and knowledge to
deliver a truly excellent service. The Trust’s People Strategy 2016-2020 sets
out our aims to create a culture where staff feel, valued, developed and
supported to provide a truly customer-focussed service. This strategy, with its
focus on patient experience, also reflects on how our staff will deliver the
excellent experiences for patients that are essential to achieving our vision.
5.
IMPROVEMENT THEMES
Having analysed the data from the above sources seven themes were identified
where we aim to make improvements, these are shown below.
Diagram 1: Key Triangulated Themes from a range of sources between
September 2015 - 2016
5.1 Ambitions
We have set ourselves four main ambitions, all designed to tackle the seven
thematic issues identified above, recognising the considerable work already being
done to improve patient pathways and clinical care across all our acute and
10
community services. Our ambitions are aimed at delivery of a great patient
experience throughout the patient journey. As an integrated organisation providing
acute and community services the ambitions were identified through a range of
methods used to test patient experience. It is important that patients and service
users know that the time and effort they spend providing us with information on their
experience of our services is valued and used, therefore providing feedback on what
we have done and the changes made is essential.
Diagram 2: Feeding back what we have done
CAPTURE
the experience
ANALYSE
the information
IMPROVE
our services
MEASURE
the change
FEEDBACK
what we have
done
This strategy will underpin our efforts to achieve our ambitions with our staff, patients
and the public, commissioners and partner organisations. An annual evaluation of
progress towards our ambitions will be undertaken and published on the Trust’s
website.
Ambition 1: We want to improve the experience of our patients and carers from
their first contact with the Trust, through to their safe discharge from our
care.
Ambition 2: We want to improve the information we provide to enhance
communication between our staff, patients and carers.
Ambition 3: We want to meet our patients’ physical, emotional, cultural and spiritual
needs while they are using our services, recognising that every patient
is unique. Within this we want to recognise the cultural diversity of our
patient population and other protected characteristics.
Ambition 4: We want to demonstrate that there has been real learning and change
in practice where necessary from what patients have told us about the
care we have delivered as a Trust.
11
Ambition 1: We want to improve the experience of our patients and carers from their
first contact with the Trust, through to their safe discharge from our care wherever
provided.
To do this we will:
Further develop and maintain the information on the Trust website about all Trust
services.
Further develop process for ensuring equal access to services irrespective of any
protected characteristics.
Ensure that the Trust constantly reviews and refreshes existing communication
techniques and embraces modern technologies to ensure that we are continuing to
reach all audiences.
Engage with patients, carers and representatives when developing and reviewing
services to ensure that their individual needs are taken into consideration.
Provide a process and consistent approach on how we are developing our patient
information and access to information in all formats.
Review hospital signage to ensure patients and visitors are directed to the right
ward/department in a clear and easy way. Share patient feedback relating to signage.
Ensure our staff and volunteer helpers provide a friendly and efficient welcome to
patients, carers and visitors.
12
Ambition 2: We want to improve the information we provide to enhance
communication between our staff, patients and carers.
To do this we will:
Ensure all staff are aware of the importance of introducing themselves to patients and
asking how each patient would like to be addressed. Ensuring that all patients know the
name of the healthcare professional looking after them.
Provide customer care training for our staff and volunteers with particular attention to
reception areas and ensure that patients are involved in the development of the training.
Aim to answer patients and carers questions straight away and, if there is likely to be a
delay in responding, keep them informed of the reason.
Ensure that patients are provided with well-written information leaflets on their care and
treatment to enable them to prepare for their outpatient appointment or inpatient stay.
Advise patients where they might find reliable high quality information and support from
sources such as national and local support groups, networks and information services.
Encourage patients to express their personal needs and preferences when making
decisions about their care and treatment, encouraging patients to ask questions so they
understand the benefits and risks.
Ensure that diversity is taken into account when developing patient information.
Embed a new interpreter service.
Develop and embed a new bereavement service.
Communicate good patient stories and compliments ensuring that we celebrate and
recognise areas of good practice across the Trust.
13
Ambition 3: We want to meet our patients’ physical, emotional, cultural and
spiritual needs while they are using our services, recognising that every patient is
unique. Within this we want to recognise the cultural diversity of our patient
population and other protected characteristics.
To do this we will:
Be kind, courteous and help patients, carers and visitors making them feel welcome in
our hospital.
Provide care and treatment for patients respecting their privacy and dignity.
Provide a clean, safe and comfortable environment, accessible to patients with disability,
dementia and other specific needs where possible.
Encourage access to Chaplaincy service.
Ensure that our staff have access to the equipment they need to meet patient care needs
e.g. activity tools.
Increase the number of volunteers and increase the number of volunteer roles e.g.
Mealtime support.
Review meal/food provision for patients taking into account diversity and other specific
needs.
Continue with work on dementia and frailty especially related to environments and
information.
Actively encourage feedback from patients in a variety of ways, including National
surveys and the Friends and Family Test.
14
Ambition 4: We want to demonstrate that there has been real learning and change
in practice where necessary from what patients have told us about the care we have
delivered as a Trust.
To do this we will:
Use the Patient Experience Group (PEG) to ensure that appropriate strategies,
frameworks and structures are in place across the Trust and for ensuring continual
improvement in the experience of patients. The Terms of Reference have been revised
to reflect the emphasis on learning and change.
Use the data gained through various surveys and stakeholder engagement to identify
changes and improvements.
The Listening into Action initiative is well established to empower staff to deliver change
and will use this format to raise staff engagement and support delivery of the strategy.
Use the Patient Experience Team to engage with and support staff in understanding the
principles of measuring patient experience and using the intelligence gained to make
changes.
Support the introduction of a Customer Care Revolution to address the communication
theme. Developing a Kitemark Scheme with three levels, Bronze, Silver and Gold for
recognising good communication.
Develop a Communication Plan for sharing feedback and demonstrating changes made
as a consequence of engaging with patients and the public.
The Ambitions and priorities for delivery of the strategy are summarised in in the
Patient Experience Implementation Plan at Appendix 2.
6.
PERFORMANCE MONITORING & ASSURANCE
We benchmark our performance with other NHS Trusts and aim to be
amongst the best.
We endeavour to learn from other organisations to provide excellent care
for our patients
Divisional Directors are responsible for performance monitoring of patient experience
taking place in their divisions which is measured through FFT, national and local
surveys and complaints monitoring. Patient Experience should be on agenda item at
all divisional quality boards.
15

The Patient Experience Team will support the patient experience agenda by:
implementing and meeting KPIs including those set nationally and locally by the
CCG; collection, analysis and dissemination of the findings across the Trust;
encouraging staff engagement to lead to better patient outcomes and better
use of resources; identifying learning and improvement outcomes; developing
systems for supporting action plans to close the feedback loop; offering good
quality reporting that is triangulated with other key patient experience
indicators.

The Director of Nursing is the Trust Board lead for Patient Experience and has
specific responsibility for advising the Board on all aspects of this strategy.

The Trust Non-Executive Director who is the Trust Patient Experience
Champion ensures that: the Board and the Trust acts in the best interests of
patients and the public; that patients and service users are treated with dignity
and respect at all times, and that the patient is central to Trust decision making.

Divisional Teams are 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 and reports provided to the Patient Experience
Team.

Patient Experience Group receives regularly progress reports from divisions
and thematic work streams.

Trust Quality Executive receives monthly monitoring information and quarterly
triangulation reports.

Quality and Safety receives quarterly reports of triangulated feedback and
progress against plan.

Trust Board receives summary from Quality and Safety. The Trust Board is
responsible for ensuring it receives and acts appropriately on information about
the areas of public concern and assuring itself that consultation with patients,
relatives, carers and the public has taken place.
Whilst the above have the responsibilities described, all Trust staff at every level has
a responsibility to promote positive patient experience and the principles of this
strategy.
16
Walsall Healthcare Trust Board
Quality & Safety Committee
Trust Quality Executive Committee
Patient Experience Group
Divisional Quality Boards
7.
EQUALITY IMPACT ASSESSMENT
This Patient Experience Strategy will be equality impact assessed to ensure that the
guidance provided does not place at a disadvantage any service, population or
workforce over another.
8.
RISKS AND MITIGATIONS
Risks
Mitigations
Staff not engaging or prioritising good
patient experience.
Staff receive the necessary training and
are supported to understand/undertake
patient experience activities.
Not meeting the recommended measure
based on average national target for FFT.
Promotion of the FFT ensuring that
patients have an opportunity to take part
and are encouraged to provide honest
feedback.
Publication of the results and outcomes
including service improvement.
17
Trust is not able to demonstrate
improvement in patient experience
against national standards.
The creation of an environment in which
staff are encouraged to report learning
and improvements from engaging with
patients.
Cost of monitoring patient experience
and making changes as a consequence
of feedback received.
Focusing on patient experience,
measuring it and acting on the results of
that measurement and identifying any
associated cost.
Identification of the factors that influence
patient experience including those that
may need new investment or those
where better use of existing resources
may be appropriate.
9.
CONCLUSION
The Trust aims to actively improve the patient experience by implementing the aims
outlined in this Patient Experience Strategy.
Key focussed themes from all the data at our disposal have been identified which
should impact upon and improve patient experience and fulfil the ambitions that we
have set for ourselves.
Successful implementation of the Patient Experience Strategy will enable the
following outcomes:







More than 95% of patients would recommend the Trust to friends and relatives.
100% of patients feel they are treated with dignity and respect.
Service planning, redesign and delivery is able to demonstrate it has taken
account of patients’ views and feedback.
Early detection of poor performing clinical areas and subsequent avoidance of
poor care.
A reduction in the number of complaints received by the Trust.
Trust compliance with the CQC Essential Standards for Safety and Quality.
The Trust will aim to have excellent Patient-led Assessments of the Care
Environment (PLACE) scores.
10. REVIEWING THIS STRATEGY
This is a five year strategy underpinned by an Implementation Plan. The Plan will be
reviewed on an annual basis.
18
Appendix 1
Recommendations and guidance from national policy and guidance have been considered in
the development of this Strategy:
Equity and Excellence: Liberating the NHS (2010)
Putting patients at the heart of the NHS. Services to be more responsive and designed around
the patient with shared decision-making the norm ‘no decision about me, without me’.
DoH Framework for patient experience (2012)
The NHS National Quality Board agreed a working definition of patient experience to guide the
measurement of patient experience across the NHS.
Compassion in Practice – the Six C’s (2012)
Aim to deliver high quality, compassionate care and to achieve excellent health and wellbeing
outcomes. The values and behaviours are at the heart of the vision and are set out as the 6 C’s
which are Care, Compassion, Competence, Communication, Courage and Commitment.
NHS Constitution (2013)
Describes the purpose, principles and values of the NHS and illustrates what staff, patients and
the public can expect from the service.
Francis Report recommendations (2013)
Two inquiries into the events at Mid Staffordshire Hospital identified a number of themes and
recommendations. A key action is to listen to the patient and public voice about the quality of
care provided.
NHS England Commitment to Carers (2014)
Commitments that NHS England will do to support carers.
NICE quality standard for patient experience in adult NHS services (2012 & 2014)
Sets out how a high-quality service should be organised so that the best care can be offered to
people using NHS services. It is made up of 14 statements that describe high quality care for
patients.
Putting Patients First: The NHS England Business Plan for 2014/15-2016/17 (2014)
NHS England plans to deliver high quality care for all now, for the future and developing the
organisation. Patient experience is a key objective within the plan.
NHS Outcomes Framework 2015/16
A driver for quality improvement and outcome measurement throughout the NHS. Structured
around five domains; Domain 4 ‘ensuring that people have a positive experience of care’.
National Quality Board Improving experiences of care: our shared understanding and
ambition (2015)
Sets out what is meant by national statutory organisations across the health and care system
about people’s experiences and the NQB role in improving experiences of care.
Independent oversight of NHS and Department of Health investigations into matters relating
to Jimmy Savile (2014)
Jimmy Savile NHS investigations: Update on the themes and lessons learnt from NHS
investigations into matters relating to Jimmy Savile (November 2015).
19
Appendix 2
Patient Experience Implementation Plan
Ambition 1: We want to improve the experience of our patients and carers from their first contact with the Trust, through to their safe discharge from our care
Steps we will take
How we will measure success
Timeframe
Annual Programme
 Minimise waiting times in clinics and departments
 Measuring our national surveys including: Inpatients, A&E, Maternity, Children &
ensuring that staff keep patients and carers informed
Young People, and Cancer.
of the reasons for any delays.
 Inpatient survey responses about:
Improvement measured
 Improve the administration process for outpatients
including the booking of appointments, reducing
cancellations.
 Develop our admission and discharge information
including likely expected discharge date.
 Ensure that family carers are fully involved in the
discharge process and are able to provide care and
support for their relative at home.
Given printed information on medicines
2014-2015 = ↓7.4/10 (national average 8.2/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
annually with target achieved
by 2018
Family given all information on discharge
2014-2015 = ↓5.6/10 (national average 7/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
 Ensure our patients receive high quality care at the
end of their life in line with the Trust’s End of Life Care
Strategic Plan.
Did you see/were you given any information explaining how to complain about
care received?
2014-2015 = ↓2.16/10 (national average 3.2/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
 Continue to improve the patients stay by working with
our identified partnerships to enable a programme of
activities which benefit both the community and the
hospital.
Written or printed discharge information
2014-2015 = ↓6.8/10 (national average 8/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
 Monitoring the number of complaints received regarding delays in care/
treatment/ appointment.
Monitoring the number of complaints received regarding cancellation of
appointments/ clinics.
 Measuring the Voices Bereavement Questionnaire data
Quarterly monitoring through
PEG
Monthly monitoring through
End of Life Strategic Group
Quarterly monitoring through
PEG
 Measuring the impact of volunteering and engagement activities
1
Ambition 2: We want to improve the information we provide to enhance communication between our staff, patients and carers
Steps we will take
How we will measure success
 Deliver 2 day Train the Trainer Course in Complaints
 Measuring the number of concerns raised to the Patient Relations team.
Handling and Investigation Training and develop a
network of complaints champions across the
 Measure the number of Complaints Champions
organisation. The training will also be included in the
2016 = 160
Effective Managers Programme.
2018 Target 320
 Provide patients and carers with information, verbal
and in writing, about their care and treatment that is
clear and understandable.
 Ensure that patients and carers are given the
opportunity to complete a ‘This is Me’ booklet
(dementia) to share important information about the
patient with staff. This includes the Dementia Carers
Questionnaire.
 Ensure that staff are able to access interpreter and
other services for patients who require information in
alternative formats.
 Improve our mechanisms in the way we are engaging
our patients, relatives and carers to provide feedback
about their experience through improvements in the
national Friends and Family Test question.
 Ensure that all services are supported to collect
patient experience feedback and this is shared within
teams and with the organisation. Display results of
patient feedback in public areas and on the Trust
website including our ‘You Said – We Did’ posters to
share actions taken as a result of feedback.
 Improvement in key communication areas of the
National Inpatient Surveys:
 Patients understanding answers to questions from
doctors.
 Doctors not talking in front of you as if you weren’t
there.
 Patients being involved as much as they wanted to
be in decisions about their care and treatment.
 Achievement of the Dementia CQUIN that relates to carer experience.
 Procure of a new Interpreter Service and measure improved patient experience as a
result.
 Measuring the number of responses to the Friends and Family Test survey:
2015-2016 = 35714 Responses
2018 Target: 45,000 Responses
Reduce neutral scores with a move to promoters by a third.
 Measuring the impact of the new FFT Provider:
Improved user satisfaction survey for staff
Improvement in response rates
 Measuring our national Inpatient survey responses about:
Patients understanding answers to questions from doctors
2014-2015 = ↓7.8/10 (national average 8.5/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
Timeframe
Quarterly monitoring through
PEG
Quarterly monitoring through
PEG
Bi-monthly monitoring through
the Dementia Steering Group
st
1 November launch. Monthly
monitoring through contract
monitoring group and
quarterly reporting through
PEG
Monthly monitoring to the PEG
Monthly monitoring by the
Patient Experience Team
Monthly monitoring by the
Patient Experience Team and
reporting to the PEG
Did doctors talk in front of you as if you weren't there?
2014-2015 = ↓8.2/10 (national average 9/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
Patients being involved as much as they wanted to be in decisions about their
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 Scope current information provided to patients within
our care environments.
 Develop a process and agree a standardised approach
for how we design patient information in the
organisation.
care and treatment
2014-2015 = ↓6.9/10 (national average 7.5/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
Ambition 3: We want to meet our patients’ physical, emotional and spiritual needs while they are using our services, recognising that every patient is unique
Steps we will take
How we will measure success
Timeframe
Monthly audits
 Continue the programme of development around
 Measuring the results of PLACE audits.
nutrition, dietary requirements, religious and cultural
 Increase in the recruitment and retention of mealtime support volunteers. Four
needs. Maintain relaxed ‘protected mealtimes’ where
Monthly monitoring
target recruitment campaigns and training sessions per annum.
staff, volunteers and carers can focus on helping
patients to enjoy their meal in a calm environment.
 Monitor our patient concerns and complaints in relation to nutrition.
 Display information on our wards about staffing levels,
numbers of infections, falls, pressure ulcers,
cleanliness scores so you know ‘How we’re doing’.
 Ensure our patients and carers have access to all the
practical, emotional and spiritual support they need
and provide contact information for organisations and
support groups. Make sure that patients and carers
have an opportunity to speak to a doctor, nurse,
member of the chaplaincy team or other healthcare
professional if they wish to.
 Recognise that the patient and/or carer are the
‘expert’ on their condition and respect their
knowledge, skills and expertise.
 Revisit our Equality and Diversity approach to ensure
that we are compliant with the nine protected
characteristics and derive an action plan for areas of
improvement.
 Improve our family facilities to support our care of
dying patients on our acute site.
 Contact and Activity reports from the Chaplaincy Team.
 Number of carers attending the Looking After Me Carers Programme.
 Monitoring the action plan for improvement in Equality and Diversity.
Monthly audits through the
PLACE assessments
Monthly monitoring
Monthly monitoring
 Measuring our national surveys including Inpatients about:
Do you feel you got enough emotional support during your stay
2014-2015 = ↓6.7/10 (national average 7.7/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
Monthly monitoring
Improvement measured
annually with target achieved
by 2018.
Did you get enough help from staff to eat your meals?
2014-2015 = ↓6.9/10 (national average 8/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
Patients overall rating of their experience
2014-2015 = ↓7.8/10 (national average 8.5/10)
2017/18 Target = meet national average
2020/21 Target – exceed national average
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Ambition 4: We want to demonstrate that there has been real learning and change in practice where necessary from what patients have told us about the care we have
delivered as a Trust
Steps we will take
How we will measure success
Timeframe
October 2016
 Define the process for reporting within the organisation
 Development of a Standard Operating Procedure for reporting National Survey
the results of the National Surveys.
audit results.
 Monitor Divisional Improvement Plans on a quarterly
November 2016
 Development of a Standard Operating Procedure for managing and reporting
basis through our Patient Experience Group format and
Friends and Family Test results.
reporting mechanism. There are three Clinical Divisions
within the Trust: Quarterly divisional reporting through the Patient Experience Group for
Quarterly PEG meetings
 Medicine: General/Elderly Care, Specialist Medicine,
Improvement Plans.
Emergency Medicine and Long Term Conditions
December 2016
 Surgery including Cancer
 Successful, established expanded Patient Experience Team.
 Women’s & Children’s: Women’s Services and
January 2017
Children’s Services and Support Services
 Develop a patient experience data capturing tool.
 To ensure that Strategic Patient Groups hosted by service
areas are reporting and sharing their learning through the
January 2017
 Auditing the implementation success, review of process and technology used.
Patient Experience Group.
 Increase the capacity of the Patient Experience Team to:
act as a central co-ordination hub for all of these activities
and support staff with new initiatives.
 Develop a tool for capturing all patient experience
activities and engagement.
 Through enhanced Friends and Family Test provision we
aim to improve our response time to patient feedback at
a service level.
 To publicise more widely our learning from what patients
are telling us through the ‘You Said, We Did’ model.
 To develop a more robust approach to collecting, sharing
and using feedback from websites such as ‘NHS Choices’,
‘Patient Opinion’ and ‘Healthcare Communications’.
 Implementation of the Friends & Family Test trust wide
using technology based methodology e.g. SMS testing and
IVM voice messaging allowing real time data capturing.
 Work with Partners to identify ways to improve patient
experience through collaboration.
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