Annual Complaints Report 2012/13

Transcription

1 Annual Complaints Report 2012/13

2 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Paper prepared by: Director of Patient Services/Chief Nurse - Gill Heaton Director of Nursing (adults) Cheryl Lenney Deputy Director of Nursing (Quality) Deborah Carter Date of paper: July 2013 Subject: Annual Complaints Report 2012/13 Purpose of Report: Indicate which by Information to note Support Resolution Approval Consideration of Risk against Key Priorities (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) Recommendations The Board of Directors is asked to note the content of this report and in line with statutory requirements give approval for it to be published on the Trust s internet. Executive Summary The Trust adheres to the statutory instrument 309 which requires NHS bodies to provide an annual report on its complaints handling, which must be made available to the public. This report provides an overview of the Trust s Patient Advice and Liaison Service (PALS) and complaint activity between the 1 st April 2012 and the 31 st March The Trust recorded an increase in the number of contacts made to PALS and through the formal complaints process in line with the national trend. The Trust considers these contacts as valuable opportunities to receive feedback from patients and service users, contributing to a culture of continuous improvement 1

3 Following the publication in February 2013 of the Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry, chaired by Sir Robert Francis (Referred to hereafter as the Francis Report); there has been a renewed focus on both raising and responding to concerns. The Trust has noted an increase in the final quarter of 2012/13 in the number of formal complaints and the number of contacts with the PALS team. The PALS department responded to 3306 contacts during the last financial year, an increase of 26% compared to 2011/12. In the vast majority of contacts PALS, in liaison with the Divisions, were able to provide a timely and proportionate resolution to the enquirers query or concerns. Royal Manchester Children s Hospital received the highest number of PALS queries experiencing a 21% increase; however Corporate Services, Division of Specialist Medical Services and Saint Mary's Hospital all experienced reductions of 9%, 6% and 14% respectively. For a third year patients or their relatives did not raise any Red rated cases through PALS. The key themes emanating from complaints remained relatively static to that of 2011/12. The Trust received 1084 written complaints in year which required a Chief Executive response; this is a 35% increase on the previous year. The Division of Surgery received the highest number of complaints with a rise of 27% on 2011/12, and replaced RMCH for the first time in four years. Those cases graded red have seen a slight rise from 9 in 2011/12 to 11 for the last year. Quarterly reports have been provided to the Operational Managers Group (OMG) to ensure consistent reporting and sharing of thematic learning across the Trust. In line with our contractual obligations this information is also shared with the Clinical Commissioning Group (CCG), and formerly the PCT. Complaint response times have improved (by 5%) to 89% compared to 84% last year. Complaint themes have remained consistent however concerns relating to staff attitude in both PALS contacts and complaints have increased on last year s figure by 43%. Meetings held with patients and or their relatives continue to increase, with 160 being held in 2012/13 compared to 105 in 2011/12, a 34% increase. Since 2009/10 to date, the Trust has seen a 78% growth in the number of meetings held. Meetings tend to be regarding positively by patients and service users. The Parliamentary Health Service Ombudsman (PHSO) has notified the Trust of its intention to undertake a full investigation of a complaint for the first time in over four years (this relates to a case from 2009 and further information has been provided to the PHSO). In addition, a case relating to Trafford Hospitals, predating the Trust s acquisition, was fully upheld. The PHSO has indicated that the threshold for investigating concerns will reduce following recommendations by the Francis Report and the Trust anticipates a greater involvement of the PHSO in following up cases in the future. 2

4 The Trust can demonstrate a number of noteworthy improvements developed from learning identified from complaint investigations. The Complaint Review Group Chaired by a Non Executive Director has continued to meet monthly and the review and recommendations provide additional rigour and quality to the complaints management processes. The group have noted an improvement in both response times and the quality of responses provided. This report provides information for planned improvements to the complaints process for the year 2013/2014 and also sets out the progress made by both the Divisions and the PALS and complaints team. Both work in partnership to meet the needs of patients and their families to ensure that complaints are used to improve services and where possible ensure that lessons are learned once. The Board of Directors is asked to note the content of this report and in line with statutory requirements give approval for it to be published on the Trust s internet. 1. Introduction 1.1 The Trust adheres to the statutory instrument 309 which came into effect in April These require NHS bodies to provide an annual report on its complaint handling and consideration, a copy of which must be available to the public. This report provides an overview of the Trust s Patient Advice and Liaison Services (PALS) and complaint activity between the 1st April 2012 and the 31 st March PALS has maintained its position with patients, the public, staff and external organisations as a department that is responsive and pro-active to queries and concerns. PALS remains an effective resource in supporting patients, their representatives and staff respond to real time queries and concerns. Within the PALS remit is the management of complaints which require a Chief Executive response. Through this work PALS seek to maintain an appropriate level of contact with the complainants, and external agencies; whilst working with the responding Divisions to compile a response or hold a meeting that effectively addresses the complaint concerns on behalf of the Chief Executive. 1.3 To support the increase in PALS contacts the team responding to enquiries and concerns regarding children have re-located into the PALS office situated in the Manchester Royal Infirmary in order to make the most effective use of resources. PALS will continue to attend the Family Support Centre should a family require assistance, thus maintaining ease of access. 2. PALS Activity 2.1 During the last financial year PALS responded to 3306 contacts; a 26% increase in contacts from 2011/12. The increase in PALS contacts is reflective of the general rise regionally and nationally in the public approaching PALS departments. The increase in contacts may signify that some staff and/or Trust s services are not adequately meeting particular patients and their relative s needs. 3

5 However, it also demonstrates that the public are confident in approaching PALS to discuss and seek support to address their concerns. 2.2 Table 1 provides a breakdown of the number of PALS contacts per Division. Please note that the Trust acquired Trafford Hospitals (including Altrincham General and Stretford Memorial) on April 1 st Table 1 PALS Contacts Division 2010/ / /13 Not stated/general Enquiry Clinical Scientific Services Corporate Services Dental Hospital Division of Medicine and Community Services Division of Specialist Medical Services Division Of Surgery Manchester Royal Eye Hospital Royal Manchester Children s Hospital (RMCH) Saint Mary's Hospital Trafford Hospitals - 790* 533 Total * Data taken from Trafford NHS Trust s Annual Report & Accounts 2011/ The Trust has seen some fluctuation on the volume of contacts per Division for this reporting period in comparison to 2011/12. Clinical Scientific Services has seen a 26% increase in the number of contacts. The Dental Hospital, Division of Medicine and Community Services and Division of Surgery have also seen increases of 23%, 11% and 11% respectively. The Manchester Royal Eye Hospital contacts have risen by 5%, with the Royal Manchester Children s Hospital experiencing a 21% increase. Although the increases do not represent the overall picture, as there have been decreases in contacts regarding Corporate Services (down 9%), Division of Specialist Medical Services (6%), and Saint Mary's Hospital (14%). 2.4 The acquisition of Trafford Hospitals has accounted for 16% of the overall rise in PALS contacts. Positively, the Trafford Hospitals Division has seen a 33% decrease in the number of contacts to that received in 2011/ The themes regarding each Division do contain some variation; for instance PALS contacts regarding the Royal Eye Hospital relate to communication and appointment delays and cancellation. Patients report difficulty in getting through to MREH by telephone to arrange, check, or cancel their appointment. MREH senior management team with the service improvement team are in the process of addressing these issues through review and reorganisation of systems and processes and through the use of technology. 2.6 Graph 1 provides the number of PALS contacts received by month for the past year. 4

6 Graph All PALS contacts are graded by a PALS Case Manager based on the details provided by the person contacting the service; the grades range from White, Green, Yellow, Amber and Red. For instance a White graded query would be a low level enquiry such as informing a person of the Trust s wheelchair facilities, whilst a Red grade issue would relate to a suspected serious untoward incident or outcome for the patient. The PALS team refer to an adapted risk matrix to assist their grading of the concerns. The grade is reviewed by PALS at the end of their involvement to ensure it has accurately reflected the issues identified. 2.8 For the past three years no red graded cases were brought to PALS attention by patients or their relatives. This continues to indicate that the most concerning incidents have been identified around the time it occurred, and responded to by the staff involved. Table 2 denotes the number of contacts per grade. 2.9 PALS contact by risk rating Table 2 Category 2010/ / /13 Not Stated White N/a N/a 3 Green Yellow N/a N/a 2 Amber Red PALS contacts by enquirer 2.11 The predominant enquirers to PALS continue to be the patients relative followed closely by the patient s themselves. Table 3 outlines the breakdown of enquirer. 5

7 Table 3 Enquirer Type 2010/ / /13 Not Stated Patient Relative Carer / Friend Not stated Hospital Staff External Agency Members of Parliament Not stated Total Table 4 lists the number of contacts by age range and gender; the ages and genders captured relate to those of the people who were the focus of the PALS enquiry PALS contacts relating to the 0>18 age range remains the largest group and is line with the volume received for RMCH. Those contacts across the age ranges of 19>89 are relatively comparable with 2011/12 figures, taking into consideration the increase in contacts PALS contacts by women constitute 57% of the overall number of enquiries. Table 4 Age Number Gender groups 0 > Female > Male > Not specified > > > > > > Table 5 offers an insight into the ethnicity of the patients referred to within the contacts. Table 5 Category Any Other Ethnic Group 19 Asian or Asian British : Bangladeshi 2 Asian or Asian British : Indian 17 Asian or Asian British : Other Asian 9 Asian or Asian British : Pakistani 46 Black or Black British : Black African 17 Black or Black British : Black Caribbean 16 6

8 Table 5 (Continued) Black or Black British : Other Black 8 Chinese or Other Ethnic Group Chinese 6 Mixed : Other Mixed 5 Mixed : White & Asian 3 Mixed : White & Black African 3 Mixed : White & Black Caribbean 3 Not Stated 2143 White : British 957 White : Irish 20 White : Other White 32 Total The PALS team will work with the Trust Equality Team over 2013/14 to strengthen its capture of patients and their representative protected characteristics', such as age, disability, religion and sexual orientation (as outlined in the Equality Act 2010), to ensure the services remains accessible to all sections of the community Reason for PALS contact 2.18 Table 6 provides the leading themes why people contacted PALS during the past year. Table 6 PALS Enquires No. Consent/Communication/Confidentiality 1162 Treatment/Procedure 971 App, Delay/Cancellation (OP) 661 Attitude of Staff 258 Access, Admin, Transfer, Discharge Complaints Activity 3.1 The Trust received 1084 written complaints for the year 2012/13, in which the complainant requested a Chief Executive response letter. This is a 35% increase on 2011/12, which mirrors the increase within PALS contacts. 3.2 Overall complaints have increased Trust wide, with no predominant Division(s) and/or theme apparent to account for the increase. It is noteworthy to highlight that complaints within the NHS have increased regionally and nationally. Table 7 lists the complaint number received over the past three years. Table 7 Year 2010/ / /13 Complaints Received

9 3.3 The age ranges and genders of the patients involved in the complaints are captured in Table 8. Table 8 Age Number Gender groups 0 > Male > Female > Not known 21 40> > > > > > Table 9 contains the ethnicity of the patients represented within the complaints. Table 9 Category Number Any Other Ethnic Group 10 Asian or Asian British : Bangladeshi 1 Asian or Asian British : Indian 10 Asian or Asian British : Other Asian 6 Asian or Asian British : Pakistani 22 Black or Black British : Black African 6 Black or Black British : Black Caribbean 14 Black or Black British : Other Black 2 Chinese or Other Ethnic Group Chinese 2 Mixed : Other Mixed 5 Mixed : White & Asian 3 Mixed : White & Black African 1 Mixed : White & Black Caribbean 2 Not Stated 603 White : British 371 White : Irish 14 White : Other White 12 Total Table 10 represents the number of complaints received per Division; however a number of the complaint responses will involve multiple Divisions due to various specialities involved in delivering the patient s care. 8

10 Table 10 Divisions Clinical Scientific Services Corporate Services Dental Hospital Medicine and Community Services Specialist Medical Services Surgery Manchester Royal Eye Hospital RMCH Saint Mary's Hospital Trafford Hospitals 76* 87* 101 External Total * Data taken from Health & Social Care Information Centre KO41a report 2011/ All of the Divisions have seen an increase in complaints, with the most notable rises being in Clinical Scientific Services up 60%; Specialist Medical Services a rise of 49%; and Royal Eye Hospital up by 41%. The remaining Divisions, Corporate Services, Division of Acute and Community Services and Division of Surgery have seen rises of 35%, 27% and 27% respectively. RMCH received one of the lowest percentage increases of 17%, Saint Mary's Hospital 15% and Trafford had an increase of 14%. 3.7 Placing Trafford Hospital s complaints contribution of 9% to the overall figure to one side, the Trust has still experienced a 28% increase on last year s total. 3.8 For the first time since 2008 the Division of Surgery received the highest number of complaints, replacing RMCH. 3.9 The Trust assisted in providing information towards 20 external complaints Complaints risk rating 3.11 Complaints grading has been widened in line with the grading given to PALS contacts to better reflect the impact upon the patient/complainant. The Trust has seen a rise in the Yellow and Amber (medium level of seriousness) graded complaints. The Trust has a number of current programmes of work as part of the Improving Quality Programme designed to understand and address the underlying concerns. This includes the use of the patient experience tracker to gather local data along side the Quality Care Rounds. In addition the implementation of Patient Focus Rounding has enabled early redress of patients concerns; from April this year this will be strengthened to explore concerns about worries and fears. Table 11 lists the numbers of complaints by grade. 9

11 Table 11 Category 2010/ / /13 Not Stated White n/a n/a 10 Green Yellow n/a n/a 547 Amber Red Complaint response times 3.13 The Trust has maintained the internal default standard response time of 25 working days, which can be extended following discussion with the complainant and the respective Division(s); to ensure the complainant receives an open, concise and proportionate response to their concerns The progress of every complaint within the Trust is monitored weekly through the PALS performance report and meetings. This is in close liaison with the responding Divisions to make certain that responses are on target for the agreed response date Providing high quality and timely responses to increasingly complex, multi- Divisional and often multi-trust complaints remains a challenging agenda. The Trust s overall performance rate has improved, although there has been some fluctuation in performance within the Divisions as captured in Tables 12 and 13. The time period for response can be re-negotiated with the complainant, and is only undertaken when absolutely necessary. Table 12 Target / /13 Achievement of target response time against agreed timescale 767 (93%) 705 (84%) 1084 (89%) 3.16 Table 13 provides the Divisional response rates. It is important to note that the patient journey often involves several Divisions including diagnostic and support service. The impact of investigating concerns across services and departments can build delays into the responses. Table 13 Divisions Percentage responded to within agreed time period 2011/12 Percentage responded to within agreed time period 2012/13 Clinical Scientific Services 87% 77% Corporate Services 100% 94% Dental Hospital 100% 95% 10

12 Table 13 (Continued) Medicine and Community Services 93% 87% Specialist Medical Services 80% 94% Surgery 91% 96% Manchester Royal Eye Hospital 98% 93% RMCH 87% 88% Saint Mary's Hospital 78% 90% Trafford n/a 75% 3.17 Complaint themes 3.18 Table 14 lists the three main complaint themes captured from complaints. The themes have remained the same however complaints relating to Consent/Communication/Confidentiality have become the second largest category. Table 14 Category 2010/ / /13 Clinical Assessment (Diag/Scan) Treatment / Procedure Consent/Comms/Confidentiality Table 15 outlines the number of concerns directly related to attitude of staff from PALS contacts and Complaints, which have risen by 43% from the previous year. Table 15 Attitude of Staff 2010/ / /13 PALS Complaints Total Chart 1 provides a breakdown of the staff groups mentioned in reference to staff attitude in complaints; whilst Chart 2 lists the combined 3 most referred to professions within PALS contacts and complaints. Chart 1 Chart 2 11

13 3.21 Meetings between complainants and staff 3.22 Meetings between patients and/or their representatives and staff in response to their complaints provide a beneficial method of sensitively addressing concerns. In 2012/13 the Trust held 160 meetings, which is a 34% increase on 2011/12. Over the past four years meetings have grown by 78%, with the Division of Medicine and Community Services (no.34), Division Of Surgery (no.33) and Saint Mary's Hospital (no.32) providing the main number of meetings The option of a meeting with appropriate staff members is offered by the Trust from the outset of the investigation, where appropriate. PALS and the respective Divisions work hard to provide a timely meeting date, however scheduling can be affected by the availability of staff. The Trust is considering options as to how best set meeting dates with the minimum disruption to front line services that meets the needs of the complainant. Increasingly meetings are recorded onto CD and a copy provided to the complainant, this has been very well received. 4. NHS Choices 4.1 NHS Choices is a website where patients and the public can comment on any NHS service. Positive and negative comments are posted usually anonymously and the site is monitored by the Care Quality Commission. The CQC monitors issues and concerns raised and the responses from the service provider. Appendix one provides a divisional activity report 5. Independent Review of the Complaints Process 5.1 The Parliamentary and Health Service Ombudsman (PHSO) represents the second and final stage of the NHS complaints process. The Trust continues to work directly with PHSO to satisfactorily resolve complaints. 5.2 The Trust received 39 requests for complaint case files and their associated medical records from the PHSO. This is a 46% increase on the previous year. The status of the cases area as follows: 5.3 Following preliminary review the PHSO declined to investigate 27cases. 5.4 Following the acquisition of Trafford Hospitals the Trust inherited an upheld complaint in respect of Trafford. The requirements of the PHSO in respect of their finding have subsequently been resolved. 5.5 The PHSO partly upheld a complaint due to the Trust s maladministration of a patient s care. As part of the resolution the Trust offered financial recompense, however the patient declined the sum offered. 5.6 The Trust resolved two PHSO cases through undertaking Interventions; these are tasks identified by the PHSO which they have agreed with the complainant will bring a satisfactory end to the concern. 12

14 5.7 The PHSO have decided to undertake a full investigation of one case, which they aim to complete by August This will be the first PHSO investigation at the Trust in over four years and relates to a complaint from At the time of completing this report the Trust was awaiting the decision on seven on-going cases; the Trust will work closely with the PHSO to satisfactorily resolve these cases. 5.9 On March 22 nd 2013 the Ombudsman announced that from 2 nd April 2013, the service will be investigating more complaints and sharing their decisions with the NHS organisation. The Ombudsman will now apply some basic tests to a complaint and if met the concerns will be investigated; with the intention to raise the number of their investigations from the hundreds which they have previously undertaken into thousands. 6. Service Improvements as a result of learning from complaints 6.1 It is essential that the Trust continues to learn from complaints, and ensures that what is learnt results in service improvements which are embedded in everyday practice. What follows are some service improvement examples from the Divisions, who are responsible for implementing and monitoring lessons learned through their governance systems. 6.2 Emergency Surgery Trauma Unit ward nurses are to receive training and instructions on how to clean speech valves so that they can educate patients how to do this on a daily basis. Speech and Language Team add speech valve cleaning to the regular trachea training sessions that is undertaken with ward staff so that they are all trained and competent. 6.3 The letters sent out to patients about samples which require sensitive disposal have been reviewed and reworded as feedback from families demonstrated that this was required. These letters have now been worded in ways which ensure that the family know exactly what is meant by the terminology used and are also in a softer tone, taking into account that most of these patients are grieving. 6.4 In order to provide a safer laboratory service in relation to blood products. The Haemophilia Unit will in future, inform the Blood Transfusion Laboratory of any patients requiring Octoplas (a solution of pooled human plasma) prior to their appointment, this should enable the laboratory to update the patient s record for Special Requirements on the Laboratory Information System and act as an additional check that the correct type of units are prepared. 6.5 Following a complaint which involved wound care, the wound surveillance nurse has provided an e-learning educational package to staff on ward 3&4, which explains how wounds heal, problems associated with wound healing and appropriate use of dressings etc. to reinforce the importance of wound care. 6.6 Changes to the Manchester Heart Centre Cardex system (the in house computerised system). This system has been re-programmed so that the patient s current status recorded on PAS, transfers directly to Cardex automatically; previously this had to be done manually. 13

15 In addition for any deceased patients the Cardex system now highlights this by the screen having a red background (rather than the usual blue) so it is immediately clear that the patient is deceased. 6.7 The Division of Medicine and Community Services now use patient comment cards on all their wards and in the community. It is hoped that they will serve to allow patients and relatives to feed back concerns and compliments about the quality of the care and how they would like services to improve. 6.8 In response to a number of complaints about capacity in the endoscopy clinics the division of Specialist Medicine have provided extra out of hour clinics to reduce the waiting times. 6.9 Renal Services, have introduced a regular management ward round which has significantly reduced the number of complaints in this area The Division of Surgery has introduced admission and discharge information packs to ensure patients are fully aware of events around these important times In Urology Services telephone log books have been introduced so that all patient telephone calls are recorded. The call, or series of calls, cannot be signed off until the matter is resolved. The system is monitored closely by the administration manager and has resulted in an improvement in the response rates and turnaround times to patient/relative queries Small business cards have been produced in the Division of Acute medicine and Community which have the names and contact numbers of the Matrons, senior nurses and managers for patients and families to contact if they have concerns about care whilst they are in hospital 6.13 The roll out of the core values Trust wide has commenced and is intended to inform a behavioural framework (Living the Values) to address poor attitude and behaviour fostering a culture of front line accountability 7. Demonstrating Compliance with Legislative Requirements 7.1 The predominant feedback from PHSO responses, following their initial reviews, indicates that the Trust s processes and performance with complaints handling remains robust. 7.2 The Complaint Review Group has welcomed the inclusion of a Trust Governor in to the core group. The Group continues to be chaired by a Non Executive Director and supported by an Associate Medical Director. The meetings are held monthly with 8 held in 2012/13 with the respective Divisional senior management teams. The Group s review and recommendations provides additional rigour and quality to the complaints management processes. 7.3 Monitoring of complaint processes against level 3 NHSLA standards continues to receive a high level of focus. 14

16 8. Plans for 2013/ Implement the behavioural framework Living the Values that is underpinned by the core values of the organisation to address the theme of poor staff attitude and to enhance the areas of practice where the attitude of staff is well received 8.2 Review the complaints handling training needs across the Trust. 8.3 Continue to explore a more structured timeframe in which to provide meetings between complainants and Trust staff. 8.4 Review the Complaints Review Group terms of reference in light of the Francis Report and contribute to the Trust response to the recommendations by September In liaison with the Trust s Organisational Development and Training create an internal complaints handling course to support the delivery of consistently good complaint responses. 8.6 Undertake a re-organisation of the PALS department to strengthen its delivery of high quality responses and meetings. 8.7 Provide a thematic review of complaints and concerns for divisions and departments to provide a focus for development 8.8 Use the Living the Values framework to support the Voices programme in engaging staff and focusing on the patient experience 8.9 Develop a process for patients to raise concerns and receive a response in real time whilst in our care 8.9 Review and update the Trust Complaints Policy 9. Conclusion 9.1 The Board of Directors is asked to note the content of this report, and in line with statutory requirements give approval for it to be published on the Trust s internet site. 15

17 APPENDIX 1 Report paper: NHS Choices Divisional Activity Report Report Prepared by: Eve Koutidou Patient Experience & Quality Officer On behalf of: Berenice Postlethwaite Patient Experience Manager Date of Report: May 2013 Introduction The report of the Francis Enquiry, published on 6 th February 2013, has identified the widespread failures of care at Mid Staffordshire NHS Foundation Trust and has highlighted the profound implications that those have had for the whole of the NHS. The report recognises that it is vital that all those involved in the provision and regulation of health care services are clear about where accountability lies and what actions must be taken when concerns about quality of care are voiced. Currently, the Trust is being assessed by the Care Quality Commission (CQC) against the Quality and Risk Profile (QRP). The evidence that supports the QRP is required from a range of sources including Patient Surveys, Trust self-assessments against the Essential Standards of Quality and Safety (ESQS), PLACE scores, NHSLA Assessment, inspection reports and the comments posted by patients on the NHS Choices and Patient Opinion websites. One method of receiving patient feedback and their experiences of care is through the NHS Choices and Patient Opinion website which offers patients and the public the opportunity to contribute to the sites. Patients and the public can comment on any NHS service, including hospitals, and in some cases patients and their carers work alongside inspectors to provide uses views of various services. Positive and negative contributions are therefore made by patients and service users of the Trust which are being monitored by the CQC. The Care Quality Commission also monitors issues and concerns raised and, in particular, the responses made and any activity that results to improve the patient experience. Methodology The Patient Experience and Quality Team (PE&QT) is the first point of contact for NHS Choices and Patient Opinion responses posted on the website via alerts. The team has a responsibility to circulate these responses to the appropriate Divisions for dissemination, response and action planning where appropriate, following a system of quality assurance for responses for high level comments and generic responses for low level comments managed by the PE&Q team. The comments posted are scored using a Red / Amber / Green score rating system using trigger words which align to complaints, incidents, Ombudsman and the CQC key words and areas. The evidence and audit trails also have a reporting system and process for delivery and action. 16

18 All received comments are sent to the appropriate Divisional contacts via Clinical Governance routes by the PE&Q Project Officers so that the PE&Q Team and Clinical Governance Leads can implement the internal arrangements for complaints responses or comments. The Clinical Effectiveness Leads co-ordinate the responses from the relevant Divisions and an agreed template response is then submitted to the PE&Q Project Officer for publicising on the website. A Quality Assurance Reporting form is completed in the event that a more personalised response to a posted comment is deemed more appropriate. In this case, the Quality Assurance form is signed off via the complaints framework by the appropriate Head of Nursing / Divisional Director and is forwarded on to the Deputy Director of Nursing (Quality) by the PE&Q Project Officer for final sign off. The monitoring of response quality assurance is monitored by the PE&Q Project Officers and Clinical Governance Leads. A comprehensive database is used to record and monitor all received comments and posted responses. Weekly reports are submitted to the Deputy Director of Nursing (Quality) by the PE&Q Project Officers for information and action where appropriate. Facts and Figures From 1 st April 2012 until 31 st March 2013 a total of 94 comments were received via the NHS Choices and Patient Opinion websites. Table 1 Division Postings received Responses Altringham General 2 1 Corporate Services 2 2 Clinical & Scientific Services 1 1 Children's Hospital 6 6 Dental Hospital 6 4 Div. of Medicine and Community Div. of Specialist Medicine 9 7 Div. of Surgery 11 3 St. Mary's 6 5 Royal Eye Hospital Trafford General 9 0 Total The top three themes identified are Positive Experience (36), Negative Experience (20) and Communication (17) responses. Positive and Negative Experience was selected as a separate theme to include those comments that both complimented staff and services and also identified areas for service improvement. It should be noted that in some cases more than one themes / issues were identified in the received comments. Figure 1 below shows a breakdown of all the identified themes and hotspots Trustwide. 17

19 Fig. 1 Breakdown of identified themes and hotspots Figure 2 below shows the various themes by Division identified in the NHS Choices and Patient Opinion comments received from 1 st April 2012 until 31 st March Fig. 2 Themes Identified per Division Table 2 below shows a breakdown of themes highlighted in the received postings, as well as the themes received for each of the Divisions. In some occasions, more than one themes / issues were identified within a single comment. 18

20 Table 2 The graphs below show a breakdown of themes and hotspots by Division. From 1 st April 2012 until 31 st March 2013 Altringham General received 2 comments regarding the services provided. Those included positive comments about staff as well as comments in relation to communication and staff attitude. Fig. 3 Two comments received via Patient Opinion and NHS Choices required a very considered and prompt Corporate response by the Deputy Director of Nursing (Quality). 19

21 Fig. 4 From 1 st April 2012 until 31 st March 2013 the Dental Hospital received 6 postings regarding the services provided. A third of those comments complimented staff for their contribution to improving patient experience. Fig. 5 The top three themes for the Division of Medicine and Community that were identified in the 22 comments that were received are Positive Experience, Information and Communication, with the positive comments representing more than a third of the total postings received. 20

22 Fig. 6 Out of the 9 comments received for the Division of Specialist Medical Services, Positive Experience was the theme that featured the most, followed by Communication, Treatment and an overall negative experience. Fig. 7 The Division of Surgery received 11 comments in total, with 40% of them identifying an overall negative patient experience of the service users who believed service improvements would need to be considered. 21

23 Fig. 8 Half of the comments received for St. Mary s Hospital were positive, with patients complimenting the attitude of staff as well as the clinical care and treatment they received whilst they were in the hospital. Fig. 9 A total of 21comments were received from 1st April 2012 until 31st March 2013 with regards to the Royal Eye Hospital, 29% of the postings published identified a positive experience, mostly with regards to the clinical treatment and the attitude of staff. The main issues and concerns of service users highlighted referred to the long waiting times and the unavailability of earlier appointments. 22

24 Fig. 10 A total of 6 comments were received with regards to the Children s Hospital services from 1st April 2012 until 31st March Those involved positive experiences about staff attitude and the care and treatment the users received, issues around appointment times, lack of information provided and concerns regarding the attitude of staff and the clinical treatment. Fig. 11 Conclusion The Trust is committed to improving the patient experience and treating comments posted on NHS Choices and Patient Opinion with the same level of scrutiny and also demonstrate evidence of learning as those comments and concerns raised directly with the Trust. 23