Listening and Improving July 2015 How Healthcare Improvement Scotland has listened to feedback, comments, concerns and complaints to make improvements during 2014 2015
Healthcare Improvement Scotland 2015 First published July 2015 The contents of this document may be copied or reproduced for use within NHSScotland, or for educational, personal or non-commercial research purposes only. Commercial organisations must obtain written permission from Healthcare Improvement Scotland before copying or reproducing any part of this document. www.healthcareimprovementscotland.org
Contents Section 1: Section 2: Section 3: Section 4: Section 5: Introduction 4 Encouraging and gathering feedback 6 Encouraging and handling complaints 9 The culture, including staff training and development 11 Improvements to services 13 Accountability and governance 22 Next steps 23 Further information 24
Introduction Listening to the experience of people who use healthcare services gives a valuable insight into how those services are performing, and provides a rich source of intelligence on what is working well and what needs to be improved. The importance of listening to patients and their carers was recognised by the Patient Rights (Scotland) Act 2011. This Act gives people a legal right to give feedback, make comments, raise concerns or make complaints about NHS services and it also places a responsibility on the NHS to encourage, monitor, take action and share learning from the views they receive. Healthcare Improvement Scotland is the national healthcare improvement organisation for Scotland. Our work drives improvements in the quality of healthcare people receive. One of the ways that we seek to achieve this is by supporting and empowering people to have an informed voice in managing their own care and shaping how services are designed and delivered. Healthcare Improvement Scotland is absolutely committed to ensuring that the views of patients and their carers shape what we do. Although we do not provide healthcare services directly to patients, feedback and complaints are important to us from a number of different perspectives: we proactively seek feedback from patients, carers and the public to inform our work and improve what we do we receive a small number of complaints about what we do and ensure these are handled in line with our values and our complaints procedure data and intelligence about feedback and complaints received by NHS Boards helps to inform our scrutiny and assurance work with NHS Boards, and our improvement programmes, and we handle complaints about independent healthcare services, including independent hospitals (including voluntary hospices) and private psychiatric hospitals. 4
You may not notice Healthcare Improvement Scotland in your hospital, GP practice or clinic, but we play an important role helping others put into place the improvements to patient care that matter most to you. You may have heard of key parts of our organisation that have specific roles, including: Healthcare Environment Inspectorate - helps reduce the risk of healthcare associated infection to patients by inspecting hospitals in Scotland to ensure they are safe and clean. Scottish Health Council - supports NHS Boards to involve staff, patients, carers and communities in the development of health services. Scottish Health Technologies Group - provides advice on the clinical and cost effectiveness of healthcare technologies that are likely to have significant implications for patient care in Scotland. Scottish Intercollegiate Guidelines Network - develops evidence-based clinical practice guidelines for NHSScotland. Scottish Medicines Consortium - accepts for use those newly licensed medicines that clearly represent good value for money to NHSScotland. This report sets out for the first time how we use feedback and complaints across the whole organisation. The process of preparing this report has enabled us to reflect on how well we are doing this and to identify areas where we can strengthen our approach. Listening and Improving Report 5
Section 1 Encouraging and gathering feedback Listening to feedback from patients, carers and the public is vital to help shape the work that we do in Healthcare Improvement Scotland. There are two key ways in which this is important to us firstly, to hear what people think about the work that we do; and secondly, to hear what people think about the healthcare services that we help NHS Boards to improve. This section of the report explains more about the ways in which we listen to these views, and Section 4 gives examples of how this has resulted in service improvement. 1 Gathering feedback about the work that we do in Healthcare Improvement Scotland Our Engaging People Strategy 2014 2020 1 sets out our commitment to involving people in all that we do. The feedback that we receive is largely feedback that we have proactively sought through surveys, consultations, focus groups and social media. We believe it is essential to use a variety of methods to enable people to express their views. A number of our staff are trained in using many of the 32 methods of engagement that are promoted in the Scottish Health Council s Participation Toolkit 2, including: Ask Me 3 and Ask 3 Questions Emotional touchpoints Nominal group technique Talking mats World cafe. 6
A number of our projects and programmes have sought feedback from groups involving people with equality protected characteristics 3 and examples are provided in Section 4 of this report. We have built relationships with local and national community and third sector organisations to help us to reach the people we need to speak to. We have a local office in each NHS Board area with staff who are skilled in engaging with patients and the public. They have gathered feedback to support our work including The Scottish Medicines Consortium and public attitudes to the provision of medicines for the NHS in Scotland and Gathering public views on new arrangements for death certification, with reports published on our Scottish Health Council website 4. 2 Feedback about the healthcare services that we help NHS Boards to improve Healthcare Improvement Scotland provides public assurance about the quality and safety of healthcare through the scrutiny of NHS hospitals and services, and independent healthcare services. One of the key ways in which we do this is through inspections and reviews. These inspections and reviews are informed by complaints and feedback that NHS Boards have received about the healthcare services that we inspect or review. This includes complaints data that is published by the Information Services Division of NHS National Services Scotland as well as feedback reported on the Patient Opinion website 5. It is also informed by feedback that we receive directly from patients or the public as part of the inspection or review process. This feedback is gathered by our staff or by our Public Partners (volunteers who work with Healthcare Improvement Scotland). We consider information gathered on complaints and feedback alongside all other relevant information about the services we review or inspect. It helps us to understand what is working well, or not working well, in healthcare services enabling both us and the NHS Boards that we work with to identify improvements. 1 Engaging People Strategy, Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org/ previous_resources/policy_and_strategy/user_engagement_strategy.aspx 2 Participation Toolkit, Scottish Health Council http://www.scottishhealthcouncil.org/patient public_ participation/participation_toolkit/the_participation_toolkit.aspx 3 There are nine equality protected characteristics in the Equality Act 2010 age, disability, gender reassignment, pregnancy and maternity, marriage and civil partnership, race, religion or belief, sex, sexual orientation Listening and Improving Report 7
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Section 2 Encouraging and handling complaints This section of the report covers both complaints that have been received about Healthcare Improvement Scotland and complaints that we have dealt with in relation to certain independent healthcare services. Complaints about Healthcare Improvement Scotland Healthcare Improvement Scotland is committed to listening to and understanding people s experiences and acting on these to improve how we work. We seek to actively engage with individuals and respond to feedback received, and are committed to delivering a person-centred and values-based approach. Healthcare Improvement Scotland has no remit to consider complaints relating to services provided by NHS Boards. When such complaints are forwarded to us we provide the person contacting us with details of the complaints officer in the relevant NHS Board, to ensure their concern is made known to the NHS Board and investigated as quickly as possible. However, we do use this information when we are planning inspections. Any complaints recorded are considered along with other information we receive about NHS Boards such as statistics, patient feedback from the National Patient Survey, websites such as Patient Opinion, and complaints made to the Scottish Public Services Ombudsman (SPSO). This evidence helps us to prioritise and focus our inspections. All complaints about Healthcare Improvement Scotland are acknowledged within 3 working days by the Complaints Officer who maintains a record in our complaints database. All investigations into a complaint are completed within 20 working days wherever possible. If an investigation is extended beyond this period, the person making the complaint and other parties will be informed of the reason for the delay with an indication of when a response can be expected. In 2014 2015, Healthcare Improvement Scotland received and responded to two complaints. Both complaints took more than 20 working days to respond and were resolved without the need for use of alternative dispute resolution. One complaint related to an interview process and communication about the outcome of this; the other complaint related to staff use of social media. Our social media guidance is currently being reviewed as a result in order to identify whether further refinement is needed. Listening and Improving Report 9
Complaints about independent healthcare services While Healthcare Improvement Scotland does not investigate complaints about NHS Boards, we do have a duty to investigate complaints about registered independent healthcare services. Currently, these include independent hospitals, including the charitable hospices, and private psychiatric hospitals. Anyone who has had care or treatment from a registered independent healthcare service can complain to us. In certain circumstances, we will accept complaints on behalf of someone else. Complaints can be about any part of a registered independent healthcare service, including: the care and treatment received the environment, and any member of staff. We allow complaints to be made up to 12 months after the event that is being complained about. We can accept complaints about registered independent healthcare services at any time. However, we recommend, in the first instance that a complainant talks to a member of staff involved in their care, as this is often the quickest way to sort any problems. If this does not solve the problem, we suggest they ask the independent healthcare provider for a copy of their complaints procedure and ask them to investigate the complaint. We would normally begin an investigation if the complainant is unhappy with the independent healthcare provider s response. We will complete investigations within 20 working days and advise the complainant of the outcome in writing. If the complaint is complex and we are unable to complete our investigation in 20 working days, we write and advise the complainant of the reason why and when they can expect to get a conclusion. We are unable to take complaints about: independent healthcare services that are not regulated by Healthcare Improvement Scotland anything that is being, or has been, investigated by the Scottish Public Services Ombudsman, or an individual health professional s ability to do their job where this should be investigated by another professional body. In 2014 2015, we received six complaints about independent healthcare services. In two of these complaints, we responded within 20 working days. Of the four complaints that were not responded to within 20 working days: one was delayed due to staff needed for interview being on annual leave; one complaint took place over the festive period and there was a delay with the complainant responding to us; and the other two were beyond 20 working days because further investigation was needed. Given the small number of complaints received, it is not possible to identify particular themes. 10
Section 3 The culture, including staff training and development Healthcare Improvement Scotland is committed to developing a culture that welcomes feedback of all types from staff, patients and the public, and other stakeholders, both about the work that we undertake and the way that work is delivered. As an organisation committed to quality improvement, this feedback is a key part of informing where those improvements should take place. A number of key activities have been undertaken this year to support that commitment. Work to create the right conditions, capacity and capability in teams includes the following. Empowering people Healthcare Improvement Scotland has been explicit in its Strategic Plan about the value it places on feedback. A key strategic objective is: We listen to what patients and communities say about healthcare services, and their views and experiences inform everything we do. One way that we demonstrate this core value is by recruiting, developing and supporting public partners to participate in all aspects of our work. Listening and Improving Report 11
Values and behaviours Healthcare Improvement Scotland has adopted NHSScotland s workforce values and has defined them to help support the culture it hopes to reliably deliver. In particular, Dignity and respect we value our staff and partners views and we ensure equality and fairness in everything we do. We promote a positive working environment based on constructive relationships. We listen to and respect different points of view and will give fair and honest feedback internally and externally. We recognise that complaints and feedback present an opportunity to improve. A significant campaign to embed these values across the organisation has been supported throughout the year where every team was tasked with discussing these values and the behaviours that would underpin them. The campaign has resulted in a number of teams explicitly committed to seeking feedback from people to inform their team development. Patient Opinion Patient Opinion is an independent website which enables people to record their views of NHS services and also enables those services to respond - www.patientopinion.org.uk/services/nhsscotland An increasing number of staff across all parts of Healthcare Improvement Scotland have subscriber access to Patient Opinion and regularly use the stories contained within the website to inform the work that is undertaken with NHS Boards. Embedding feedback principles in all activity has been a priority this year and the Improvement Team leading the national collaborative for person-centred care have undertaken training and awareness sessions with internal staff to help them understand why feedback from people is a vital and rich source of data for improvement. 12
Section 4 Improvements to services Given the small number of complaints that we have received (see Section 2), this section of the report focuses on demonstrating how we have used feedback for the purpose of improvement. It provides examples from across different parts of Healthcare Improvement Scotland that show how feedback influences the diverse range of work that we do. Strengthening patient and public involvement in the Scottish Medicines Consortium The Scottish Medicines Consortium (SMC) accepts for use those newly-licensed medicines that clearly represent good value for money to NHSScotland. From May September 2014, the SMC gathered feedback from a range of key patient and public stakeholders. The aim was to improve how SMC engages with those representing patient and carer interests, and members of the public. Who SMC engaged with Voluntary organisations (patient and carer groups): 54 patient groups engaged with in total through one-to-one interviews and a survey. SMC Committee Members and User Group Forum (SMC pharmaceutical industry group): e-surveys. Public Partner Focus Group (volunteers who work with the SMC). Public discussion groups 10 groups with 94 participants in total. Listening and Improving Report 13
Feedback SMC received Patient groups need training on how to submit to SMC. Smaller and less experienced patient groups need support to submit to SMC. Patient group submission form is difficult to access, understand and use. Patient groups need more help to understand the type of information to capture. SMC needs to give greater focus on the impact to carers. Time consuming to provide detailed charitable information with every submission. Unclear way of capturing and presenting any patient group pharmaceutical company funding. SMC would benefit from an advisory group which brings together key stakeholders including representative patient groups and public partners. Website difficult to navigate. Improvements SMC has made First full day training event took place March 2015 59 patient groups attended. Further training planned. From Autumn 2014, every patient group is offered one-to-one support with their submission from the public involvement team. New submission form launched April 2015. Developed in partnership with patient groups, and in a new format, with improved accessibility. New booklet - Guide for Patient Group Partners launched April 2015. New submission form includes a section on how a medicine will impact carers. New Public Involvement Network (PIN) Advisory Group has a carer representative on it. New registration form for Patient Group Partners launched April 2015 one-off provision of charitable information (updated annually). New system for capturing and presenting patient group pharmaceutical company funding as a percentage of overall income, launched April 2015. New PIN Advisory Group launched May 2015, bringing together representative patient groups, public partners and other key stakeholders. New simplified and improved Public Involvement section in website March 2015. Further website enhancements are ongoing. 14
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Developing Proposals for a Stronger Voice the Scottish Health Council In June 2014, the then Cabinet Secretary for Health and Wellbeing, Alex Neil MSP, requested that proposals be developed for a system to strengthen the voices of patients, service users and members of the public within health and social care in Scotland. It was recognised from the start that key stakeholders must be involved in identifying the priorities for this work and in developing the final proposals. An extensive plan of engagement was carried out by the Scottish Health Council, on behalf of the Scottish Government and partner organisations, between August and November 2014. This included four national events with members of the public, service users, health and social care staff and third sector organisations, and 22 smaller focus group sessions with patient and community groups. This approach included targeting people with lived experience of health and social care services, people who had been involved in formal participation structures within the NHS, people who had no prior involvement and people from traditionally seldom heard communities including young and older people, people with English as a second language, people with long-term conditions and people with learning disabilities. Innovative approaches were used to capture the views of people who may not have been involved before, including two live Twitter chats, connecting smaller discussion groups into a virtual event using video-conferencing, two online surveys, a graphic facilitator to capture comments in a visual format at the national events, and recorded short videos so that we heard the voice of patients, carers, the public and staff directly. In total, views were gathered from almost 1,200 individuals and groups and a synthesis of their feedback was used to inform the final proposals. These included systems for creating a stronger voice during individual treatment decisions, when designing and delivering services at a local level and to develop policy at a national level. The proposals were presented to the Cabinet Secretary in January 2015, and will be further developed during 2015 2016. 16
The DECIDE project: Patient understanding of evidence-based guidelines One element of the DECIDE project (a European Union funded study) aims to identify approaches to effective dissemination and use of research evidence, including clinical guidelines, for patients and the general public. Shared healthcare decision-making between clinicians and patients requires information on treatment methods and outcome measures that are of relevance to patients in a language that patients understand. Translating clinical guidelines into patient information presents a number of challenges, as these have been developed primarily for clinician use and substitution of plain language alone may not address the needs of patients in making choices and decisions relating to their care. Healthcare professionals, NHS public involvement staff and representatives from the third sector provided views on what and how evidence-based information should be provided to patients and this, together with a survey of patients, formed the basis of the material used in a series of focus groups. The focus groups involved with individuals with a range of health conditions, including diabetes, depression and obesity. Results from this initial user testing of how patients, carers and the public prefer to see information have been analysed and the findings have been used to present recommendations from a Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline in a SIGN patient booklet in a new way. To fully implement these findings, dramatic redesign of the booklet was required. Key findings from the focus groups show that when evidence-based recommendations are presented for patients and members of the public, the information should: be chunked down, for example in tables, boxes, bullet points be age and understanding appropriate be attractive, friendly and eye catching while still appearing as credible, trustworthy health information have clear headings and sections to flag different topic areas have images that convey meaning be aware of, or work with, people s associations with colour keep charts and graphics to convey findings as simple as possible use symbols only if they have an instantly recognisable meaning, for example traffic lights, thumbs up, and use frequencies to present numbers wherever possible. The redesigned booklet is undergoing a second round of testing and the findings from these focus groups will feed into the DECIDE project as well as influence the look, design and dissemination of SIGN patient booklets. Listening and Improving Report 17
Patient participation and feedback in the development of the Standards for the Care of Older People in Hospital Patient participation and feedback is a key element in the development of Healthcare Improvement Scotland s standards and indicators, which cover a range of clinical topics, including bowel screening, cardiovascular disease, and food, fluid and nutrition. The team proactively seeks views from seldom heard groups and, in recent years, this has included focus groups in hospices, Cornton Vale Prison and with people with drug addiction. Consultation and engagement on the draft standards for the care of older people in hospital took place between November and December 2014. This included meetings and focus groups across Scotland. This included discussions with the ALLIANCE, NHS Tayside Public Involvement Group, LGBT Health and Wellbeing (Age reference group) and South Lanarkshire Seniors Together. Although feedback was welcomed on all of the standards in the draft document, we particularly wanted to hear their opinions on the three person-centred care standards, namely: Involving patients: What matters to me ; Consent and decision-making; and Maintaining dignity and privacy. We used the following questions to generate discussion on the topics: Do the standards cover what you feel is important? Is there anything that should be added? Any further thoughts? The comments received were fed back to the project group developing the standards, which in turn influenced the wording and content of the document. For example, the patient groups all felt that the role of the carer or representative of the patient should be highlighted more and this was recognised in later versions. In the case of the standard that deals with pharmaceutical care, where it formerly stated that the patient should receive the correct medicines during their stay and at discharge, it now states that patients and their representatives are involved in ensuring that the correct medication is received and that support is available to both to ensure the medicines can be administered appropriately. 18
Older People in acute care - Delirium Delirium is an acute medical emergency associated with poor outcomes that commonly affects older people admitted to hospital, particularly those with dementia, severe illness or a hip fracture. It causes great distress to patients, families and carers and has potentially serious consequences such as increased likelihood of admission to long term care and increased mortality. A collaborative approach was adopted to develop a change package to support improvements in the identification and management of delirium and to test changes, and share and spread good practice. Engaging and involving the patient and family members is emphasised as being a critical element of managing delirium. To learn about the experience of giving and receiving care during an episode of delirium, focus group discussions with staff and individual interviews with patients and families were carried out using the process of emotional touchpoints. Emotional touchpoints is a method that helps to tap into the meaning of an experience in a structured way. It focuses on particular points in the experience journey (touchpoints) and asks people to select from a range of emotional words that sum up what the experience felt like. The storyteller is then asked to sum up why they felt that way and if appropriate what would help to make the experience better. The accounts from staff, patients and family members were invaluable. They highlighted the importance of continued engagement with everyone during these episodes in order to use that experience to influence care giving. A number of strategies that helped patients, staff and family to feel safe were identified, including: supporting people to be calm in their approach finding out something about the person and using this to influence caring and develop relationships keeping people up to date about what is happening, and helping people to make sense of things. This information has been used to support staff on how to apply the delirium care bundle in practice. Listening and Improving Report 19
Scottish Patient Safety Programme Primary Care Scottish Patient Safety Programme (SPSP) in Primary Care has Public Partner representation throughout the programme and this includes pharmacy in primary care. One of our Patient Public Partners attends regular Steering Group meetings and takes a central role in coordinating feedback from patient/carer representatives who sit on the local governance groups. This has included co-ordinating feedback on a poster to be displayed in participating pharmacies to ensure that the language used is clear and will be easily understood by patients. Evaluation of national learning events All of the SPSP improvement programmes include national learning events ranging from less than a hundred participants to over 500. Following each national and regional learning session, an evaluation questionnaire is undertaken which identifies the breakdown of attendees at each event, noting if they are service user, carers, third sector, from NHS Boards or others. This feedback is used to inform after action reviews of the events which identify things that have gone well and things that could be improved. Examples of opportunities for improvement from the last year have been: improving information available for delegates on disabled access at venues making sure delegates are aware they can use rest room facilities during plenary sessions ensuring we have contingency plans for supplying additional brochures of alternative formats for delegate brochures, for example large print (above predicted requirements), and reviewing design of breakout sessions to include content that is relevant to people who use services. This feedback has been invaluable in ensuring we take into account the needs of all our delegates including people who use healthcare services. 20
Death Certification Review Service In May 2015, Healthcare Improvement Scotland took on a new role in reviewing the certification of a proportion of deaths which are registered in Scotland. The review service may impact on people when they have recently been bereaved and it is important to ensure the system is as fair and as easy to understand as possible, so that it does not add unnecessarily to their distress. An equality impact assessment highlighted the potential impact of the new review system on certain faith groups, including Muslim and Jewish communities. It is clear that anyone could potentially be upset to learn that they are unable to register a death until a review has been completed, or that a funeral may not be arranged until the death has been registered. Our project team, together with two Public Partners and colleagues from the Scottish Health Council, held a series of public focus groups in Aberdeen, Dundee and Orkney. Focus groups involving faith communities were also held in Dundee and Glasgow. Participants were asked their views on intended processes and application forms for expedited reviews and interested person reviews. Feedback from the focus groups informed the review process and the information we produced for bereaved people. We developed leaflets and simplified terminology as a result of the focus groups. Questions that were asked by participants also helped to create a frequently asked questions document on the service, and informed the project team s communications plan. Listening and Improving Report 21
Section 5 Accountability and governance Healthcare Improvement Scotland has recently reviewed its governance and accountability framework in place for the management, monitoring and assurance associated with feedback and complaints and has agreed to strengthen these arrangements in the coming year. The organisation s Code of Corporate Governance states that it is the responsibility of the Chief Executive to ensure that effective procedures for handling complaints about Healthcare Improvement Scotland and registered independent providers are established. The Director of Finance and Corporate Services is the Executive Lead for complaints and feedback. Currently, work is being undertaken with the Chair of the Quality Committee (a Non- Executive Board member) to consider how best to involve other Non-Executive Board members in the handling of complaints and feedback. A development session for Board members will take place in May 2015. The Quality Committee will receive a quarterly and annual report detailing complaints and feedback. This will enable regular progress reporting and will seek to demonstrate clearly how complaints and feedback have been used for service improvement. 22
Next steps Whilst producing this report we have also been reviewing our arrangements for how we gather complaints and feedback, and how we learn from these in Healthcare Improvement Scotland. This has enabled us to understand what is working well and how we can build on this moving forward. It has also helped us to identify actions we can take in 2015 2016 to strengthen our approach. These include: strengthening our governance reporting on complaints and feedback (see Section 5) reviewing our policies and procedures for complaints and feedback handling raising awareness with our staff and Public Partners of the importance of complaints and feedback to our work, and our policies and procedures for handling these, and sharing good practice examples across the organisation of how we have used a variety of methods for gathering feedback and how this has positively impacted on our work. Listening and Improving Report 23
Further information For more information about the work of Healthcare Improvement Scotland, please see our website: www.healthcareimprovementscotland.org If you have any questions or comments about this report, please contact: Christine Hill Executive Office Business Manager & Complaints Officer Phone: 0131 623 4319 Email: christine.hill2@nhs.net 24
www.healthcareimprovementscotland.org Edinburgh Office: Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone: 0131 623 4300 Glasgow Office: Delta House 50 West Nile Street Glasgow G1 2NP Telephone: 0141 225 6999 The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group, the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium are part of our organisation. You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Advisor on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net