Patient Experience and Feedback Committee SIRI Panel

Transcription

1 Governors Trust Board Via Chief Exec Joanna Crane Patient Engagement and Experience Committee Bill Brown Patient Experience and Feedback Committee Quality & Risk Committee Bill Brown SIRI Review Panel Quality Board Divisional Integrated Performance Review Executive Team Health Intelligence Board Strategic Planning & Delivery Board Patient First Board Divisional Clinical Governance Review Meetings Quality Standards Group Safeguarding Strategy Committee Reducing Avoidable Harm Clinical Audit and Effectiveness Committee Mortality Steering Group Triangulation Committee Infection Control Committee Medicines Optimisation Committee Health and Safety Committee Falls Tissue Viability CAUTI End of Life Board CQUIN Delivery Group

2 Patient Experience and Feedback Committee Purpose : To provide assurance to the Board that the Trust manages comments, compliments, concerns and complaints, from patients and the public, in a sensitive, open and effective manner, and That a process of organisational learning is in place to ensure that identified improvements are embedded within the organisational framework.

3 Authority Has the delegated authority, within its remit, to act on behalf of the Board Empowered to investigate any activity within its terms of reference and to seek any information it requires from staff Authorised by the Board to obtain independent legal and professional advice in consultation with the Company Secretary

4 Membership Chair NED Members Two further NEDs * Director of Nursing and Patient Safety Medical Director Other Customer Relations Manager PALS Manager Head of Patient Experience * Preferably one of whom should be Chair of the Quality and Risk Committee

5 Quarterly Proceedings Quarterly Report Actions taken as a result of formal complaints in the quarter under review Detail level report/management presentation on areas of concern Trend information of both formal complaints and PALS enquiries: by quarter over 2 years and 12 month moving average by patient category v. national benchmarks by type of complaint/pals, by sub-type, by division, by site, by sub-type last 18 months For major complaint/pals areas deep dive into department/process By consultant and by ward - last 18 months

6 Agenda Item. : Agenda Item. : Agenda Item. : Review of each complaint graded HIGH in the quarter - reviewed for action status/learning and linkage with prior complaints, PALS, SIRIs Patient Experience Report : Lisa Ekinsmyth, Head of Patient Experience : review of Real Time Patient Experience surveys, Friends and Family, local and national surveys, Sit and See outcomes.. Review of outcome of Governors PEEC committee against ongoing actions

7 NED Audit of Complaint Files Prior to the quarterly PE&FC meeting, NEDs select at random approximately 10 Formal Complaint files that have been closed in the quarter under review

8 Formal Complaints v National Benchmark Average Last National 12 months Average Inpatients per 1,000 admits Outpatients per 10,000 OP attends A & E complaint level is below national average

9 Management Process for Comments, Concerns and Complaints Complaint or Concern Customer Relations or PALS Is this informal? 150 Per quarter No Yes PALS 1,100 Per quarter Same day Immediate remedy Generally verbal Formal Complaint

10 Formal Complaint Acknowledge formal complaint within 3 days Triage : High - Response 1 to 3 months Medium - 25 working days Low - 5 working days Investigation Chief Executive s written response

11 Timeliness in response to Complaints Average number of closed formal complaints per month 54 Grade Low 96% Medium standard : < 25 days April to Dec : only 10% closed within 25 days January 2016 : 38%

12 number of complaints Patient Experience and Feedback Committee Formal Complaints A-J J-S O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M Quarter Inpatient Outpatient A&E Other

13 Analysis of cause of : Formal Complaints PALS Clinical Treatment 63% 13% Communication (verbal) 6% 24% Communication (written) 6% 12% Date for Appointment 4% 21% Date of Admission/Attendance 3% 7% Admission/transfer/discharge general 9% 2% Staff Attitude 5% 6% Test Results 2% 3% Other 2% 12%

14 number of complaints/concerns Patient Experience and Feedback Committee PALS concerns and Formal Complaints PALS Formal Complaints J-M A-J J-S O-D J-M A-J J-S O-D J-M Quarter

15 number of contacts Patient Experience and Feedback Committee PALS Contacts Other Outpatient Inpatient A&E O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M Quarter

16 PALS Contacts Communication (Verbal and Written) Date for Appointment/Admission Clinical Treatment Staff Attitude All Other O-D J-M A-J J-S O-D J-M A-J J-S O-D Number of Contacts

17 Formal Complaints Analysis : Outpatients (42%) Per 10,000 first attends Medicine Surgery Q3 Q2 Q1 Q3 Q2 Q1 Worthing St Richards

18 Formal Complaints Analysis : Inpatients (42%) Per 1,000 admissions Medicine Surgery Q3 Q2 Q1 Q3 Q2 Q1 Worthing St Richards

19 Clinical Treatment Sub-category : Co-ordination of Medical Treatment Formal Complaints concerning Co-ordination of Medical Treatment Average per Quarter : last 8 Quarters Worthing 20 St Richards 7

20 Chair : NED* Two further NEDs* Medical Director Director of Nursing and Patient Safety plus : Head of Clinical Governance Risk and Patient Safety Manager Representatives of Clinical Divisions as required * One of these must be the Chair of the Patient Experience and Feedback Committee

21 Serious incidents requiring investigation were defined by the Serious Incident Framework (NHS England, 2015), as : an adverse event where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. The occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved.

22 DEFINITION OF A SERIOUS INCIDENT REQUIRING INVESTIGATION (SIRI) An incident resulting in one of the following: Unexpected or avoidable death of one or more patients, staff, visitors or members of the public. Unexpected or avoidable injury to one or more people that has resulted in serious harm (recently widened to include any FALL resulting in harm that requires surgical intervention) Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional to prevent death or serious harm Allegations of abuse One of the core set of NPSA Never Events An Incident or series of incidents that prevents or threatens to prevent an organisation s ability to continue to deliver an acceptable quality of healthcare

23 Review SIRI RCAs brought forward on Tracker Review all RCAs relating to closed SIRIs two quarters back : eg Dec SIRI panel looks at quarter ending June Review SIRIs from 18 months prior for learning and embeddedness

24 March Dec Sept Falls (requiring Surgical Intervention) Pressure Ulcers (Grade 3 or 4) 7* 0 2 Maternity Other Clinical SIRIs of which Never Event * 6 at SRH of which 4 deemed avoidable