Report from: NHS Greater Glasgow and Clyde Report for: Scottish Health Council Report on: Participation Standard Self-Assessment 2015 Date: July 2015

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1 Report from: NHS Greater Glasgow and Clyde Report for: Scottish Health Council Report on: Participation Standard Self-Assessment 2015 Date: July 2015 Outcome: NHS Greater Glasgow and Clyde considers that we have achieved the Developing Level in Section 1 of the Participation Standard. The Patients Rights (Scotland) Act 2011 requires Boards to ensure that patient s feedback, comments, concerns and/or complaints are actively collected, monitored and used to improve services. In response NHSGGC has developed systems that will: encourage all patients and families to give feedback evidence numbers, themes and actions taken to improve healthcare services as a result of feedback 1.1 Gathering Feedback NHSGGC is currently in the process of implementing four key approaches to listening to our patients and carers; the four main feedback systems currently used are: Universal Feedback each inpatient is given a feedback card at point of discharge. Cards and process tested with patients and carers. On-line Patient Feedback web based patient, carer or public feedback system. Tested with patients, carers, members of the public, and those with additional needs. Patient Opinion on line, externally run website. Carer s Audit developed with carers; format and content checked with each and every carer. All four main methods of feedback have been developed with and progress shared with the Patients Panel. They receive regular updates on the feedback received These centrally managed systems are complemented by bespoke, local approaches such as service surveys, patient s forums and patient stories which help to build a rounded picture of the patient experience in NHSGGC. [pp 5-9, NHSGGC Annual Report 2014/15] NHSGGC embeds listening to patients with protected characteristics in mainstream engagement activity as well as in a range of targeted activities designed to better understand the needs of equality groups. Projects undertaken in with British Sign Language (BSL) Users; the Roma Community and Transgender people demonstrate how listening to patients has led to a range of actions to meet their issues. Examples of these actions include the introduction of a British Sign Language Mediator to gather and collate feedback from Deaf people about their use of NHSGGC services; awareness-raising on services for the Roma Community and staff training on how Transgender people should be responded to within mainstream services. These projects, and others in Gender Based Violence and Social Class, illustrate how NHSGGC is working with patients and carers to ensure there is barrierfree access to our services for those protected by the Equality Act [pp 10-13,

2 Feedback processes in independent contractors are described in pp13-20, NHSGGC Annual Report 2014/15. Patient Advice and Support Service: NHSGGC promotes PASS: on the NHSGGC website all complaint acknowledgements enclose a PASS leaflet via responses on Patient Opinion via outreach clinics held in two ambulatory care hospitals all Patient Information Centres have PASS leaflets available in talks given to PPFs, patient and carer groups by PASS Staff promoted to staff via induction training by supporting a PASS Local Advisory Group whose membership includes two patient representatives [pp 36-37, 1.2 Early Resolution of Complaints NHSGGC has made available posters and leaflets publicising how and where to raise complaints and we encourage and try and empower our staff to deal with as many concerns/complaints at the frontline as is possible in order that a satisfactory local resolution can be achieved. The performance against a 3 day or similar target has not been captured however the only area where this is achieved regularly and consistently is with prison healthcare complaints. This is shown in the performance of more than 90% of complaints handled within 20 working days, despite the high numbers of such complaints. [p 29, 1.3 Publicising Feedback Leaflets and posters describing the complaints process, giving contacts for advice and support and describing what patients and their families can expect from the process are widely available. PASS materials are widely available. Posters and leaflets promoting Universal Feedback on all participating wards. Each Universal Feedback card promotes online feedback systems and a telephone feedback helpline. Feedback is promoted on line. Offer to provide materials in minority languages made routinely. Offer of support including translation and sign language interpretation given to each carer in Carers Audits. [p 29, 1.4 Training and Staff Development Within NHSGGC 5 e-learning modules are available to staff via LearnPro and the uptake is monitored, all of which support the delivery of a health service which actively listens and acts in response to patient feedback. These modules were developed by NES. They are included within the statutory/ mandatory training programme for all new staff as well as those staff who transfer internally within NHSGGC and meet the definition of a Health Care Support Worker (HCSW). A new Complaints Investigation Skills module was developed by NES in March 2015 and this is also now available via LearnPro. This module has been specifically developed for staff who play a key role in conducting investigations. [pp 45-47,

3 1.5 Processes to Demonstrate Improvements The Board's Acute Services Division and Partnerships have implemented systems to monitor the lessons learned and the implementation of recommendations and/or actions arising from complaints and the recommendations contained in any Scottish Public Services Ombudsman (SPSO) reports to ensure these are translated into service improvements. These reviews are normally carried out through the Clinical and Care Governance arrangements. [p 29-32, The Community Engagement Team, as was, and the Patient Experience Group, which includes patient representation, devised a robust monitoring and governance scheme for feedback as required by the Patients Rights Act. This involves the feedback received from centrally managed systems is collated into a monthly Patient Experience Service Improvement Report. This report highlights where suggestions for improvement have been identified. Currently each Acute Sector/Directorate receives an individual monthly report specific to their area and copies are also provided to General Managers and Directors. Every three months each area is asked to update their report with information on the actions that have been taken to address the issues identified. This report helps to inform the quarterly Complaints, Feedback, Comments and Concerns Reports which are submitted to the NHSGGC Board. This process was trialled throughout It has now gone live and will be reviewed in [p 9,

4 Report from: NHS Greater Glasgow and Clyde Report for: Scottish Health Council Report on: Participation Standard Self-Assessment 2015 Date: July 2015 Outcome: NHS Greater Glasgow and Clyde considers that we have achieved the Developing Level in Section 3 of the Participation Standard. A key section of the Patients Rights (Scotland) Act requires Boards to establish robust monitoring and governance processes that evidence numbers, themes and actions taken to improve healthcare services as a result of feedback. 3.1 Developing Accountability and Governance Mechanisms to Learn From and Take Action from Complaints: Local Clinical Governance structures within Acute Directorates and Partnerships and CH(C)P Committees review complaints and lessons learned locally to ensure shared learning. The Annual Report sets out the arrangements within Partnerships to review such matters from the independent contractors. [pp 38-41, NHSGGC Annual Report 2014/15] The Board Nurse Director submits a Quarterly Complaints Report to the public meeting of the NHS Board providing commentary and statistics on complaints. These reports cover numbers and trends within Directorates, Partnerships, services and hospitals and provide information on the Investigative Reports from the Scottish Public Services Ombudsman s Office (SPSO). They also cover complaints received by General Practitioners, General Dental Practitioners, Opticians and Community Pharmacists and highlight the improvements against themes and trends. NHS Board Members review service improvements for the benefit of patients together with the recommendations and trends contained within the SPSO and Information Services Division (ISD) Annual Reports. In addition, a quarterly report is submitted to the Quality & Performance Committee which highlights all actions taken as a result of any recommendation contained within SPSO Investigative Reports or Decision Letters. NHS Board Members have been concerned at the number of issues which the SPSO has upheld in relation to NHSGGC cases and have stressed to officers that they would wish to see an improvement in the local resolution stage of complaints in order to see a reduction in the number of upheld issues by the SPSO. Following this criticism the Chief Executive now writes to each relevant Director when the SPSO uphold an issue/complaint asking how that happened and what action will be taken to ensure an improvement in future. The revised Significant Clinical Incident (SCI) Policy has brought significant improvements to handling SCIs with family s involvement and a formal process of liaison between complaints staff and those staff handling SCIs has been introduced in order ensure significant clinical complaints are brought to the attention of the Clinical Governance staff.

5 Lastly, the PASS Local Advisory Group receives a copy of the Quarterly Complaints Report and Annual Reports and discusses the issues, trends and themes raised. [p 47, 3.2 Developing Accountability and Governance Mechanisms to Learn From and Take Action from Feedback, Comments and Concerns: NHSGGC has been implementing a reporting format that will evidence numbers, themes and actions taken to improve healthcare services as a result of feedback. Working with the Patient Experience Group, which includes patient representation, it was agreed that there are three elements to this system: Patient Experience Service Improvement Reports: compiled by the Patient Experience Public Involvement Team, these are sent monthly to Directors, General Managers and Patient Experience Leads and include information from the 4 centrally managed feedback systems: Universal Feedback; NHSGGC Patient Feedback System; Patient Opinion and Carers Audits. These reports summarise feedback and identify actionable points. [p 9, Directorate Quarterly Returns: summarises the actionable points identified in the previous quarter s Patient Experience Service Improvement Reports and asks for progress on these. In addition it asks Directorates to provide a high level summary of feedback received via locally managed systems. Board Reports: the Directorate Quarterly Reports, in turn, form the basis of quarterly Board reports which systematically summarises feedback received, identify exceptions to a 95% standard for positive Universal Feedback and track actions taken and service improvements resulting from feedback. The format has been designed to provide both information and assurance to Non-Executives regarding the quality of services, the satisfaction of patients and carers and, where there are issues or areas for improvement, that appropriate action is taken, The Board Report, the Quarterly Report on Complaints and Feedback, is presented by the Board Nurse Director. It combines reports on complaints and feedback in order to facilitate a fully rounded picture of the views of patients, carers and the public. The Annual Report on Feedback, Comments, Complaints and Concerns compliments the processes for the scrutiny of the handling of complaints and feedback and how both have led to genuine service improvements and lessons learned for the benefit of future patients and provision of services. [pp 42-44, NHSGGC Annual Report 2014/15]