Transcript KPMG Full Page Talkbook Template

West Suffolk Hospital NHS Trust
Report To:
Trust Board
Date:
April 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
This report presents the completed year end quality data April 2011- April 2012.
The following CQUIN targets were achieved in Q4:
• 35% reduction in falls
•No avoidable Grade 3 or 4 pressure ulcers
•Patient risk assessment for hydration
•Smoking cessation referrals (590 referrals in Q4) and 2 staff from each clinical area trained in brief
intervention therapy
•5 cardiac arrest RCAs completed each month and action plans developed
•VTE risk assessment
•Achievement of EAU phone calls
•Achievement of roll out of clinical management system ( CMS)
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
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
30
Total no of C. diff
infections: Hospital
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 March.
There were 2 cases of clinically significant hospital acquired C. difficile during March (giving a total of 23 this year).
In respect of compliance with the High Impact Interventions (HII), all interventions scored 100%.
During the sideroom audit, of the 33 siderooms in the Trust, 24 were used for IC purposes. There were 7 high risk patients who should
have been isolated and were not due to lack of capacity.
The F9c cohort became operational again as of 15 March 2012 (having been used since January 2012 as additional bed capacity) and
there were 4 patients in the cohort on the day. ( 1 already in the side room)
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 98% in March.
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
%
100
%
VTE: Completed risk assessment (monthly Unify audit)
VTE:
Completed risk
assessment
(monthly Unify
audit)
98
96
94
VTE: Prophylaxis compliance
100
VTE:
Prophylaxis
compliance
80
60
Target
40
92
Target
20
90
0
88
Apr May Jun
Jul Aug Sep Oct Nov Dec Jan Feb Mar
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance with risk assessment was 96.69% for March. The overall result for Q4 was 98.17%
VTE prophylaxis compliance for March was 98%.
5
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 March was 30 giving a
Quarter 4 total of 116 falls, therefore meeting the reduction required for this quarter. The ward areas with red scores from fall incidents are F4, G4, G3, G1
and CCU:
One patient fell on CCU:
•This gentleman fell out of bed while sleeping.
G1 reported three falls by two patients:
•One patient with Parkinson’s disease fell twice. This lady was at very high risk of falling and had a wanderguard in situ to alert staff when she was getting
up but she frequently unclipped the device.
•One patient fell while transferring from bed to chair.
One patient fell on G3:
•This patient was sitting on the edge of the bed and slipped to the floor as the overlay mattress had not been re-fastened to the bed mattress following
cleaning and slid off the bed.
G4 reported 6 falls involving 4 patients. During March, G4 had a significant number of confused patients (approx 50% of total patients). All the patients who
fell had dementia/delirium:
•5 falls occurred at night which is a high risk time for confused patients. Although G4 increased their staff numbers at night by 2 health care assistants, they
are unable to constantly observe and supervise 16 confused patients.
•1 fall occurred during the daytime, this was a lady with Parkinson’s disease who stood
Number
unaided and fell on the floor.
No of patient
Falls
80
F4 had 3 patient falls during March:
• One lady slipped and fell on the wetroom floor following her shower.
• One gentleman slipped and fell when getting out of bed wearing anti-embolic stockings
and no slippers. It is felt that the stockings were the causative factor.
• A patient, following a knee replacement, walked across to the toilet without her sticks
and fell.
falls
60
40
No of patient
falls resulting in
harm
20
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Actions
All ward areas have taken individual actions relating to their fall causes.
The Business Case for the 3 month Safina grip anti-embolic stocking trial on F3,4,5 and 6 is being presented at a TEG in May.
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
1 patient developed a Grade 3 hospital acquired pressure ulcer during March on G4. This
lady had all care provided but had significant medical problems which were risk factors for
tissue damage. The RCA has not yet been held to determine if it was avoidable or
unavoidable.
Number
Pressure ulcers
12
No of patients with
ward acquired
pressure ulcers
10
8
4 patients developed Grade 2 hospital acquired pressure ulcers this month, 2 of which
were avoidable:
6
F9: 1 patient developed a Grade 2 unavoidable sacral pressure ulcer. All preventative care
was in place.
2
4
No of patients with
ward acquired Grade
3 or 4 pressure ulcers
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
G1: a patient on the Liverpool care pathway developed a Grade 2 pressure ulcer which
was reported the day before she died. This was classified as unavoidable.
G3: a gentleman developed a Grade 2 pressure ulcer which subsequently healed while he was still an inpatient. We have classified this as avoidable as
the moisture damage which led to the pressure ulcer developing could have been managed better with low pH skin cleansers.
G8: a lady developed a Grade 2 pressure ulcer on her spine. As we have no documentation to support that her pressure areas were checked for two days,
we are considering this an avoidable pressure ulcer.
Actions
The pressure ulcer intensive support team commissioned by the East and Midlands SHA to support the launch of the Ambition “ No avoidable pressure
ulcers” will be visiting Suffolk on the 30th April, hosted by Ipswich hospital. They will be critically reviewing all Trust’s processes and pathways and making
suggestions for improved practice to achieve further reductions in avoidable pressure ulcers.
The CQUIN target for 2011/12 is to have no more than 2 hospital-acquired avoidable Grade 3/4 pressure ulcers in each of Quarters 1,2 and 3 and 1
hospital-acquired avoidable Grade 3/4 pressure ulcer in Quarter 4 with a quarterly payment of £41,250. We have met all these CQUIN quarterly targets.
7
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
Number of
responses
Inpatients
89
99
505
Outpatients
94
99
342
Short stay
98
100
52
A&E
96
100
27
Maternity
96
100
9
Stroke
89
100
15
Over the year improvements have been seen in doctors and nurses
not talking in front of patients as if they were not there. The national
inpatient survey results that surveyed inpatients from August 2011
showed a two point increase in these questions, but if the more
recent results are maintained a further increase should be seen in
this years survey.
Overall percentage scores for the surveys for March are provided in
the table (left). From next month the new recommender question will
be used with associated scoring system.
539 adult inpatient, stroke and midwifery survey responses were
obtained as compared to 169 responses during February. This was
18% of inpatient discharges (excludes all day cases).
The number of surveys completed for Outpatients and DSU also
increased but higher numbers will be required for DSU and A&E in
future in order to meet next years CQUIN targets.
%
100
95
90
85
80
75
70
65
60
55
50
Did nurses talk in front
of you as if you were
not there?
Did doctors talk in front
of youas if you were not
there?
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
8
3a/b) To continuously improve the experience of patients using our services
CQUIN patient experience targets
Patient experience goals for CQUIN during 2011/12 centred on the national patient survey and internal surveys for specific patient
groups: maternity, paediatrics, stroke, dementia and learning disability.
Internal Surveys
CQUIN required the development of feedback mechanisms during Quarter 1 for each group, the collection of baseline data and
development of an improvement plan in Quarter 2, and the delivery of improvement during Quarters 3 and 4. The results of the
baseline surveys and improvement plans were presented to the Patient Experience Committee. In fact the results of the baseline
surveys was very positive and left little room for increasing the scores. Despite this improvement actions were identified and these
have been implemented.
National Patient Survey
A report on the results from the national inpatient survey of inpatients in August 2011 will be reported separately to the Board. The
CQUIN target focused on five questions with an overarching theme of “responsiveness to personal needs of patients”. CQUIN
required the Trust to achieve a 5.5 point increase in the composite score for these questions and a 15.5 point increase in the
question relating to being informed of the side effects of medication on discharge. As can be seen in the table below, an increase
was seen in some of the questions but the CQUIN targets were not achieved.
Involvement in
decisions
Staff available to
talk about worries
Privacy when
discussing condition/
treatment
Informed about side
effects of medication
Informed of who to
contact after
leaving if worried
Composite score
2010
70.7
62.2
80.6
40.5
73.3
65.5
2011
73.7
61
82.3
46.7
78.2
68.4
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3c) To continuously improve the experience of patients using our services
Environment and Cleanliness
All wards achieved at least 85% except Theatres (83%), F14 (76%) and F3 (80%)
•Theatres score was comprised of 87 % cleaning, 86% nursing and 67% estates.
•F14 score was comprised of 76% cleaning, 80% nursing and 67% estates. The nursing issues related to stains under the drug trolley and a dusty
base on the blood pressure monitoring equipment that were rectified when they were identified to staff.
•F3 score was 83% cleaning, 75% nursing and 71% estates. This score has improved in April’s audit to 86%.
%
Environment and Cleanliness
100
98
96
94
92
90
88
86
84
82
Environment
and
Cleanliness
Target
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
88
86
84
82
80
78
76
74
72
Dec 10-Jan 12
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
70
Jul 09-Aug 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.
National Rate
from last
Oct
May
Aug
reporting Jul 09- Aug 09- Sep 09- 09-Nov Nov 09- Dec 09- Jan 10- Feb 10- Mar 10- Apr 10- 10-Jun Jun 10 Jul 10- 10-Sep Sep 10- Oct 10- Nov 10- Dec 10period
Aug 10 Sep 10 Oct 10
10
Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 11
Jul 11 Aug 11 11
Oct 11 Nov 11 Dec 11 Jan 12
Rolling 12 Month HSMR-All Admissions
-
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
80.3
Rolling 12 Month HSMR-Non Elective
-
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
80.8
SMR Stroke (Acute Cerebrovascular
Disease)
86.2
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
69.6
90
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
58.6
SMR - FNOF
81.6
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
81.2
Mortality from Low Risk Conditions
0.84
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
0.6
SMR - Heart Attack (AMI)
11
We are publishing the Number of Deaths as a
trial to see if it is useful to be used alongside the
HSMR and the SHMI data. It does NOT allow
meaningful comparisons to be made with other
providers or national averages as its solely the
crude number of deaths in hospital.
What it should allow us to see trends at West
Suffolk over prolonged periods of time. Month to
month figures will fluctuate but generally we
should be wary of over interpretation.
The dataset used to calculate the SHMI includes all
deaths in hospital, plus those deaths occurring
within 30 days after discharge from hospital. The
expected number of deaths is calculated from a
risk-adjustment model developed for each
diagnosis grouping that accounts for age, gender,
admission method and co-morbidity .
There isn’t much variation month on month. Unlike
HSMR, it is "rebased" every quarter so the trend is
smoothed out unlike HSMR.
12
Local issues requiring escalation
Patient surveys
All wards have improved their number of patient surveys completed during March.
No ward had a significant number of red scores although F7’s performance still requires close monitoring by the Matron. The ward manager returns to
work in May.
G8 however does have a deterioration in patient satisfaction which will be discussed at the ward governance meeting. The stroke care plan is routinely
given to the patients by the Emergency Stroke Outreach team at discharge so this process will be reviewed to ensure that patients have the care plan
prior to completing the patient experience survey.
Wards
Nurse staffing in the medical directorate continues to be of concern due to the continued requirement to provide staff from each area to the escalation
area, F14 and the escalation beds open on F9c and G8. As the escalation area has been open for five months this is having a noticeable impact on
ward establishments. It should be noted that the directorate put forward for the model for opening of F14. Additional beds on F9C and G8 were not
included in the original capacity plan.
G5 currently have significant registered nurse staffing challenges as they have 3 vacancies which is 10% of their workforce establishment. They are
interviewing at the end of April but this is a difficult ward to recruit to due to as there is no assigned speciality.
Complaints
A&E have had an increase in complaints during March- 8 complaints. These have been related to dissatisfaction with escalation area, misdiagnosis on
initial attendance, attitude of nursing and medical staff, medication errors on discharge, and transport home. All complaints will be reviewed at the
department’s governance meeting.
13
Other CQUIN Targets (not reported elsewhere)
Nutrition
•Nutrition screening, assessment, and action for 95% of patients with nutritional requirements
At least 97% compliance was achieved in each quarter of 2011/12 thus meeting the target.
•Review of nutritional supplements prior to discharge
Procedures were put into place in the first quarter of 2011/12 to ensure that dietitians are notified of all patients to be discharged with nutritional
supplements to allow review to take place. This has enabled the Trust to achieve the target therefore this will be maintained throughout the coming
year.
Hydration
•Identification of patients at risk from dehydration
A risk assessment tool was developed and implemented in Quarter 1 and audits of compliance undertaken in Quarters 2, 3, and 4. Improvement targets
were met and an average compliance of 97% was achieved in Quarter 4.
Deteriorating Patient
•RCAs to be carried out in a sample of 5 patients per month who have a cardiac arrest outside critical care
RCAs were carried out on all patients suffering a cardiac arrest outside critical care throughout the year and an action plan was developed and
monitored through the Deteriorating Patient Group to address issues identified for learning/improvement thus meeting the CQUIN target.
Smoking Cessation
•Number of referrals to the NHS Suffolk Smoking Cessation Service
The numbers of referrals increased during the year in line with the targets set.
Therapy for stroke patients
•Eligible patients to receive a minimum of 45mins of therapy for a minimum of 5 days per week. 30% Q2, 45% Q3, 60% Q4.
The improvement targets were met for each quarter.
14
Local Priorities - Governance Dashboard
Indicator
Performance target
R
A
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
CG (Clinical guideline) baseline assessments beyond
agreed deadline timeframe
1-4
G
Mar12
Commentary
0
2
0
0
0
1
1 action relating to the setting up of a meeting to discuss specific
aspects of the case is overdue. This is being addressed within the
Directorate.
>=1
0
0
SIRIs 7 day report beyond timeframe
>=1
0
0
The 6 SIRIs reported in March all had the relevant reports
submitted within the required timescale.
SIRIs 45 day reports beyond timeframe
>=1
0
0
75 – 94%
>=95%
97%
75 – 94%
>=95%
99%
4-9
0-3
9
>9
4-9
0-3
8
>9
4-9
0-3
9
1-4
Two NPSA alerts remain overdue and on the Risk register:
PSG/2007/001 Medicines reconciliation and SPN/2008/014Right
Patient Right Blood. PSG/2007/001 Medicines reconciliation was
reviewed at CSEC in March and it was agreed to benchmark
against local Trusts.
There were no SIRI 45-day reports due in March.
There has been a reduction from 11 down to 9 outstanding
business cases. There has been continued targeting of the
backlog. Of the 9 outstanding TA’s 3 have been submitted to NHS
Suffolk. No TAs due since November 2011 are outstanding. This is
a 2 month delay on approvals. It is forecast that the delay will be
down to 1 month by then end of May. ( June board report will
verify)
Ops Group will review the outstanding TAs to allocate timescales
for closure.
The Trust still following up the PCT on the decision regarding the
proposed reduced size of business case paperwork to streamline
the process.
Clinical Audit
Complaints
Trust participation in relevant ongoing National audits
(reported by Quarter)
<75%
75 – 89%
>=90%
97%
Response within 25 days or negotiated timescale with the
complainant
<75%
75 – 89%
>=90%
99%
Number of second letters received
>=5
1-4
0
7
Health Service Referrals accepted by Ombudsmen
>=2
1
0
0
Red complaints actions beyond deadline for completion
>=5
1-4
0
0
This increase is representative of the overall increase in the
number of complaints received during January 2012.
15
Local Priorities
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Reporting to NRLS
300
250
200
150
100
50
number of PSIs (1ary axis)
NRLS Median Trust (1ary axis)
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
0
Apr-11
1ary (patient safety incidents)
350
% serious harm (2ary axis)
2ary Axis (serious harm incidents %)
The eight serious incidents in March included three (3) Neonatal / Intrapartum / Intrauterine deaths and one (1) SUDIC. The other four were: Grade 3 Pressure ulcer (1
reported as SIRI in March), Deteriorating patients (2 not SIRIs), 4th degree perineal tear
(1 not a SIRI).
2ary Axis (all harm incidnets)
0
Serious harm incidents (1ary axis)
SIRIs (1ary axis)
Mar-12
0
Feb-12
20
Jan-12
2
Dec-11
40
Nov-11
4
Oct-11
60
Sep-11
6
Aug-11
80
Jul-11
8
Jun-11
100
May-11
In March there were seven SIRIs reported initially but in two cases the 7-day report
provided evidence to allow the PCT to downgrade (1 controlled drug incident and 1
obstetric incident). The remaining five were: Grade 3 Pressure ulcer (1), Deteriorating
patient (1 Feb incident), Confidentiality issue (1 no harm incident) and Neonatal death /
Intrauterine death (2 incidents requiring comprehensive RCA to decide status).
120
10
Apr-11
There were 197 patient safety incidents reported in March of which 96 resulted in
harm. The number of serious incidents in March was eight. Following receipt of a
report from the PCT it has been agreed that all Neonatal, Intrapartum and Intra-uterine
deaths will be submitted (as catastrophic) initially for review by the PCT but it is
expected that a number of these will be reclassified as ‘not an incident / not a SIRI’
after the 2-day or 7-day report.
Harm incidents
12
1ary Axis(Serious harm & SIRIs)
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)
Harm incidents (2ary axis)
 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 (e.g. 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). NPSA data to be rebased in the next report.
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 is high in March as a consequence of a slight reduction
in the total number of incidents reported and the additional reporting of Neonatal /
Intrapartum / Intra-uterine deaths. This figure is expected to reduce after the
review of these cases.
Local Priorities
Complaints
Complaint response within agreed timescale with
the complainant: 95% of responses due in March
were responded to within the agreed timescale
(target 90).
Of the 22 complaints received in March, the
breakdown by Primary Directorate is as
follows: Medical (14), Surgical (7), Clinical
Support (0), Women & Child Health (1) and
Facilities (0).
Trust-wide the most common problem areas are
as follows:
- All Aspects of Clinical Treatment
- Communication
- Attitude of Staff
- Admission, Discharge & Transfer
9
6
6
3
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 deadline for completion.
17
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 Apr11 to Mar 12 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:
Information (advice)
22
Other (relating to queries about other organisations)
7
All aspects of clinical treatment
14
Admissions, Discharge and transfer arrangements
6
Appointments delay/cancellation
3
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 there is now evidence that the Manager consistently meets this target.