Transcript KPMG Full Page Talkbook Template - West Suffolk NHS Foundation

West Suffolk Hospital NHS Trust
Report To:
Trust Board
Date:
March 2012
Title:
Quality Report
Report of:
Nichole Day, Executive Chief Nurse
0
Introduction
This Quality Report provides the narrative for performance in three key areas: Quality priorities, CQUIN
performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust
dashboards.
The layout of this report identifies performance data followed by themes identified during the analysis process
and actions being taken. The ward quality report summary has been used to highlight wards that have a
number of red scores and these are discussed within the report.
1
Executive Summary
There are a number of wards that have demonstrated exceptional performance during February
particularly F3.
The SIRI incidents look very high for February, this is due to individual occurrences of norovirus
being identified on several individual wards that were then closed. They were reported externally
as one SIRI.
There were 9 Grade 2 hospital acquired pressure ulcers identified during February which is a
high incidence rate, however 5 were attributed to end of life care. We have commenced a
priority piece of work reviewing our slide sheet availability as lack of availability was identified as
a theme from 2 avoidable pressure ulcers.
The total number of falls in February was 42 which leaves us just above the CQUIN trajectory
for month 2 in Q.4 (ceiling = 84 falls, current total = 86 falls). Reduction of falls remains a priority
for clinical staff during March and the current incident count for March looks optimistic.
2
1. To further reduce hospital acquired infections
Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no
more than 29 cases between April 2011 and April 2012
Number
3
Number
MRSA
Total no of MRSA
bacteraemias:
Hospital
2
MRSA Cumulative
Ceiling: Hospital
Acquired
1
1
0
0
0
0
0
0
0
0
0
0
0
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
MRSA Cumulative
Actual: Hospital
Acquired
Total no of C. diff infections: Hospital
Total no of C. diff
infections: Hospital
30
25
20
C. diff cumulative
ceiling: Hospital
15
10
5
0
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
C. diff cumulative
total hospital
infections (to date)
There were no cases of MRSA bacteraemia or MSSA bacteraemia during February.
There was 1 case of clinically significant hospital acquired C. difficile during February (giving a total of 21 year to date).
In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except peripheral cannula ongoing care
(95%). This lower score is mainly attributed to F10 where some cannulae were not changed after 72hrs and G1 where documentation
was an issue. An additional audit programme has been developed by the IPT and they will ensure that there is a renewed emphasis on
compliance, including ensuring that there is a set time for the patient checks and a standard place where this information is documented.
On the audit day, of the 32 side rooms available (capacity increased by 1 side room as F7 operating at 4 following refurbishment), 19
were used for infection prevention purposes and additionally there was 1 infectious patient in a side room on Critical Care. There were 4
high risk patients who should have been isolated and were not. These were patients who needed to stay within the specialty ward, and
other side rooms on the ward contained patients with infections.
3
1. To further reduce hospital acquired infections
Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy
The compliance with the antibiotic prescribing policy was 97% in February.
It was reported last month that a revised rolling programme of audits will be initiated this year. Therefore a rolling quarterly compliance
graph is displayed but the historic data may not be completely accurate as the wards audited within a quarter may not be consistent.
From April 2012 the new programme will have taken full effect.
4
2a) To achieve the highest levels of patient safety
Aims
i) To assess at least 98% of admissions for risk of VTE
ii) Provide prophylaxis to 100% patients at risk
%
VTE: Completed risk assessment (monthly Unify audit)
100
98
VTE: Completed risk
assessment (monthly
Unify audit)
96
94
92
Target
90
88
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance with risk assessment was 98.16% for February. Prophylaxis data is reported quarterly and is due in April’s report.
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2b) To achieve the highest levels of patient safety
Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12
The CQUIN ceiling is 126 falls in Quarter 4 and the payment associated with Quarter 4 is £41,250. The total number of falls in February was 42. This
leaves a ceiling of 40 falls for March which we have placed a high priority on achieving. The benchmarking data provided in last month’s report should read
that 13 falls per week would be average for a Trust this size. We are currently reporting approximately 10 falls per week.
The falls in February occurred in 19 confused patients, 5 patients who refused all help in mobilising, 7 independent patients and 7 patients who had a
sudden onset of dizziness/ condition deteriorated. To demonstrate the types of falls, examples are provided below:
Independent patients who fell:
• Gentleman on EAU spilt a little tea on the floor, tried to mop it up himself and slipped in the tea.
• Lady with plaster cast on her leg, decided not to put a slipper on the affected leg to dash to the toilet, slipped over.
Confused patients
• Gentleman on G5 got up and fell. He was unsupervised as staff were responding to an emergency buzzer.
• Gentleman isolated in side room because of Clostridium difficile fell out of bed while unsupervised. The cohort unit was closed and he was isolated in a
ward side room with the door closed.
Sudden deterioration
• Independent patient, stood, felt dizzy and fell.
• Independent patient, in toilet alone, her blood pressure dropped when
she
• stood up and she fell.
Actions
• Pharmacy to audit the medication review process. They currently
identify “offending medications” but we have no data re: whether the
medications are reviewed by medical staff.
• Sub-group to consider standing and lying blood pressure guidelines.
• The pilot to provide patients with non-slip anti-embolus stockings is
being commenced.
• Environmental assessments are to be carried out on the ward toilets to
identify any modifications that could be made to mitigate falls.
Number
No of patient falls
Falls
70
60
No of patient falls
resulting in harm
50
40
No. of serious
injuries or deaths
resulting from falls
30
20
10
0
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
6
2c) To achieve the highest levels of patient safety
Aim: To reduce the number of avoidable Grade 3 and 4 pressure ulcers by 80% in the last quarter of
2011/12
No patients developed a Grade 3/4 hospital acquired pressure ulcer during February.
9 patients developed Grade 2 hospital acquired pressure ulcers this month:
Number
12
10
8
Pressure ulcers
No of patients with
ward acquired
pressure ulcers
• A 102 yr old patient with a # shoulder who was on the Liverpool Care Pathway developed a 6
Grade 2 sacral ulcer. This was considered unavoidable as the patient had all equipment in
4
No of patients with
ward acquired
place but did not want to be re-positioned.
2
Grade 3 or 4
• A patient on G1 developed a Grade 2 pressure ulcer. He was also on the Liverpool Care
pressure ulcers
0
Pathway and the pressure ulcer was unavoidable.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
• A patient on G4 developed Grade 2 heel and sacral ulcers. Although all care was in place,
the pressure ulcers appear to have resulted from friction which have been attributed to poor manual handling techniques. We therefore consider these
patient’s ulcers to be avoidable.
• A patient on F5 developed a Grade 2 Kennedy pressure ulcer (a pre-cursor to end of life). This was unavoidable.
• Two patients on G8 developed Grade 2 pressure ulcers from friction. One appeared to be due to manual handling technique and was considered
avoidable. One was due to the patient’s constant agitation in bed and was considered unavoidable.
• Three patients developed Grade 2 pressure ulcers on F7 during February. One patient was on the Liverpool Care Pathway and one patient had bone
metastases and refused to be repositioned due to the pain or have an alternating pressure mattress. These were both considered unavoidable. One
patient developed a Grade 2 pressure ulcer which we considered to be avoidable. Although she had everything in place when reviewed, there was a
delay in acquiring the repose cushion, which could have led to the development of the ulcer.
Actions
• 2 avoidable pressure ulcers were attributed to manual handling technique. On investigation, there is a problem with the supply of slide sheets which is
causing considerable problems for nursing staff. This has been escalated to the manual handling advisor, estates and facilities manager and will be
discussed at the pressure ulcer prevention group.
• We are reviewing some parafrictor products which may prevent pressure ulcer damage from friction caused by continuous patient movement in the
future.
The CQUIN target is to have no more than 2 hospital-acquired Grade 3/4 pressure ulcers in each of Quarters 1,2 and 3 and 1 hospital-acquired Grade 3/4
pressure ulcer in Quarter 4 with a quarterly payment of £41,250. We have met all these CQUIN quarterly targets so far and are confident in achieving
Quarter 4. We now aim to eradicate avoidable Grade 2 pressure ulcers.
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3a/b) To continuously improve the experience of patients using our services
Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction
rating in our internal patient experience surveys.
Survey results
Survey
Overall
satisfaction
Recommender
question
Inpatients
90
99
Outpatients
94
94
Short stay
97
100
A&E
97
100
Overall percentage scores for the surveys for February are provided in the
table (left). As can be seen from the graph below, the issue that impacts on
the overall experience score for Outpatients is the question relating to
information provided about delays and the score has reduced over the last 2
months. A group is being convened to identify the best way to address this
as in some outpatients areas, the reception where the patient books in may
not be aware of delays, due to the separation of the areas.
169 inpatient survey responses were obtained during February. This needs
to be increased if we are to achieve feedback from 10% of inpatients. The
wards with low numbers of responses are being targeted to ensure that
numbers are increased. Already in March, the numbers have dramatically
increased on the two surgical wards with low response rates.
%
Were you informed of any delays in
being seen?
Patient Experience: Out-Patient
100
95
90
Were staff professional,
approachable and friendly?
85
80
Did staff explain about your
condition and treatment in a way
you could understand?
Did you feel as involved as you
wanted to be in decisions about
your care?
Were you given enough privacy
when being examined and treated?
75
70
65
60
55
50
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Overall how would you rate the
care you received in the
department?
8
3a/b) To continuously improve the experience of patients using our services
Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction
rating in our internal patient experience surveys
Survey results
%
In your opinion, how clean was the
hospital room or ward that you are
in?
Patient Satisfaction: In-Patient
100
95
The inpatient survey results show slight variation from
month to month on most of the high scoring aspects of care.
Were you ever bothered by noise
at night from other patients?
90
85
Several of the wards were impacted during February by
sub-optimal staffing levels due to norovirus and this may
explain the slight dip this month in issues such as timely
response to call bells and patient being able to find
someone to talk to about their worries and fears.
Were you ever bothered by noise
at night from hospital staff?
80
There has been a small increase month on month in respect
of doctors and nurses not talking in front of patients.
Awareness of this issue has been heightened with both
doctors and nurses. Nurses have been carrying out a
review of handover as part of the Productive Ward initiative
and it is felt that this will have a significant impact when it is
fully implemented.
75
Were staff professional,
approachable and friendly?
70
65
60
Did you find someone on the
hospital staff to talk to about your
worries and fears?
55
50
Apr
May
%
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Were you given enough privacy
when discussing your care?
Patient Satisfaction: In-Patient
100
Were you involved as much as you
wanted to be in decisions about
your condition and treatment?
90
Were you given enough privacy
when being examined or
treated?
80
Did nurses talk in front of you as
if you were not there?
70
Did doctors talk in front of youas
if you were not there?
60
50
Timely call bell response
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
9
3c) To continuously improve the experience of patients using our services
Environment and Cleanliness
All wards achieved over 85% except Recovery (82%), A&E (84%) and F7 (84%).
• F7 score was comprised of 82% cleaning, 85% estates and 89.4% nursing.
• Theatre’s score was comprised of 86% cleaning, 69% estates and 75% nursing.
•
A&E’s score was comprised of 89% cleaning, 73% estates and 63% nursing. The low nursing score related to several things including dust on
the nurse’s station and tape on walls. The nursing score has improved to 90% in the March maximiser assessment.
%
Environment and Cleanliness
100
Environment
and
Cleanliness
98
96
94
92
90
88
Target
86
84
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
10
4a) To achieve optimal clinical outcomes and effectiveness
Aim: To consistently achieve a Hospital
Standardised Mortality Ratio that is below the
expected rate
Rolling 12 Month HSMR-All Admissions
90
85
80
75
70
Aug
Nov
Apr
National Rate
Jun
Jul
0909Sep
09Dec
Jan
Feb
Mar
10from last
10- 10-Apr May
reporting 09-Jul Aug Sep 09-Oct Oct 09- Dec 09-Jan 1010
10
10
10 Nov 10 10
11 Feb 11Mar 11 11
11
period
Rolling 12 Month HSMR-All
Admissions
Rolling 12 Month HSMR-Non
Elective
Nov 10-Dec 11
Oct 10-Nov 11
Sep 10-Oct 11
Aug 10-Sep 11
July 10-Aug 11
June 10-July 11
May 10-June 11
Apr 10-May 11
Mar 10-Apr 11
Feb 10-Mar 11
Jan 10-Feb 11
Dec 09-Jan 11
Nov 09-Dec 10
Oct 09-Nov 10
Sep 09-Oct 10
Aug 09-Sep 10
Jul 09-Aug 10
65
Jun 09-Jul 10
HSMR remains well below the expected level as can be seen by
the overall mortality shown in the graph and the table giving a
mortality rate for the five Dr Foster - How Safe is Your Hospital
indicators. This table provides information on relative risk, with
red, blue and green traffic lighting. Blue indicates that the score is
within the standard deviation.
May June
1010June July
11
11
July
10Aug
11
Aug
10Sep
Sep 10-Oct Oct 10- Nov 1011
11 Nov 11 Dec 11
-
89
87.8
86.3
84.6
84.1
80.3
81
79
79.3
76.9
76.3
76.3
84.8
83.6
83.2
82.3
82.2
82.5
-
89.1
88.1
86.7
84.8
84.2
80.3
81.1
79.1
79.4
77.1
76.4
76.4
85
83.9
83.4
82.6
82.4
82.8
SMR Stroke (Acute
Cerebrovascular Disease)
86.2
86.8
88.7
88.6
84.2
84.4
79.7
80.5
75
78.1
74.3
74.2
74.2
76.5
77.8
71
67.7
69.2
68.2
SMR - Heart Attack (AMI)
90
94.5
89.4
82.4
78.5
77.9
81.8
94.1
82.5
79.6
77.7
71.1
71.1
69.7
67.7
71.5
64.9
65.2
61.7
SMR - FNOF
81.6
69.2
60.7
62.9
66.2
66.9
67.4
65.9
64.2
64.3
64.1
62.4
62.4
88.7
76.4
82.1
85.5
82.8
84.5
Mortality from Low Risk Conditions
0.84
0.62
0.53
0.49
0.44
0.49
0.45
-
-
0.55
0.6
0.51
0.51
0.52
0.57
0.58
0.54
0.65
0.65
11
Local issues requiring escalation
Patient surveys
G5 had very low scores for their patient experience surveys this month which was immediately considered during an emergency senior
nurse meeting. The following actions have been taken:
• Enforce compliance with trust policy on nurse handover to ensure patients are involved in their care and do not feel that staff are talking
in front of them.
• Reinforce standards of behaviour regarding professional discussion in front of patients.
• Proactively seeking real-time patient experience feedback by asking patients and visitors daily about their experience, introduction of
real-time patient experience feedback cards for patients and visitors to use and monitoring of responses with feedback displayed for
staff, patients and visitors to see.
•
Recruit into vacant posts: 3.4 wte RN posts.
The results of the survey will also be shared with the medical staff and cleaning staff as some of the responses are directly attributed to
them.
Wards
The majority of emergency clinical areas have had high sickness rates during February (6-12%) which has undoubtedly had an impact on
the quality of care delivered in some areas, G1 in particular has had a number of senior nursing staff absent during February and senior
medical matron cover has been implemented to ensure quality standards are maintained.
Nutrition
Several wards had lower than normal nutritional audit scores. This was mainly due to a lack of regular weighing of patients. Staff have
been asked to ensure that there is a system for completing weights weekly. An issue with availability of functional scales has been
identified and new scales ordered.
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Local Priorities - Governance Dashboard
Indicator
Performance target
National
safety alerts
Number of NPSA alerts beyond national implementation
deadline
>=5
Timely
completion of
Red incident
investigations
and action
RCAs (non SIRI) completed more than 45 days after
incident reported
>=1
Actions beyond deadline for completion
>=5
Timely
reporting of
SIRIs to NHS
Suffolk
SIRIs 2 day report beyond timeframe
Risk
assessments
Active risk assessments in date
<75%
Outstanding actions in date
<75%
NICE
TA (Technology appraisal) business case beyond agreed
deadline timeframe
>9
IPG (Interventional procedure guideline) baseline
assessments beyond agreed deadline timeframe
Clinical Audit
Complaints
R
A
1-4
G
Feb12
Commentary
0
2
Two NPSA alerts remain overdue and on the Risk register:
PSG/2007/001 Medicines reconciliation and SPN/2008/014Right
Patient Right Blood
0
2
154452 (Trimethoprin) and 138325/155040/155888 both delayed
due to clinical availability of staff.
0
0
>=1
0
0
SIRIs 7 day report beyond timeframe
>=1
0
0
SIRIs 45 day reports beyond timeframe
>=1
0
0
75 – 94%
>=95%
95%
75 – 94%
>=95%
96%
4-9
0-3
11
>9
4-9
0-3
9
CG (Clinical guideline) baseline assessments beyond
agreed deadline timeframe
>9
4-9
0-3
9
Trust participation in relevant ongoing National audits
(reported by Quarter)
<75%
75 – 89%
>=90%
Response within 25 days or negotiated timescale with the
complainant
<75%
75 – 89%
>=90%
96%
1-4
The 4 SIRIs reported in February all had the relevant reports
submitted within the required timescale.
The 1 SIRI 45-day report due in February was submitted within the
agreed timescales
TA Business case process was discussed in depth at NICE
Coordination Group. Issue is a combination of the increasing
levels of information requested by the PCT for each case which
delays date to CPG and trust process. Several actions identified.
1. Maintain extra 7.5hr pharmacy time . 2,Utilise the Directorate
Performance Meetings to notify new TA cases needed and
outstanding cases, allocate actions from the meeting to the
relevant staff. This should cut down the time before submission to
D&T then CPG. 3.Take out baseline assessment process for TAs
and go straight to business case. 4. Working with PCT to review
business case template to reduce to 2 sides, should be agreed by
the end of Feb. Discussed at Clinical Safety & Effectiveness group
on 9th March.
97% in Quarter 3
Number of second letters received
>=5
1-4
0
3
Health Service Referrals accepted by Ombudsmen
>=2
1
0
0
Red complaints actions beyond deadline for completion
>=5
1-4
0
0
Number of PALS contacts that became formal complaints
>10
6-9
<=5
7
13
Local Priorities Care Quality Commission (CQC) Quality & Risk Profile
Background
The CQC publish a monthly Quality & Risk Profile (QRP) outlining the external sources of data which can be used to assess a Trust’s level of
compliance using a statistical assessment to identify if a Trust’s performance is Much worse than expected; Worse than expected; Tending towards
worse than expected; Similar to expected; Tending towards better than expected; Better than expected or Much better than expected. The expectation
is that each Trust will study this QRP and use it to provide evidence of compliance and/or act upon those areas highlighted as below expected. In
addition, this report contains Negative Comments or Positive Comments taken from local engagement, external inspectors’ reports and a range of
other sources. The Operational Steering Group allocate actions to individuals to address the areas highlighted as a concern and monitor the
completion of these actions and the Quality & Risk Committee review in details progress to address areas of concern.
QRP issued February 2012 (Jan12 data) – new items in the Negative categories with narrative from Operational Steering Group
Item
Score
Comparison of observed to expected number of elective hip
Much worse
replacement admissions with an emergency readmission within
than
28 days of discharge [Dr Foster Intelligence, Hospital Guide 2011] expected
No. of
items
1
Narrative
This item has been flagged up by Dr Foster reports regularly. Review has identified that
patients sent back into hospital with a suspected DVT were being “admitted” instead of being
managed as “ward attenders”. This has followed up and future reports from Dr Foster will be
monitored to ensure the issue has been successfully addressed .
QRP issued February 2012 (Jan12 data) – new items in the Positive categories. There were also 17 items graded as “Similar to expected”
No. of
items
Item
Score
Multiple indicators [Dr Foster Intelligence, Hospital Guide 2011]
Much better than expected
5
Proportion of unplanned re-attendance at A&E within 7 days of original attendance AUG 2011 [Information Centre for Health & Social
Care, Accident and Emergency Clinical Quality Indicators]
Much better than expected
1
Proportion of alerts acknowledged within deadline out of total number of alerts issued to the organisation. (Report 2) JAN-DEC 2011
[Medicines and Healthcare products Regulatory Agency (MHRA), Central Alerting System]
Better than expected
1
Multiple indicators [Information Centre for Health & Social Care, Accident and Emergency Clinical Quality Indicators]
Tending towards better than expected
3
The proportion of unjustified mixed sex accommodation breaches DEC 2011 [Department of Health, Eliminating Mixed Sex
Accommodation]
Tending towards better than expected
1
Proportion of alerts completed out of total number of alerts issued and due for completion within the time-period AUG 2009 – JAN 2012
[Medicines and Healthcare products Regulatory Agency (MHRA), Central Alerting System]
Tending towards better than expected
1
14
Local Priorities
Patient Safety Incidents (PSIs) resulting in harm
(including Serious harm), Serious Incidents requiring
investigation (SIRIs) and reporting PSIs to the National
Reporting and Learning Service (NRLS)
There were 220 patient safety incidents reported in February of
which 91 resulted in harm. The number of serious incidents in
February was 9 and there were 4 SIRIs reported: Norovirus outbreak
(multiple outbreaks reported as one combined SIRI); compliance
with cardiac arrest policy (1); failure to follow neutropenic sepsis
policy (1) and fall resulting in fractured clavicle (1).
The 9 serious incidents in February were: Norovirus outbreaks (6
reported as one SIRI in February); fall resulting in fractured clavicle
(1 reported as SIRI in February); deteriorating patient (1 reported as
SIRI in March) and one awaiting confirmation of grade.
 The top graph shows how many harm incidents have been reported
in total, how many were serious harm and how many were reported as
a SIRI by month over the last 12 months.
The number of SIRIs do not directly correlate to the number of serious
harm in the same month because some SIRIs did not cause actual
major harm (eg a breach of confidentiality) or the SIRI was not reported
until the following month.
The bottom graph shows all incidents (including near miss and no
harm) reported to the NRLS against a benchmark of the median Trust
for incidents per 100 admissions in the small acute Trust category (6.2
based on the Oct 10 – Mar 11 dataset).
The second (red) line on the bottom graph shows what percentage of
the incidents reported in total are categorised as serious (Red: actual
major/catastrophic harm). This showed a marked increase in February
as a consequence of a slight reduction in the total number of incidents
reported and an increase in the serious harm incidents reported in the
month mainly due to the 6 instances of Norovirus outbreak.
Local Priorities
Complaints
Complaint response within agreed timescale with
the complainant: 96% of responses due in
February were responded to within the agreed
timescale (target 90).
Of the 21 complaints received in February, the
breakdown by Primary Directorate is as
follows: Medical (9), Surgical (9), Clinical
Support (1), Women & Child Health (2) and
Facilities (0).
Trust-wide the most common problem areas are
as follows:
- Communication
9
- Admission, Discharge & Transfer
7
- Attitude of Staff
6
- Patients Privacy & Dignity
6
This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint
so the total number of problem areas does not correlate with the total number of complaints) .
The data in the graph above demonstrates that there has been an increase in the number of complaints received in 2011/12 compared to 2010/11.
Themes from Red complaints
All actions identified from Red complaints are currently within the deadlines for completion.
16
Local Priorities
PALS (Patient Advice & Liaison Service)
The revised PALS database is now functional
and, together with prompt recording of contacts
and enquiry details, accurate and meaningful
information is now readily available. As
previously reported, categories are being collated
to correspond with the categories for formal
complaints but additional information is being
recorded on primary and secondary concerns. A
comparison of the number of enquiries dealt with
from Mar11 to Feb12 is given in the chart and a synopsis of enquiries received for the same period is given below. Trust-wide the most common five
reasons for contacts are as follows:
Communication/Information (oral or written)
21
Other (relating to queries about other organisations
11
All aspects of clinical treatment
14
Appointments (delays / cancellations)
8
Attitude of staff
8
Communication, concerns about aspects of clinical treatment and general enquiries remain the most prominent reasons for contacting PALS.
However, there are no trends identified for specific groups of staff, speciality or discipline.
The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about
treatment given, future care plans, outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge
arrangements.
A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries
about services not directly managed by West Suffolk Hospital.
The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad.
Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process.
The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for
responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being
monitored and evidence of compliance will be submitted in the new year, after three months data has been collected.