Annual Report and Accounts - The Great Western Hospital

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3.25 Using patient experience to drive service improvements 3.25.1 Comment Cards Across the Trust we use ‘Tell us how we’re doing’ comment cards to capture four elements of patient feedback: - What was good about your visit? - Was there anything we could do better? - Would you recommend us to a friend? - Please tell us about any person or team who provided you with excellent care. A measure of satisfaction regularly used in the commercial industry is recommendation to a friend, which is included within the comment cards. It has proved challenging to generate enough responses via these comment cards to confidently track performance, particularly in relation to the patient recommendation question. Towards the end of the year each directorate was set a monthly target of returning 100 completed cards to enable a statistically reliable comparison to be made each month. The response rate is reported by Directorates in the monthly patient experience report to the Executive Committee and Trust Board. Due to low response rates, the last reliable indicator of patient recommendation was in January 2012 tracking at 97%. During the other months when the response rate was large enough for a statistically significant response, the recommendation rate ranged from 84% to 97% showing a high level of satisfaction. 3.25.2 Online Feedback The Communications Team monitors and interacts with patients through feedback through online channels. The Trust is experiencing a rapid growth in online feedback and user interaction through relatively new websites such as PatientOpinion.org. This site has been established as a ‘Trip Advisor’ style site for users of the health service and is likely to become more widely used by patients in the future. During the course of the year, the site established formal links with NHS Choices and information posted on Patient Opinion is automatically linked to the NHS Choices website (and vice versa). Several thousand people view the GWH sections of these sites on a monthly basis, so it is important to be actively engaged with users through these channels. Sites such as this present both an opportunity for the Trust in providing a rich vein of user feedback, and at the same time they present a challenge as typically, people posting on these sites expect a response within 48 hours. This means the Trust needs to be much more responsive than we have been previously and we need to ensure responses (as they are in the public domain) not only respect confidentiality but also are actually useful to the user and those viewing the site in the future. Patients and the public are also able to ‘follow’ the Trust on Twitter and Facebook. There are over 450 followers at present. In the year ahead PALS will be looking at alternative ways to seek feedback such as using a dedicated children’s PALS website aimed at engaging and sharing information with children and young people. Page 33 of 211
3.25.3 Patient Surveys The PICKER Institute is a not-for-profit organisation which undertakes a range of qualitative and quantitative research into patient experience. The Trust has historically commissioned PICKER to undertake the Mandatory Surveys issued by the Care Quality Commission (CQC). During 2011/12, the PICKER Institute has carried out the following surveys: • Quarterly Inpatient • Annual Inpatient - results from this survey are used for national benchmarking purposes by the CQC • Annual Outpatient 3.25.4 Quarterly Inpatient Surveys Quarterly Inpatient Surveys give the Trust an opportunity to monitor service improvements and exceptions reports are presented to a Patient Safety and Quality Committee on a quarterly basis. The results of the PICKER Inpatient survey are used to monitor five elements of Commissioning for Quality and Innovation (CQUIN) relating to patient experience at GWH. The table below shows the CQUIN results gathered from the quarterly Inpatient Surveys. Lower percentages are better. TABLE - Great Western Hospital Quality Account results on patient experience Indicator Wanted to be more involved with decisions about care GWH Could not always find staff to discuss concerns with GWH Not enough privacy when discussing care or treatment GWH Side effects of medication not fully explained GWH Not told who to contact after discharge if worried GWH Regulator Target 2011/12 Quarter 1 QA, PCT, CQUIN
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Great Western Hospitals NHS Foundat
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CONTENTS 1 Chair and Chief Executiv
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The Great Western Hospital became a
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Underpinning this, our values are t
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3.2 Principal activities of the Tru
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Further Companies Act Disclosures 3
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Business Review / Management Commen
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3. To ensure that staff are proud t
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6. To work in partnership with othe
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With funding received from the Depa
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3.13 Contractual arrangements The T
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Patient care 3.16 Development of se
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3.20 New or significantly revised s
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3.24 Complaints Handling For the Tr
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The Trust actively responds to feed
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3.25 Using patient experience to dr
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The table below shows the CQUIN res
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Action plans based on the Quarterly
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3.27 Development of services with o
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3.29 Health and Overview Scrutiny C
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3.32.5 Interests held by Directors
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4.3 Attendance at meetings of the R
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4.7 Board of Directors’ employmen
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Remuneration Name Title Salary (Ban
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4.8.4 Additional disclosures The Tr
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5.1.2 Elected Governors - Public Co
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5.1.4 Nominated Governors Name Nomi
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5.1.6 Lead and Deputy Lead Governor
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“Eyes and Ears” - An initiative
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5.1.12 Nominations and Remuneration
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Rowland Cobbold, Non-Executive Dire
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Lyn Hill-Tout, Chief Executive (unt
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5.2.3 Length of appointments of Non
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5.2.6 Attendance at meetings of the
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5.3 Audit Committee 5.3.1 The Audit
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5.4 Directors’ responsibility for
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Note: Angela Gillibrand and Rowland
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The Mental Health Act / Mental Capa
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The Trust has a wide range of staff
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5.8.6 Membership Strategy To encour
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5.9 Code of Governance Disclosure S
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6 QUALITY REPORTS Part 1 - Statemen
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Part 2 - Priorities for improvement
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6.3.1 Review of services and partic
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The trust chose not to contribute t
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No. Audit Title Reconstruction Audi
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The reports of 273 local clinical a
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No. Audit Title 15. Non Invasive Ve
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No. Audit Title Antibiotic Prescrib
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No. Audit Title 50. NICE CG111 - No
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Part 3 - Other Information 6.4 Over
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GRAPH - Clostridium Difficile WCHS2
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GRAPH - Medicine incidents by type
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Harm from falls WCHS: It was not po
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• Rolling educational programme w
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CHART - Relative risk SW Acute Trus
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Following the Trust’s merge in Ju
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Priority 7: Participation on the Re
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All the guidelines have been dissem
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This has been achieved by: • Mont
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• As a result of complaints and c
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CHART - National Sentinel Stroke Au
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Priority 16: To ensure patients are
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6.5 Care Quality Commission (CQC) I
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6.7 Statement of Directors’ respo
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a Quality Account and the opportuni
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Overall, the Trust has good plans t
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Graph 1 - GWH carbon footprint (ton
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The Trust is working with local bus
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Graph 9 - Total tonnes of waste pro
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The Trust will be working towards a
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Detailed below is a summary of the
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Wiltshire Community Health Services
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providers. Feedback obtained across
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The Musculoskeletal Disorder team a
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10.2.2 Governance risk rating The t
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11 OTHER DISCLOSURES IN PUBLIC INTE
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13 AUDITOR’S OPINION AND CERTIFIC
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14 ANNUAL GOVERNANCE STATEMENT 14.1
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• the key controls to mitigate ag
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14.4.6 Organisation Culture The Tru
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14.5 Review of economy, efficiency
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Process Board Role and Conclusions
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15 GLOSSARY OF TERMS BARS - Blood A
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16 FOREWORD TO THE ACCOUNTS 16.1 Fo
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Page 193 and 194: Great Western Hospitals NHS Foundat
Page 209: Great Western Hospitals NHS Foundat
Page 214: Great Western Hospitals NHS Foundat
Page 217 and 218: 1 CHAIR AND CHIEF EXECUTIVE’S REP
Page 219 and 220: 2 OUR TRUST 2.1 Vision - Your healt
Page 221 and 222: 3 DIRECTOR’S REPORT General Compa
Page 223 and 224: 3.3.2 The Brunel Treatment Centre O
Page 225 and 226: 14 In relation to the use of financ
Page 227 and 228: Checklist, a World Health Organisat
Page 229 and 230: organisations to adapt to these cha
Page 231 and 232: TABLE - Wiltshire Community Activit
Page 233 and 234: The Trust is currently reviewing it
Page 235 and 236: Enhanced Quality Governance Reporti
Page 237 and 238: The Trust is using its foundation t
Page 239 and 240: of implementing the programme. Incl
Page 241 and 242: As part of the corporate back offic
Page 243: What patients and service users hav
Page 247 and 248: 3.25.5 Annual Inpatient Survey The
Page 249 and 250: CHART - Percentage of patients who
Page 251 and 252: 3.28 Working with our partners to s
Page 253 and 254: 3.31 Statement as to disclosures to
Page 255 and 256: 4 REMUNERATION REPORT Information n
Page 257 and 258: 4.5 Remuneration of senior managers
Page 259 and 260: 4.8 Pension Benefits and Remunerati
Page 261 and 262: The accounting policies for pension
Page 263 and 264: 5 NHS FOUNDATION TRUST CODE OF GOVE
Page 265 and 266: There is currently a vacancy for th
Page 267 and 268: 5.1.5 Attendance at meetings of the
Page 269 and 270: In addition, in preparing the Trust
Page 271 and 272: 5.1.11 Council of Governors Meeting
Page 273 and 274: 5.2 Board of Directors 5.2.1 The Bo
Page 275 and 276: Roger Hill, Non-Executive Director
Page 277 and 278: Helen Bourner, Director of Business
Page 279 and 280: 5.2.4 Statement about the balance,
Page 281 and 282: 5.2.9 Significant Commitments of th
Page 283 and 284: 5.3.2 The work of the Audit, Risk a
Page 285 and 286: 5.6 Nominations Committee 5.6.1 The
Page 287 and 288: 5.7 Mental Health Act / Mental Capa
Page 289 and 290: 5.8 Membership 5.8.1 Membership The
Page 291 and 292: The groupings of the members in the
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G.1.2 - The Board should clarify in
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and Governors. We have also commenc
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Regulation 1. To sustain compliance
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Audit / confidential enquiry title
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Audit Title Submitted/Required (%)
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No. Audit Title Learning From The P
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No. Audit Title 8. Diabetes Ketoaci
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No. Audit Title Audit Summary/Learn
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No. Audit Title Audit Summary/Learn
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6.3.4 Registration with Care Qualit
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Steering Group, provides a quarterl
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Clostridium Difficile: The goal for
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Priority 2: To reduce harm associat
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Priority 3: To reduce harm associat
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Pressure ulcers Community: The comm
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Safe care of the patient receiving
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CHART - Serious Incidents grouped b
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The three top serious incident caus
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West conference call in August 2011
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Priority 9: To review the clinical
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Priority 12: To undertake nutrition
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• A regular ongoing training prog
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Community: • Q1 Performance April
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The survey results demonstrate that
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6.6 Performance against key nationa
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6.8 Statements from Primary Care Tr
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6.8.4 Wiltshire Primary Care Trust
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6.9 Independent Assurance Report to
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7 SUSTAINABILITY REPORTING 7.1 Stro
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Graphs 3 and 4 show energy consumpt
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Graph 7 - Water consumption in WCHS
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8 EQUALITY REPORTING 8.1 Equality d
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9 STAFF SURVEY REPORT 9.1 Our staff
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It was agreed that we would focus o
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Appraisal rates. The overall rate f
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A quarterly “Voluntary Service Ma
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10 REGULATORY RATINGS REPORT 10.1 M
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10.3.2 Explanation for differences
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12 STATEMENT OF ACCOUNTING OFFICER
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14.4 The risk and control framework
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Risk Licence to operate (compliance
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The governors and wider stakeholder
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Steps which have been put in place
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14.8 Conclusion I have not identifi
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Annual Report and Accounts - The Great Western Hospital

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