Patient Experience, Engagement and Involvement Strategy
‘Seeing the Person in the Patient’ *
Version:
1a
Ratified by:
Quality Assurance Committee
Date ratified:
April 2014
Title of originator/author:
Hilary Fawcett, Quality Governance
Lead
Title of responsible
committee/individual:
Patient Experience Group
Date issued:
June 2014
Review date:
Interim review: June 2015
Full review: 2017
Target audience:
All staff Trust wide
*‘Seeing the Person in the Patient:
The Point of Care Review Paper
The King’s Fund
Page 1 of 18
Contents (to be finalised when all amendments completed)
Section
Title
1
Summary
3
2
Introduction
4
3
The Strategy
5
4
How will we do this?
6
5
Culture and capability
7
6
Child and Young People’s services
7
7
Turing strategy into action
8
9
References
8
Appendix 1
NICE Quality Standard Statements
Page
10
Appendix 2 Patient Experience strategy - Implementation Plan: Year 1
11
Appendix 3 TRFT Core Values
14
Appendix 4 Factors affecting experience
15
Appendix 5 National Drivers for improving the Patient Experience
16
Appendix 6 Equality Impact Assessment
17
1.
SUMMARY
It is the prime objective for The Rotherham NHS Foundation Trust (TRFT) to ensure
the provision of highest quality care for all patients who use its services. With the
required components of ‘quality’ widely accepted as being the combination of safe,
effective care and a positive experience for patients, this strategy sets out the
Trust’s intention to ensure the best possible experience of care for all patients.
This strategy sets out how staff will understand their responsibility in ensuring each
patient not only receives excellent clinical care, but that it is delivered in a manner
that treats them as an individual, recognises their needs and cares for them with
empathy and compassion.
The strategy sets out how this will be achieved, how progress will be monitored and
within the implementation plan describes a structured approach to involving and
engaging patients and working with stakeholders in the development and
improvement of service delivery
Page 2 of 18
This approach puts further substance and meaning behind the Trust core values:
Compassion * Safe * Together
* Right First Time * Responsible * Respect
(Appendix 1)
In ‘High Quality Healthcare for All’ Lord Darzi states that quality is the ‘organising
principle for the NHS with emphasis on patient safety, patient experience and clinical
effectiveness.
‘High quality care should be as safe and effective as possible, with patients treated
with compassion, dignity and respect. As well as clinical quality and safety, quality
means care that is personal to each individual’
This is the overarching principle that guides the direction of this strategy.
Throughout this document the term ‘patient experience’ is used. The importance of a
positive experience for parents, relatives and carers is also fully acknowledged and
these groups should be assumed to be included wherever relevant.
I was admitted to the Ward after my operation and again was cared for and supported with compassion and
understanding of my condition. I was there for 6 days and they were all stars.
’Patient Opinion – TRFT patient
2.
INTRODUCTION
The overwhelming majority of NHS staff come to work with the intention of providing
excellent care to their patients. Unfortunately it is not always the case that patients
leave the Trust with a positive impression and feeling their care was as good as it
could and should have been, with numerous reasons affecting the possible
outcome.
(Appendix 2)
.
Patients receiving health care are frequently at their most vulnerable and dependent
on others for their care. Whatever the nature or duration of their care, it is a
fundamental requirement that their care is delivered with compassion and respect at
all stages by both clinical and non-clinical staff. At the same time, staff can be under
considerable pressures with increased volume of activity, the need for greater
efficiency. The drive to improve the patient experience therefore is linked to the
requirement for strong leadership, management and support for staff. There is a
strong correlation between staff satisfaction and patient outcome and this can be a
factor in addressing reports by a patient that the standard of care ‘depends on who
is looking after me’
Patient experience can be defined as ‘feedback from patients on what actually
happened in the course of receiving care or treatment, both the objective facts and
their subjective view of it’
(Dr Foster’s Intelligent Board report 2010 - Patient Experience)
Page 3 of 18
Through this strategy the aim is to determine what it is like to be a patient, or their
relative or carer, at the Trust, from their own perspective.
Why is the experience of patients important?
1.
First and foremost is the moral obligation that people at their most vulnerable
should be treated with the utmost compassion and respect.
2.
Professional codes of conduct set out this requirement and it is mandated
within the regulatory frameworks of the Care Quality Commission and
Monitor.
3.
There is evidence that a patient experiencing fear and anxiety can suffer
delayed recovery. Good communication with patients can contribute to wellbeing and reduction of stress. For patients with long term conditions, good
communication, information and education is vital for effective selfmanagement and could prevent unnecessary hospital admissions.
4.
Good patient experience is beneficial for business and financial reasons,
enhancing reputation, affecting patient choice and commissioning decisions
as well as avoiding the waste of valuable resources when we do not get it
‘right first time’.
5.
A number of national drivers set out the imperative to focus on improving the
experience of patients and are summarised in appendix 3. A theme which
runs throughout is the drive towards a more open, transparent way of
delivering care, with care delivered in an environment where the experience
of the patient is paramount.
Engagement with patients
Patient and public engagement is defined as the active participation of citizens,
patients their carers and their representatives in the development of health services
and as partners in their own care. This includes the planning, designing, delivery
and improvement of health services.
Why is engagement important?
1.
It is not possible adequately to define and improve the experience of patients
without engaging them in the process. Good engagement is beneficial to
patients, staff and the organisation. It means services are more responsive to
individual needs, are developed with a stronger focus on patients and local
community and can lead to improvement in quality of care.
2.
On a one to one basis it means patients feel involved in their own care. They
are treated as an equal partner who has some power to influence, and
develop stronger and positive relationships with health professionals.
3.
Staff can gain greater understanding of patients’ needs and perspective and
see the benefits of improved patient compliance which results from patients’
use of a service which better meets their needs.
Improved patient experience will only take place effectively with active and
meaningful engagement of patients and is therefore a central element of this
strategy
Page 4 of 18
‘I am really sorry I have to leave all the wonderful nurses on the ward as they treat all their patients with kindness, respect,
dignity and friendship. Also, the receptionists Lynn and Tom.’
Patient Opinion, TRFT Patient
3. THE STRATEGY
The National Institute for Health and Clinical Excellence (NICE) has developed a
quality standard and clinical guidance for patient experience and this will drive the
direction of the strategy. The Trust will prioritise key areas for improvement annually
based on this guidance with the goal of achieving the quality outcomes described by
NICE and summarised at appendix 1.
This clinical guidance offers evidence-based guidance on ensuring a good
experience of care for people who use adult NHS services.
Objectives for year 1 are set out in the implementation plan at appendix 2, which will
be monitored via Patient Experience Group (PEG). This high level plan will be
supported by detailed action plans developed and monitored via PEG
Central to improving the experience of papers will be the strengthening of processes
whereby patients are consulted with and involved in the development and
improvement of care and the approach and objectives for for year 1 in achieving this
are set out in the implementation plan
There will be a review of the strategy at least annually with the appropriateness of
these key areas re-assessed and adjusted if appropriate, or as targets are achieved.
This process will be linked with the annual Quality Accounts consultation process,
ensuring involvement of patients, staff, governors as well as external stakeholders
such as Healthwatch.
The following valuable sources of data and information will be analysed and acted
upon by the Patient Experience Group in order to measure progress :
Surveys:
Patient Experience Questionnaires
Friends and Family Test: staff and patients
Local patient surveys
National patient surveys
Patient stories
A valuable method for ‘seeing the person in the patient’, patient stories, told in the
words of the patient or extracted from complaints letters, can help make the patient
experience alive and relevant particularly for example in committee meetings.
Patient Feedback
Patient Opinion
Patient Forums and listening events
Complaints, concerns and compliments
Via Quality Assurance ‘Walkabouts’
Healthwatch reports
NHS Choices
Page 5 of 18
Observation / inspection of practice
Quality Assurance ‘walkabouts’
Executive team visits – e.g. night visits
Patient led assessment of the care environment assessment (PLACE)
Nursing Accreditation Scheme
The Trust will seek to:
•
Ensure staff are appropriately recruited and adequately trained to meet these
responsibilities
•
Listen to what patients tell us, and use this information to act and improve
quality of care
•
Engage and consult with patients, their relatives and carers, including
children and young people, those who may be vulnerable or difficult to reach
•
Identify where there is evidence of excellence in terms of patient experience
and seek to replicate practice
•
Where there are concerns, carry out thorough investigations using root cause
analysis principles, taking necessary action
•
Explore opportunities to benchmark with other comparable organisations.
•
Engage actively with Rotherham Healthwatch and Carers services, seeking
opportunities for partnership working
•
Develop use of performance metrics related to patient experience, owned
across the organisation and monitored appropriately.
‘If I am unlucky enough to need hospital treatment again I shall request that I be admitted to Rotherham Hospital. A big
thanks to every member of their hard working staff’
Patient Opinion, TRFT patient
4. HOW WILL WE DO THIS?
The strategy will directly support the achievement of the Trust’s strategic quality
objectives. The strategy implementation plan (appendix 2) will be led via the Patient
Experience Group, with named leads for the work streams and detailed action plans
to support the achievement of annual goals.
Roles & responsibilities
• The Board of Directors is responsible for setting the strategic direction for
improving the quality of the experience of patients.
• The Chief Nurse is responsible for the Trust Quality Strategy and its
implementation, and all supporting documents. The Patient Experience Strategy is a
key element in the successful delivery of the quality strategy
• The Deputy Chief Nurse has delegated operational responsibility for the
implementation of the strategy and is chair of the Patient Experience Group.
• The Quality Governance Lead is responsible for supporting the Deputy Chief
Nurse in the implementation of this strategy, acting as deputy chair for the Patient
Page 6 of 18
Experience Group
Directorates
and
supporting
relevant
governance
structures
within
•
The Patient Experience Lead is responsible for ensuring implementation of the
strategy in relation to the management of complaints, concerns and compliments.
Also responsible for maintaining an oversight of processes which ensure that
learning is identified, monitoring of implementation of action plans for improvement
and supporting Clinical Directorate leads in achieving this
•
The clinical directorate senior leadership team, ‘triumvirate’ holds responsibility
for ensuring engagement and involvement within their area of responsibility, and
ensuring implementation of this strategy and associated plans for delivery. Each
directorate will have a named individual with responsibility for patient experience
who will be a member of the directorate governance group, also representing the
directorate at the Patient Experience Group.
Responsible for ensuring Trust processes for effectively managing and responding
to complaints, concerns, compliments, are fully implemented, and via the directorate
governance groups ensuring learning is identified, monitoring action plans to
completion
• All Staff are responsible for ensuring that people accessing our services are treated
with warmth, courtesy and helpfulness recognising Trust core values and the
diversity of the population. Staff must familiarise themselves with this strategy and
understand their responsibilities.
Culture and Capability
Strategic direction within the People and Organisational Development and the
direction of the Nursing and Midwifery Strategy supports delivery of this strategy. A
new people, staff communication and engagement strategy is being developed and
this will provide consistent and regular dialogue with all staff, involving them in the
process. A new performance management system will be launched in April 2014.
This will measure employees’ contribution against delivery of their objectives and
also how they have performed in relation to the Trust values.
The Trust is developing a leadership philosophy that promotes transformational
leadership and team effectiveness to deliver better quality patient care.
Integral to the theme of the Trust’s ‘nurses and midwives care’ strategy to ‘recruit
well’, the Trust will embed the use of assessment centres to ensure that the
selection of staff meets both the competency and behavioral standards in line with
the Trust values. This is designed to ensure that applicants have the required
qualities and talents for the Trust’s three goals to be safe, caring and reliable The
Trust will continue to work in partnership with NHS Employers as one of the pilot
sites for values based recruitment.
Children and Young People’s Services
This strategy is applicable to patients of all ages and approaches which are specific
to the needs and age of children and young people will be developed within the
Family Health Directorate
Page 7 of 18
‘It’s fair to say I was scared and worried as I have never had anything like this so I was in fear of the unknown but the staff
were brilliant at putting me at ease and explaining everything that was going on.’
Patient Opinion , TRFT patient
Measuring and monitoring progress
The Patient Experience Group (PEG) is the forum through which the implementation
of the strategy will be led and monitored. Named leads from each Directorate, both
clinical and corporate, will attend the PEG and will have clear understanding of their
responsibility in implementing this strategy within their own department of division.
PEG will receive reports from directorate governance groups based on their local
plans for contributing to the success of this strategy, increasing patient satisfaction
and involvement with service design. Where appropriate to ensure a focused and
consistent approach, ‘task and finish’ groups will be established, reporting to PEG.
PEG is accountable to the Operational Quality, Safety and Experience Group
(OQSEG) and will provide quarterly assurance reports to this group and to the
Quality Assurance Committee, a committee of the Board.
5.
REFERENCES
NICE Quality Standard: Adult Patient Experience
http://guidance.nice.org.uk/QS15
Care Quality Commission: Essential Standards of Quality and Safety
www.CQC.org.uk
Monitor
www.monitor-nhsft.gov.uk
‘Seeing the Person in the Patient:’
The Point of Care Review Paper
The King’s Fund
Page 8 of 18
Appendix 1
NICE Quality Standard Statements
Evidence of compliance obtained via patient experience surveys and feedback. Trusts should have the structures in place to make sure these statements
reflect actual patient experience
1. Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty
2. Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills
Additional required process: Staff are compliant with NICE guidance on patient experience, assessed at PDR, measured as proportion of staff who have this
assessed as part of PDR process
3. Patients are introduced to all healthcare professionals involved in their care and are made aware of the roles and responsibilities of the team
4. Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their individualised care
5. Patients are supported by healthcare professionals to understand releva treatment options, including benefits, risks, potential consequences
6. Patients are actively involved in sharing decision making and supported by healthcare professionals to make fully informed choices about investigations, treatment
and care that reflect what is important to them
7. Patients are made aware that they have the right to choose, accept, decline treatment and these options are respected and supported
8. Patients are aware they can ask for a second opinion
9. Patients experience care that is tailored to their needs and personal preferences, taking into account their circumstances, their ability to access services and their
coexisting conditions
10. Patients have their physical and psychological needs regularly assessed and addressed including nutrition, hydration, pain relief, personal hygiene and anxiety
11. Patients experience continuity of care delivered whenever possible by the same healthcare professional or team throughout a single episode of care
12. Patients experience coordinated care with clear information exchange between relevant health and social care professional
13. Patients’ preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care
14. Patients are made aware who to contact, how to contact them and when to make contact about their ongoing healthcare needs
Page 9 of 18
APPENDIX 2
Patient Experience, Engagement and Involvement Strategy - Implementation Plan: Year 1
Implementation of this plan will support compliance with regulatory standards as follows:
Care Quality Commission Essential Standards: Outcome 1, Respecting and Involving people who use services and Outcome 17: Complaints
Monitor: Quality Governance Framework
Strategic Objective
Action/outcome
Timeframe
To
be
completed:
1.
2.
Develop and strengthen Trust
systems and processes for
evaluation and improvement
of patient experience
•
review
of Patient
Experience
group Q1
membership
to
ensure
appropriate
representation of directorates
•
Named lead for patient experience identified in
each clinical and corporate directorate as Q1
appropriate, who will attend PEG
•
PEG and sub-groups work plans to be reviewed
to ensure they are aligned to the objectives of
this strategy required actions are addressed
Q1
and monitored
•
Strengthen processes for working in
partnership with governors and Trust members Q2
to form an integrated approach towards
improving patient experience
•
a programme of training in complaints
Linked
to
NICE Lead
Quality Standard
Supports
Deputy Chief Nurse via
implementation of all Patient Experience Group
statements of the
standard
Complaints Management
1. All complaints and concerns
Statements 1, 2
Patient Experience and
Quality
Governance
Page 10 of 18
raised with the Trust will be
responded to in a timely and
empathic
manner,
in
accordance
with
the
Ombudsman's best practice
guidelines - Principles of Good
Complaints
Handling.
Parliamentary and Health
Service Ombudsman 2009 and
Care
Quality
Commission
Essential standards: outcome
17, Complaints
2. The organisation will have a
systematic
approach
to
demonstrating learning from
complaints,
concerns
,
compliments
3.
Development of systematic
processes for patient and
public involvement across the
Trust
management will be delivered to key staff Q2
across all Clinical Directorates designed to
ensure all understand their responsibilities,
and to enhance skills to preparing response
letters
•
•
•
action plans demonstrating actions to be taken
following substantiated complaints will be
established, implemented in each Clinical
Directorate which will be monitored at each
Clinical Directorate Quality Governance and Q 2
Assurance Group
This will be subject to audit by the Patient
Experience Team
An audit of quality of complaints against
ombudsman standards will be scheduled
Q4
Teams
Clinical Directors / Heads
of Nursing, Midwifery,
Clinical professions
Patient Experience Lead
Q4
•
Develop and strengthen use of patient stories Q3
for delivery at corporate meetings, verbally or
written, in the words of the patient using the
‘Patient Safety First’ framework: Leadership for
Safety
•
By the end of Quarter 2 , 2014/15, one patient
story will be developed for delivery at Board Q2
and corporate committees as appropriate,
which uses the patient’s own words.
•
Develop the role of volunteers to support the
Patient Experience and involvement agenda
Supports
Quality governance Lead
implementation of all
statements of the
standard
Q2
Deputy Chief Nurse /
Page 11 of 18
Processes for involvement
will be designed to be
inclusive of all members of
the community with no group
disadvantaged
due to
disability
4.
5.
•
Systematic process in place whereby new Q3
service
developments
include
patient
involvement in planning
•
Implement Experience Based Design method of
designing a better experience for patients
Q4
PEG
•
Focus groups / forums will be designed to Q3
be inclusive of all members, where
necessary utilizing for example hearing
loops,
ensuring
wheelchair
access,
interpreters.
Focus groups / involvement initiatives will
be designed to obtain specific feed back Q4
from minority groups
PEG
•
All staff understand their
responsibility in meeting the
objectives of this strategy and
are aware of the NICE quality
standard
•
Full roll out and communication plan of the Q2
strategy
•
Liaise with People & Organisational
Q1
Development re process to include awareness
of the strategy and NICE standard in the PDR
process, linking with Trust values and
Behavioural Framework
The Trust works in partnership
with Healthwatch and patient
user groups to identify and
implement
areas
for
improvement
•
Strengthen processes for receiving feedback, Q1
and acting upon it, from Healthwatch via
quarterly reports
•
Use information received to inform annual
quality accounts consultation process
Q3
Quality Governance Lead
Statement 2
Deputy Chief Nurse /
Quality Governance Lead
Quality Governance Lead
/ POD
Will
inform
statements
all Deputy chief Nurse /
Patient Experience Lead
Quality Governance Lead
Page 12 of 18
6.
The Trust will sign up to the
Dignity in Care Campaign
•
Network of Dignity champions established Q4
across all Clinical directorates
Statement 1
TBA
7.
All patients have same sex
accommodation in accordance
with national and Trust policy
•
Root cause analysis to be undertaken Completed
whenever this standard is breached in line
with Trust identification of this as a local Never
Event
Statement 1
Implemented
Nurse
•
Reports to be received at PEG so that the Q1
outcome and recommendations can inform
relevant work streams
8.
Achieve a 3 point increase in
the
overall
in-patient,
maternity and A&E NPS
Achieve a 3 point increase in
A&E NPS
Achieve a 3 point increase in IP
NPS
Achieve a 40% response rate
for A&E, inpatients and
maternity combined
by
chief
Deputy chief Nurse /
Quality governance Lead
Priorities identified from survey for year 1
based on most current survey:
•
Reduction of noise at night
•
Provision of choice of food
•
Same sex accommodation
•
Discharge Planning
Q4
Action plan for each priority to be developed to
Q1
address these priorities by PEG / PEG sub-groups
Statement 1
Statement 10
ALL
PEG task & finish group
leads
Page 13 of 18
Appendix 3
TRFT CORE VALUES
Compassion
We treat everybody as individuals, showing dignity, kindness and compassion. We respond
with humanity and kindness to each person’s pain, distress, anxiety or need. We do not wait
to be asked. We find time because we care
Together
We strive to improve health and well-being. We believe that each member of our team
makes a valuable contribution towards delivering excellent patient care. We value
professionalism. We talk and listen and we rely on each other.
Safe
We earn trust by putting safety first. We make people feel secure and safe in our care. We
take pride in the quality of care we provide.
We accept praise and criticism in equal measures and when we make a mistake we learn
from it.
Right first time
We are accountable for our use of public money and take this responsibility seriously. We
use our resources wisely for the benefit of the whole community and make sure nobody is
excluded of left behind. We know that when we waste resources, we waste opportunities.
Responsible
We are proud to be part of the community. We are conscious of our impact on the
environment, on the economy and on society and we embrace opportunities to make a
positive impact on our community.
Respect
We respect people’s aspirations and commitments in life and seek to understand their needs
whilst maintaining their privacy. We treat everybody with courtesy and respect and provide
them with a healthy and nurturing environment where they feel supported.
Page 14 of 18
Appendix 4
Seeing the Person in the Patient
Point of Care Review Paper
The King’s Fund
Factors shaping patients’ experience at individual level
Organisational factors
Human factors
Staff
Staff
Patient
Education, training and
qualifications
Induction, preparation
Job description
Accountability
Delegated responsibilities
Morale
Clinical need
Experience
Health status
Tiredness, stress, well-being
Professional and personal
attitudes, values
Support
Mental and Physical capacity
Ability to speak for self
Spoken English
Age
Spoken English
Active family or other
support
Depression, anxiety, fear
Permanent/Temporary
status
Support
Supervision, appraisal
Social status
Appendix 5
Page 15 of 18
National Drivers for improving the Patient Experience
•
The NHS Constitution
Makes clear the right of members of the public to be involved in decisions about the
planning and delivery of local health services.
•
NHS Transparency Agenda
A raft of measures aimed at increased public participation as part of its on-going pledge to
openness and transparency. Innovations under this programme are said to represent ‘the
biggest moves ever taken by any health service anywhere in the world to put transparency
and patient participation at the very core of the health system. ‘
•
Care Quality Commission
Sets out a regulatory framework based on outcomes. In accordance with the CQC
Essential Standards of Quality and Safety, people have the right to expect that their care
will be delivered in a manner which respects their dignity. Also sets out standards for
complaint management. Compliance with the standards is a legal requirement and part of a
healthcare provider’s licence to practice
•
Monitor Risk Assessment Framework (RAF)
The Foundation Trust regulator responsible for ensuring Trusts remain in compliance with
their governance and continuity of services licence, including compliance with the Quality
Governance Framework (QGF). The ‘Processes and Structure’ domain of the QGF requires
Trusts to actively engage patients, staff and stakeholders on quality. The RAF sets out their
process for ensuring Trusts are well led, from both a quality, service delivery and financial
perspective.
•
The NHS Outcomes Framework
Launched in December 2010, sets out direction of quality healthcare in England. Based on
5 domains:
1.
Preventing people from dying prematurely
2.
Enhancing quality of life for people with long term conditions
3.
Helping people to recover from ill health or injury
4.
Ensuring that people have a positive experience of care
5.
Creating a safe environment and protecting people from avoidable harm
•
High Quality Healthcare for All (2008)
States that quality is the organising principle behind everything we do
•
Francis Report
The report by Robert Francis QC, following the public inquiry in to the failings at Mid
Staffordshire NHS Foundation Trust.led to 290 recommendations designed to make the
NHS more open, more accountable and more focused on safety and compassion
•
Commissioning for Quality an Innovation (CQUINS)
Local CQUINS must include at least one goal covering patient experience
•
Quality Accounts
Appendix 6
Page 16 of 18
Annual public reports from healthcare providers about the quality of the services they
deliver. They require boards to monitor and assess the quality of the services they provide.
EQUALITY IMPACT ASSESSMENT (EIA) INITIAL SCREENING TOOL
Patient Engagement Strategy
Document
Name:
Lead
Officer:
2015 - 2017
Date/Period of
Document:
Deputy chief Nurse
Quality governance Lead
Directorate:
Chief
Nurse
Function
Policy
Procedure
X Strategy
Describe the main aim, objectives and intended outcomes of the above:
Reviewing
oficers:
Quality
Governance
Lead
Joint Document, with whom?
You must assess each of the 9 areas separately and consider how your policy may affect people’s human rights.
1.
Assessment of possible adverse impact against any minority group
How could the policy have a significant negative impact on
Response
If yes, please state why and the evidence
equality in relation to each area?
used in your assessment
Yes
No
1
Age?
x
2
Sex (Male and Female?
x
3
Disability (Learning Difficulties/Physical or Sensory
x
Disability)?
4
Race or Ethnicity?
x
5
Religion and Belief?
x
6
Sexual Orientation (gay, lesbian or heterosexual)?
x
7
Pregnancy and Maternity?
x
8
Gender Reassignment (The process of transitioning
x
from one gender to another)?
9
Marriage and Civil Partnership?
x
You need to ask yourself:
•
Will the policy create any problems or barriers to any community of group? No
•
Will any group be excluded because of the policy?/No
•
Will the policy have a negative impact on community relations? No
If the answer to any of these questions is yes, you must complete a full Equality Impact Assessment
2.
Positive impact:
Could the policy have a significant positive impact on equality by
Response
If yes, please state why and the
reducing inequalities that already exist?
evidence used in your assessment
Yes
No
Explain how will it meet our duty to:
1
Promote equal opportunities
2
Get rid of discrimination
3
Get rid of harassment
4
Promote good community relations
5
Promote positive attitudes towards disabled people
6
Encourage participation by disabled people
x
Sets out plans for patient /public
involvement inclusive of all, including
harder to reach groups
7
Consider more favourable treatment of disabled people
x
As above
8
Promote and protect human rights
3.
Summary
On the basis of the information/evidence/consideration so far, do you believe that the policy will have a positive or negative adverse impact
on equality?
Positive
Please rate, by circling, the level of impact
Negative
HIGH
MEDIUM
LOW - X
NIL
LOW
MEDIUM
HIGH
Date assessment completed:
Is a full equality impact assessment
Yes
No X
(documentation on the intranet)
required?
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