NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control Reference Approving Body Trust Board Date Approved Implementation Date Version Consultation Undertaken Directors Group Directorate Patient Groups January 2013 Patient Public Involvement Steering Group January 2013 Patient Partnership Group January 2013 Members January 2013 Date of Equality Impact 3/12/2012 Assessment Date of We Are Here for You 3/12/2012 Assessment Date of Environmental 3/12/2012 Impact Assessment Legal and/or Accreditation Care Quality Commission Essential Implications standards of quality and safety March 2010 Equality Act 2010 Government to the NHS commissioning Board April 2013 to March 2015 Health and Social Care Act 2012 NHS Constitution 2010 NHS Friends and Family Test Guidance 2012 The Mandate A mandate from the Government to the NHS commissioning Board April 2013 to March 2015 Target Audience Staff, Patients and the Public Review Date 2016 Lead Executive Jenny Leggott, Director of Nursing and Author/Lead Manager Midwifery and Deputy Chief Executive Katie Moore, Head of Patient Public Involvement (PPI) Extension 76029 Further Guidance/Information Katie Moore Head of Patient Public Involvement (PPI) Extension 76029 1
CONTENTS Paragraph Title Page 1. Introduction 3 2. Executive Summary 3 3. Policy Statement 4 4. Definitions (including Glossary as needed) 4 5. Roles and Responsibilities 5 6. Policy and/or Procedural Requirements 9 7. Training, Implementation and Resources 11 8. Trust Impact Assessments 13 9. Monitoring Matrix 14 10. Relevant Legislation, National Guidance and 15 Appendix 1 Appendix 1A Appendix 1B Appendix 1C Appendix 1D Appendix 1E Appendix 1F Appendix 1G Appendix 1H Appendix 1I Associated NUH Documents Involvement Flow chart Questions to consider when planning PPI PPI Planning Processes PPI Planning Checklist PPI Costing Template PPI Volunteer Job Description PPI Volunteer Job Remit Request for Members PPI Volunteer Local Induction PPI Volunteer 12 Month Review Appendix 2 Patient Experience, how it fits in with PPI 30 Appendix 3 Equality Impact Assessment 31 Appendix 4 Environmental Impact Assessment 33 Appendix 5 We Are Here For You Assessment 35 Appendix 6 Certification Of Employee Awareness 37 16 17 18 19 20 22 26 27 28 29 2
1.0 Introduction 1.1 This policy; outlines the Trust s commitment and approaches to further developing Patient Public Involvement (PPI) so that the views and needs of patients and the public are at the heart of our decision making. provides a framework to enable staff to listen and respond to the views of patients and the public and increasingly involve them in the planning, provision and evaluation of services. 2.0 Executive Summary 2.1 2.2 2.3 To facilitate the Trust working in partnership with patients and the public, staff will; involve patients and public as partners in decision making so that the Trust provides services based on the needs of those we serve. listen and respond to patients and the public, politely and respectfully, capturing and using their views to further improve the hospital experience. Each directorate will be expected to work with patients and the public to develop PPI appropriately to the needs of patients, the public and their service. They will be expected to develop systems to involve patients and the public from the range of diverse communities served and work towards meeting the following PPI promises made to patients and the public; we will involve you in the planning, monitoring and development of services and let you know what has changed. we will ask regularly for your views on the services we provide and let you know what action we have taken. we will involve you in the planning and co- ordination of your care. When involving PPI staff should follow the involvement flowchart (Appendix 1) and agree the following in partnership with patients and public; why patients and public are being involved. the roles of those participating and what is expected of them. 3
the expected outcome of the involvement and how and when the outcome will be fed back to participants. how participants will be recognised and rewarded for their involvement.this may include reimbursement of expenses, attending presentations/conferences and being put forward for special trust recognition. how the views of the diverse range of people who may use the service are collected and listened to. 3.0 Policy Statement 3.1 This policy sets out a framework to enable the trust to work in partnership with patients and public in the planning, development and day to day delivery of services. 4.0 Definitions 4.1 4.2 Directorate - In the policy the term directorate encompasses all clinical and corporate directorates. Patient Experience - Patient experience at NUH results from a range of activities that all impact upon patient care, access, safety and outcomes. Patients have told us for a good patient experience at NUH, they want the Trust to; provide good treatment in a comfortable, caring and safe environment, delivered in a calm and reassuring way. give them information to make choices, to feel confident and to feel in control. talk and listen to them as an equal and treat them with honesty, respect and dignity. NUH has used the NICE quality standard for patient experience as the basis for defining the elements that make up patient experience at the trust which are; knowing the patient as an individual. essential requirements of care. tailoring healthcare services for each patient. continuity of care and relationships. 4
enabling patients to actively participate in their care. For definition of patient experience at NUH and how it fits with PPI see (Appendix 2) 4.3 4.4 Patients and the Public in this policy the term patients and the public encompasses patients, other service users, carers, families, patient advocates, Foundation Trust (FT) members, individual members of the public, groups, communities. Depending on what we are looking to achieve, we may involve different elements of the patient and the public at different times. Patient Public Involvement (PPI) - PPI is the process of engaging with the needs and expectations of patients and putting the public and members at the heart of Trust decision making, to ensure that the services and care provided are outcome driven and patient centred. Specifically it is concerned with exchanging information, mutual listening, and accepting that people should be allowed to influence their own care and the services they receive. PPI defines the way in which patients and the public have a voice in decisions about how healthcare services and research are planned, designed, delivered and evaluated. PPI must therefore operate on three levels; involving individual patients and their carers as partners in decisions about their treatment and care and empowering them to make informed decisions about their healthcare wherever practicable. enabling patients and the public to be involved and consulted on planning, monitoring, evaluating and developing services, proposals to change services and decisions about the way services operate. involving and engaging patients and the public in planning, development, delivery and evaluation of relevant research and research related activities to the benefit of patients and the public. 5.0 Roles and Responsibilities 5.1 Committees The Trust Board will champion PPI across the Trust, ensuring that 5
the Trust will; meet its statutory duty to involve patients and the public. complies with the pledges made in the NHS Constitution. meets the Care Quality Commission s standards. implements its PPI policy through monitoring and review procedures. The Quality Assurance Committee (QUAC) (a Trust Board committee) will; provide the Trust Board with assurance about the effectiveness of PPI arrangements. monitors and reviews outcomes from national surveys and Trust real-time surveys, approves actions and monitors improvements. monitors, reviews and reports Trust performance against CQC Outcome 1, Regulation 17 (PPI). critically evaluates reports on each directorate s effectiveness in engaging patients and the public across the range of all its services and communities. critically evaluates information on patient experience, including regular reports on directorate performance in surveys (and all other relevant modalities) of patient and public experience of trust services. identify actions and timescales to improve on patient experience whenever required. contributes to the development of the Trust s PPI Policy. The Directors Group will; ensure that the PPI perspective is given consideration in developing all Trust projects and developments. ensures appropriate frameworks are in place for staff to carry out their PPI duties, such as in recruitment and appraisal processes. keeps appraised of directorate PPI activity. receive reports from QUAC in relation to from national surveys and Trust real-time surveys. The PPI Steering Group (a committee of the Directors Group) will; develop and implement Trust PPI policy to ensure that the Trust is an exemplar of PPI activities. monitors and evaluates the implementation of PPI policy and directorate work plans. 6
ensures close working with local PPI community groups. The Patient Partnership Group (a committee of the PPISG) will; gather and disseminate patient and public feedback, especially best practice, throughout the Trust. Undertaking work programmes as agreed with the PPI Steering Group. Supports the PPISG in monitoring and evaluating PPI activity. The Directorate Patient Partnership Groups will; advise on patient and public involvement activity within the directorate. participate in inspection visits and observations of care. advise on service improvements and service redesign within the directorate. publicise and raise the profile of patient and public involvement within the directorate. The Directorate Teams will; lead the implementation of the Trust PPI policy at directorate level. report to PPI Steering Group, QUAC and directorate staff. ensure that there are effective mechanisms and sufficient resources to implement the Trust PPI Policy within all directorates. 5.2 Individual Officers The Chief Executive will; be responsible for ensuring that the Trust complies with all statutory PPI obligations. Where possible facilitating the role of the trust as an exemplar of PPI activity. The Director of Nursing and Midwifery and Deputy Chief Executive will; be the Executive Director Lead responsible for PPI performance. The Trust Secretary will; have overall responsibility delegated from the Chief Executive for PPI, thus ensuring that systems are in place and are working effectively to enable staff to listen and respond to the views of patients and the public, involving them whenever feasible in the 7
planning, provision and evaluation of Trust services. The Head of Patient Public Involvement will; be responsible for leading the Trusts PPI function ensure that effective relationships continually develop with all relevant patient and public groups in the community. develops mechanisms that ensure PPI views are integral to the development of services at the trust. advises on national and regional policy on PPI. The Directorate PPI leads will; champion the implementation of PPI policy best practice at directorate level. co ordinate with staff, directorates, patients and public to produce an annual directorate PPI work plan. report to PPI Steering Group and directorate management team. act as the accountable directorate link to the PPISG. The Clinical Directors, General Managers and Heads of Service will; ensure that their directorate annual PPI work plans demonstrate, appropriate and effective PPI best practice in all aspects of care they are responsible for. monitor and evaluate monthly PPI activity in their area reporting the outcomes to the directorate PPI lead. Individual Members of Staff will; adhere to the Trust s requirements relating to PPI values and behaviours. engage with patients and the public by encouraging involvement in their care, providing them with appropriate information and promptly responding to their concerns. seek patients and the publics views about their services responding to feedback promptly and involving them to find solutions. ensure that they highlight significant shortfalls in services,raised by patients and the public with their manager or PPI leads as appropriate. 8
6.0 Policy and/or Procedural Requirements 6.1 6.2 6.3 Directorate Annual PPI Work Plans and Reports. Every directorate must plan PPI activity in order to deliver the following involvement promises that the trust has made to patients and public; we will involve you in planning, monitoring, and development of services we provide and tell you what we have changed. we will ask regularly for your views on the services we provide and let you know what action we have taken. we will involve you in the planning and co-ordination of your care. This will be achieved through the implementation of annual directorate PPI work plans. Accordingly each directorate is expected to report on the implementation of these work plans and changes they have made as a result of the PPI activities involvement to their directorate team and PPI Steering group. Patient Experience Feedback. every directorate must actively listen and demonstrate that they have responded to patients and the public s views, comments, complaints and compliments about their services. every directorate to participate in national and local surveys as appropriate and respond promptly to issues raised from participants in these surveys. Patient Public Involvement Steering Group (PPISG). PPISG will meet monthly to advise and facilitate, effective PPI involvement within the work of the Trust by; ensuring that clinical and managerial expertise are brought to bear on developing PPI policies. discharging its delegated responsibility in relation to PPI decision making. ensuring that all parts of the trust are engaged in the PPI agenda facilitating close working with the local community and ensuring that services provided by the trust are as a result of genuine patient public involvement. ensuring that best practice is effectively captured and shared across the trust. monitoring and reviewing the directorate PPI annual work plans and other reports. 9
6.4 6.5 6.6 DRAFT Patient Partnership Group (PPG). The PPG will meet monthly to; bring together public and patient and staff representatives under the chairmanship of a patient and public representative. ensure that patient and public representatives and staff representatives effectively work together to deliver the trust PPI policy. advise on PPI involvement by participating in inspection visits and observations of care and publicising and raising the profile of PPI across the Trust. Directorate Patient Groups will; run and manage a variety of PPI groups within their service delivery areas. ensure that these groups will provide a base for staff, patients and public to meet together to undertake involvement work and to bring about changes to services that are ever more closely orientated to PPI best practice. Foundation Trust (FT) Members. Staff will actively encourage patients and the public to consider becoming FT members, emphasising that FT members can decide their own level of involvement and commitment. FT members will; receive a member welcome pack when their registration has been logged. Receive invites to events, conferences and other involvement events run by the Trust. receive the Trust s bi-monthly newsletter have the opportunity to be put forward as a Trust governor and vote in election for governors be invited to participate in a diverse range of PPI activity including for example, readers panel, PPI surveys, staff interviews, inspection visits, volunteering on our wards and departments. opportunities to get involved will be advertised to the FT members according to their service interest and level of involvement indicated on their membership form. All FT members will be invited to the trust s Annual General Meeting held every September. 10
7.0 Training, Implementation and Resources 7.1 Support and Training for Patients and Public All patients and public who volunteer for involvement with patients and public which involve patient contact will be required to register as volunteers and undertake volunteer recruitment process induction and mandatory training (Appendix 1, 1A, 1B, 1C,1D, 1E, 1F, 1G, 1H, 1I). All patients and public who volunteer for PPI activities, must have in a language/format that is most accessible to them, a clearly defined role, a written PPI Volunteer job description/ppi volunteer brief (see and PPI local induction (Appendix 1E, 1F, 1H). All patients and public who undertake one off involvement activities should be given a clear remit of what is required from them, the name of the person who will manage them during the activity they undertake and receive feedback following any such activities from their manager (Appendix 1). If additional training is required to meet a specific PPI activity, this specific training should be promptly offered to the particular individual/group. This training will need to be funded by the relevant directorate. All volunteers who undertake PPI activities must receive appropriate on-going training, support and appraisals outlined in this Policy and Voluntary Services Policy. Expenses for travel, car parking and meal vouchers will be allocated on an individual basis in accordance with the Voluntary Services Policy and funded by the relevant directorate. 7.2 Support and Training for Staff A copy of the Trusts PPI Policy will be readily accessible to all members of staff. New members of staff being told how it can be accessed. All new staff will receive an introduction to involvement as part of the trust induction DVD. 11
All staff should be offered an opportunity to express a special interest in the trust s PPI activities and if appropriate, be contacted by their directorate PPI lead in order to capture and utilise this special interest. The Head of PPI will work with the PPISG and the PPI leads in each directorate to offer support and advice around PPI. The Head of PPI will also offer support and advice to directorate teams across the trust. 7.3 Implementation Directorate PPI leads in conjunction with their directorate teams will be held accountable for ensuring that this Policy is implemented across their directorate. Progress in implementing this policy will be monitored through directorate PPI monthly performance reports undertaken by the PPISG. A range of Policy implementation monitoring tools will be utilised by the PPISG including the amount and type of PPI activity within and across directorates, the outcomes from implementing PPI activity and relevant feedback from patients and the public. 7.4 Resources Directorates are required to identify appropriate resources to enable them to fulfil their PPI duties, as specified in this policy. 12
8.0 Trust Impact Assessments 8.1 Equality Impact Assessment DRAFT An equality impact assessment has been undertaken on this document (Appendix 3) and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment (Appendix 4) has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document (Appendix 5) and has indicated the need for additional considerations which have been duly incorporated. 13
9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Creation and implementation of annual PPI Directorate work plans Results of National Surveys Responsible individual/ group/ committee Directorate Team Relevant Directorate PPI Lead Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Reports Monthly PPI Steering Group Responsible individual/ group/ committee for development of action plan Directorate PPI Lead Report Annually QUAC Directorate PPI Lead Responsible individual/ group/ committee for monitoring of action plan PPI Steering Group QUAC Results of National Friends and Family Test Implementation Steering Group Report Monthly QUAC Patient Experience Lead QUAC Results of local surveys and feedback Individual directorate teams as appropriate Report Monthly QUAC Directorate PPI Lead QUAC 14
10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 Legislation Health and Social Care Act 2012 Equality Act 2010 National Guidance NHS Constitution 2010 The Mandate A mandate from the Government to the NHS commissioning Board: April 2013 to March 2015 Care Quality Commission Essential standards of quality and safety March 2010 NHS Friends and Family Test Guidance 2012 Associated NUH Documents Carers Policy - GG/CM/043 Equal Opportunities Policy HR/E&D/001 Information Governance Policy GG/INF/001 Managing visits, audits, inspections, assessments and accreditations by bodies external to the trust policy - GM/CM/023 Management of Complaints, Concerns, Comments and Compliments Policy GG/CM/002 NUH Patient and Public Involvement (PPI) Handbook Patient Information Policy and Procedure GG/CM/003 Patient Advice and Liaison Service Policy- GG/CM/004 Voluntary Services Policy GG/CM/005 Voluntary Services Recruitment Policy - HR/R&C/009 15
Patient Public Involvement (PPI) Flow Chart Appendix 1 1 Plan your PPI activities (Appendix 1A, 1B, 1C) 2 3 Cost and Identify resources required (including staff time, travel costs, refreshments etc.) Appendix 1D) Complete PPI volunteer job description/ppi volunteer brief (Appendix 1E & 1F) 4 5 Advertise for members use request for members form (Appendix 1G) Review response from members, interview assess and appoint as appropriate 6 Identify type of involvement and whether it involves patient contact. 7 Does activity involve patient contact? Yes No 8 Refer person to Voluntary Services Manager for full or guest volunteer recruitment process. Full recruitment process includes completion of application form, checking of references, Disclosure and Barring Service (DBS) and Volunteer induction. 9 Voluntary Services Department will contact you to inform you the volunteer recruitment and induction processes are complete. They will go through your responsibilities as manager of the volunteer and hand over file and get confirmation you will now take over the management of this volunteer. 8 Refer to Voluntary Services Manager if taking part in more than one activity e.g. staff interviews, readers panel for guest recruitment process. 8 Contact volunteer providing PPI volunteer brief, contact name who they will be accountable to, notice and location of sessions including directions/car parking and maps, information on expenses. 10 Contact person and arrange PPI local induction (Appendix 1H) including duties, expenses, support. 11 Arrange to review at twelve monthly intervals (Appendix 1I) 12 At end of Involvement arrange final interview/ meeting 13 Inform Voluntary services Please note: All PPI activity needs to be recorded on DATIX All templates and information are available on the PPI intranet site at the following link: 16
Questions To Consider When Planning PPI Appendix 1A Planning for Success Questions to consider when planning PPI The following questions can help you to plan for successful patient and public involvement: Why use patient and public involvement? What do you hope to achieve by involving patients, carers and the wider public in a particular piece of work? Is everyone who needs to be clear about the objectives? What do you want from patients and the public? What level of involvement are you asking from them? Are you looking to understand their needs, to involve them in designing services, to get their feedback to proposals, or to measure how you are doing in delivering improvements? Are you clear about which approach to use and why? Who should you involve? Which groups of people should we engaged in your PPI? Do you need their consent to present their stories? Do you need to listen to any seldom-heard groups? How will you recruit people (complaints, flyers, groups?) How will you use their views and opinions? How are you going to analyse and present your findings? Which groups of people will you share the outcomes with? How will the views of patients and the public influence your discussions and decisions about planning and services? How will you let participants know the outcome? How do you plan to feedback to the individuals who have taken part and to the broader public and colleagues? Planning before you start Establish a planning team Bring together a small team of people to plan the exercise, set objectives and be clear about how the PPI is going to affect the service and influence decision-making. Answer key questions What information is required? How will the information be used? What resources are available Who will you involve What method will you use How will you prepare for the activity? Choose the right approach This should match the purpose and target audience. Check first if the information is available from current PPI activities. Develop and communicate your plans Plan your activity in detail. Plan to communicate to all those involved. Report and evaluation Consider and plan in advance how you will report and evaluate the activity. 17
PPI Planning Process Appendix 1B Are you clear about why you need to involve patients/public? YES NO Refer to pages 6 & 7 NUH PPI Toolkit: Why involve patients and the public? Have you effectively planned you PPI initiative and referred to the PPI Toolkit? YES NO Refer to pages 8 & 9 NUH PPI Toolkit: Planning for Success Have you decided which methods and approaches to use? YES NO Refer to pages 10 47 NUH PPI Toolkit: The PPI Circle Four types of PPI activities Do you know how you will recruit participants? YES NO Refer to section 3-7 on PPI flowchart (appendix 1 of PPI Policy) & pages 44-45 NUH PPI Toolkit: Involving seldom heard and diverse minority groups Do you know how you will evaluate and feedback on your PPI initiative? YES NO Refer to pages 50 51 NUH PPI Toolkit: Reporting and Feeding Back 18
PPI Planning Checklist Appendix 1C Gather feedback regularly and systematically Are you clear about what you want to find out? Are you clear about how you will use this information? Have you made use of existing data e.g. from the national patient survey or patient experience trackers? Do you know who you need to involve? Select the most helpful approach Are you clear where your activity sits in the PPI cycle, and whether you are looking: To learn about people s needs and views To design improvements and consult on changes To involve people in decision-making To monitor and measure progress Plan your PPI activity Do you have a clear implementation plan? Do you need the consent of the people you are involving, and have you downloaded the consent form? Have you planned ways to involve all of the diverse groups of people who need to use your services? Are you clear about how you will keep all stakeholder groups informed of findings and progress? Understand your findings Have you examined your feedback to identify priorities for improvement and success to celebrate? Have you decided how to analyse your results? Consider: Aspects of the patient journey Changes- or lack of changes-over time How you compare to other services Issues reported by large numbers of patients Positives and success to build on, as well as issues Action plan with patients, public and staff Do you have an action plan with priorities and timings? Do you have support of senior managers? Have you identified some project champions? Are clinical, managerial and support staff involved? How are you involving service users in action planning? Share results widely with staff and patients Have you identified stakeholders and how to involve them? Have you developed a practical communication strategy which identifies key audiences, messages and media? Maintaining progress Are you implementing quick wins to show progress, as well as long term changes that have greater impact? How will you measure the impact of your changes? How will you report and communicate progress? 19
PPI Costing Template Appendix 1D PPI Activity Details: Staff costs Hours (in decimals) Grade (select from drop-down list) Cost /hour Enter number of people at this band Total e.g. Matron 1.00 Band 8a 26.88 0 Staff costs total 0 0 20
Patient/public representative costs Enter amount spent on each item/activity DRAFT Total Travel costs 0 Refreshments 0 Training 0 Other 0 0 0 Patient/public representative costs total 0 0 Other costs Enter amount spent on each item/activity Total Printing & 0 Stationery Postage 0 Other 0 0 0 0 Other costs total 0 0 PPE Grand Total 0 0 21
Title: Directorate: Grade: Reports: Accountable: Commitment: Appendix 1E DRAFT Patient / Foundation trust member Ambassador On Magnet Reference steering group Job Description Patient / Foundation Trust Member Representative on Magnet Steering Group Corporate Volunteer (non-salaried) but entitled to claim reasonable expenses incurred in connection with their duties in accordance with the Trust expenses policy. Director of Nursing/ Magnet Project Lead Director of Nursing/ Magnet Project Lead The Magnet Reference Steering Group meets every two months. There may be additional meetings throughout the year that the representative will be encouraged to attend. Background At NUH our vision is to become the country s best acute teaching healthcare provider by 2016. We believe that our patients and the public we serve deserve nothing less. To help achieve this, NUH has embarked on the journey to achieve the esteemed Magnet Status, an award meaning that the nursing care delivered within the organisation is exemplary. Magnet is an internationally recognised programme, created in 1983 by the American Academy of Nursing. Magnet is a system that benchmarks and measures the care hospitals deliver against set of evidence based standards. By achieving Magnet accreditation hospitals can be assured they are providing the highest standard of patient care, particularly from its nursing and midwifery staff. As part of NUH journey to achieving Magnet recognition both an Operational and Reference Steering Group has been established to drive the process. Job Summary 1. To provide the Magnet Reference Steering group with guidance on its approach to achieving Magnet status that is consistent with the needs and views of patients/carers and the wider local community. 2. To assist the group in understanding the perspectives of patients and the public, including identifying other potential opportunities/ roles for patients/ the public to effectively involved throughout the process. 22
3. To oversee and ensure the vision and strategy to achieve Magnet status remains focused on our patients and service users. Values and Behaviours: NUH has a set of values and behaviours to improve the experience for our patients and our staff (We are here for you). This means that in undertaking this role the post holder is expected at all times to behave is a way that demonstrates commitment to the delivery of thoughtful patient care and continuous improvement as detailed in the table below. Thoughtful Patient Care Caring and helpful Polite, respect individuals, thoughtful, welcoming Helpful, kind, supportive, don t wait to be asked Listening, informing, communicating Safe and vigilant Clean hands and hospital so patients are safe Professional, ensure patients feel safe Honest, will speak up if needed to stay safe Clinically excellent Best outcomes through evidenceled clinical care Compassionate, gentle, see whole person Value patients time to minimise waiting Continuous Improvement Accountable and reliable Reliable and happy to be measured Appreciative of the contribution of others Effective and supportive teamworking Best use of time & resources Simplify processes, to find more time to care Eliminate waste, investing for patients Making best use of every pound we spend Innovation for patients Empowerment to act on patient feedback Improvement led by research and evidence Teaching the next generation KEY ROLE REQUIREMENTS 1. Experience or an interest in organisational development. 2. Experience of change management in the workplace. 3. The ability to understand the broader range of patient/public perspectives beyond personal experience, and to use that to inform the work of the group. 4. Good communication skills, the ability to listen to others, summarise issues and express views objectively with a constructive purpose. 23
5. Experience of working as a member of a team and with a broad range of people. 6. A passion and belief that nursing can make a difference to patient experience, care and outcomes. 7. An understanding of the difficulties facing the NHS, as well as opportunities for improving the NHS in the future. 8. Time to commit to the work of the group (approximately 6 meetings per year); attend meetings and do background reading. 9. The ability to think imaginatively and creatively as well as pragmatically about the ways in which nursing and midwifery care can be improved on, in line with the vision to achieve both Magnet status and to be the best Acute teaching hospital in 2016. 10. To respect and maintain confidentiality at all times. 11. Declare any conflicts of interest where appropriate. 12. Undertake training as necessary for the role. Identify any personal needs for training or support. GENERAL DUTIES In addition to the key job responsibilities detailed in this job description all at Nottingham University Hospitals NHS Trust are expected to comply with the general duties detailed below: Infection Control To ensure adherence to the Trust s standards of cleanliness, hygiene and infection control when in clinical area. Safeguarding children, young people and vulnerable adults Nottingham University Hospitals is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults. All staff and volunteers are therefore expected to behave in such a way that supports this commitment. Information Governance To be aware of and comply with requirements and with the Health Record Keeping Policy and other Health Records and Corporate Records Management policies and procedures in order to meet the Trust s legal, regulatory and accountability requirements. Health and Safety To take reasonable care to prevent injury to themselves or others who may 24
be affected by their acts or omissions. To co-operate fully in discharging the Trust policies and procedures with regard to health and safety matters. To immediately report to the Trust any shortcomings in health and safety procedures and practice. To report any accidents or dangerous incidents to their immediate manager and safety representative as early as possible and submit a completed accident/incident form. To use protective clothing and equipment where provided. Whilst the aim of the Trust is to promote a co-operative and constructive view of health and safety concerns in the organisation, all staff must be aware that a wilful or irresponsible disregard for safety matters may give rise to disciplinary proceedings. General Policies Procedures and Practices To comply with all Trust policies, procedures and practices under the guidance of the group, where applicable. WORKING CONDITIONS Volunteer/Corporate JOB REVISION This job description should be regarded as a guide to the duties required and is not definitive or restrictive in any way. The duties of the post may be varied from time to time in response to changing circumstances. Job description review date 25
Patient Public Involvement (PPI) Volunteers Brief Arts Strategy Steering Group Example Ward/Department Charitable Funds Name/Position of members of staff responsible for volunteer s: Barbara Cathcart ext 54945/ Katie Evans ext. 54929 Appendix 1F Purpose of Group The group will deal with issues relating to Arts programme in the Trust. It will support the Arts project as they develop and ensure the work stays true to their key principles specifically. To engage more people with projects and the culture they inspire. To keep the projects simple, yet ambitious and experimental. To explore the use of different media for maximum patient benefit. To support Art projects that shift attitudes, behaviours and habits. To impact positively on the Trust and its broader community. Role of PPI Volunteer Attend the Steering Group meetings. Read the meeting papers in advance of the meetings. Provide feedback from this steering group to the Patient Public Involvement Steering Group (PPISG) and Patient Partnership Group (PPG) and take comments on this feedback from the PPISG and PPG to this steering group. Provide feedback to and from the Trust Patient Partnership Group from the Steering Group. Assist the Steering Group by ensuring that the views of patients and the public are pivotal to the work of the Steering Group. Undertake any required additional training. Volunteers undertaking this role are required to be registered as volunteer with NUH, have undergone a Criminal Records Bureau check and be up to date with their mandatory training requirements. Training and support will be provided by the member of staff responsible for the volunteer and will include an annual review. Travelling expenses will be paid in accordance with volunteer policy and will be authorised by the member of staff responsible for the volunteer. 26
Request for Members Appendix 1G Date of request: Name or requester: Directorate: Details of request I have attached a PPI Volunteer Job Description / PPI Volunteer brief (You must complete and attach at least one of the above forms) Y/N Number of members you require- (Please specify the number of members you want to involve): Please specify demographics of the members you want to contact (if applicable): please tick: Gender: Male Female What timescales are you working to - i.e. when do you wish to start and finish involvement? What are the anticipated outcomes of this Involvement? Is there any other relevant information you wish to add Directorate details for members to contact: Name: Job title: Contact details: Please tick to confirm that you have discussed this member request with your directorate PPI Lead Please email completed form to: ft@nuh.nhs.uk 27
Patient Public Local Induction Appendix 1H As a patient or public representative, you can expect: personal information about you to stay confidential and anonymous the chance to see how we work before you decide to become a representative (for example by attending a meeting) a clear remit of your responsibilities. an induction, and any on-going support you require a named contact manager to whom you can address any issues clear information about your chosen area of involvement to be consulted about decisions what affect you to know how to claim travel expenses and receive the necessary forms to receive papers of meetings in advance of the meeting honesty about what you can and cannot achieve the Trust,through your directorate PPI lead to listen you re your suggestions and criticisms your points of view to be taken seriously a work in safe and comfortable place which allows people to talk and work effectively together to choose how you want to be involved to be told what has happened as a result of your involvement What we expect from you: to have an active interest in the NHS to have an interest in Trust related issues to be able to work in a team and with any relevant working groups to be able to view things with an open mind to adhere to Trust Policies and procedures, as made known to you. Your role as a patient or public representative is to: help us to improve services for patients and the public use your experience to give a patient s or public s view on services, including proposed change be willing to help change and influence services Your manager is:... Job title:... Contact details:... 28
PPI Volunteer 12 Month Review Appendix 1I Name: Name of Manager: Date of Meeting: Last Review Date: 1/2/2012 Type of PPI Volunteering: Over the last 12 months what has gone well? Over the last 12 months what would have been even better if? What will be achieved over the next 12 months? What support will be required over the next 12 months, by whom and when? Training Record Any other comments/actions Managers Signature: 29
Patient Experience and Patient Public Involvement How it fits together Appendix 2 - Elements that define patient experience at NUH - Tools NUH staff will use to deliver patient experience at NUH Definitions Patient Experience Patient experience at NUH results from a range of activities that all impact upon patient care, access, safety and outcomes. Patients have told us for a good patient experience at NUH they want us to: Provide good treatment in a comfortable, caring and safe environment, delivered in a calm and reassuring way Give them information to make choices, to feel confident and to feel in control Talk and listen to them as an equal and treat them with honesty, respect and dignity. NUH has used patient public feedback and the NICE quality standard for patient experience as the basis for defining the elements that make up patient experience at NUH. See blue section of the diagram. The NICE quality standard for patient experience in adult NHS services sets out how a high-quality service should be organised, so that the best care can be offered to people using NHS services in England. The quality standard for patient experience in adult NHS services is made up of 14 statements that describe high-quality care for patients. www.nice.org.uk/guidance/cg138. Patient Public Involvement (PPI) PPI at NUH is the process of engaging with the needs and expectations of patients and putting the public and members at the heart of NUH decision making, to ensure that the services and care provided are outcome driven and patient centred. Specifically it is concerned with exchanging information, mutual listening, and accepting that people should be allowed to influence their own care and the services they receive. PPI defines the way in which patients, carers and the public have a voice in decisions about how healthcare services and research are planned, designed, delivered and evaluated. PPI must operate on three levels: Involving individual patients and their carers in decisions about treatment and care and empowering them to make informed decisions about their health. Enabling patients, public and members to be involved and consulted on planning, monitoring, evaluating and developing services, proposals to change services and decisions about the way services operate. Involving and engaging patients, carers and the public in planning, development, delivery and evaluation of relevant research and 30 research related activities to the benefit of patients.
DRAFT Equality Impact Assessment (EQIA) Form (Please complete all sections) Appendix 3 Q1. Date of Assessment: 3/12/2102 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic group s experience? I.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: Race and No further changes to draft policy Ethnicity required. Gender No further changes to draft policy required. Age No further changes to draft policy required. Religion No further changes to draft policy required. Disability No further changes to draft policy required. Sexuality No further changes to draft policy required. Pregnancy and No further changes to draft policy Maternity required. Gender No further changes to draft policy Reassignment required. b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening 31 c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
Marriage and Civil Partnership Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation) No further changes to draft policy required. No further changes to draft policy required. DRAFT Area of service/strategy/function Q3. What consultation with protected characteristic groups Inc. patient groups have you carried out? Consultation has been undertaken with Patient Partnership Group, Members and Directorate Patient Groups. Q4. What data or information did you use in support of this EQIA? Feedback from National and local surveys and audits and patient groups. Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups What By Whom By When Resources required Q7. Review date 32
Environmental Impact Assessment Appendix 4 The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water Air Is the policy encouraging using more materials/supplies? Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? No action necessary Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (E.g. bunded containers, etc.) No action necessary Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) No action necessary Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (E.g. use of 33
a furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? No action necessary Energy Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) No action necessary Nuisances Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? No action necessary 34
We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit Appendix 5 The We Are Here for You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value 1. Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave Score (1-3) 3 3 3 3 3 35
professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues. 7. Informative We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable Take responsibility for our own actions and results. 11. Best Use of Time and Resources Simplify processes and eliminate waste, while improving quality. 12. Improve Our best gets better. Working in teams to innovate and to solve patient frustrations. 3 3 3 3 3 3 3 TOTAL 36 36