Corporate Patient Experience Plan
RAG rating:
= completed
= in progress but not yet completed
= delayed or overdue
Progress highlights:
1 Overdue items on 20/02/2013

Inpatient 2c: Refurbishment of bathrooms. The ward needs to decant to complete the work

Inpatient action 3b: Re-launch Productive Ward – failure to recruit

Inpatient 3c & Outpatients 1b: Launch of Cerner Millennium delayed to June 2013

Inpatient 4c: Ward communication project. Bid for a Darzi fellow to build on work started

Inpatient 5c: One outstanding practice development nurse post to be appointed – interview date set

Inpatient 5f: Recruitment of 48 RNs and 60 HCAs in response to coverline removal

Maternity 1a: New action identified by the Director of Midwifery – to work with General Practitioners regarding the choice
agenda and adherence to the generic SWL booking referral form - in 2013

Maternity 5a: New action – to enable Language Line to be used via a mobile phone by patients in labour
2 Activity completed since Patient Issues Committee

Inpatient 3a, 4c & Outpatient action 3a & 4a: Some patient-facing clerical staff have received Institute of Customer Service
training as part of our ICS membership to create a culture of customer service and problem solving. All staff to complete multi1
professional training to improve how we work as a team around the patient. The Chief Executive is leading a programme of
Listening into Action to put patients at the centre of care

Inpatient action 4a: Appointment of an Associate Medical Director for Clinical Governance to lead doctors in quality initiatives

Inpatient 5a: Audit calendar developed. Being presented at February Nursing |& Midwifery Board

Inpatient 5b: Appointment of a lead nurse for practice development and education. Launch of a separate healthcare assistant
development programme for April 2013, strengthening of the preceptorship programme to support newly registered, newly
appointed nurses

Maternity 3b/4a: Recruitment of 17 midwives. New leadership posts - Consultant Midwife, Safeguarding midwife, Matron for
Maternity, uplift in Obstetric Anaesthetic PA’s
The Patient Issues Committee is asked to note the progress made to date in completing planned actions. In April 2013 the
benchmarked results of the 2012 Inpatient Survey will be released. In addition there will be a survey of Maternity service users
in 2013 and the Accident and Emergency patient survey was published in December 2012. A new action plan incorporating all
areas is therefore now required to progress this work.
2
Patient Experience plan: Summary of key priorities for inpatients
Issue & Current
Performance
Too many inpatients
report that we did not
manage their pain well:
 CHS patient feedback
score 7.6/10
Too many inpatients say
the toilets or bathrooms
are dirty.
 CHS patient feedback
score 7.9/10
Too many inpatients
report that different
staff say different things
when asked questions
about their care.
 CHS patient feedback
score 7.0
Action
Tasks
1a. Audit all wards for
competence in pain
management
1. Audit the quality of
pain control, develop
solutions and re-audit to
monitor effectiveness
2. Invest in the
refurbishment of our
toilets & bathrooms
(local )
3. Improve how we work
as a team & ensure the
right information is in
the right place at the
right time to enable staff
to communicate
effectively
1b. Action sets with
relevant teams & nurses
to problem solve the
issues identified
2a. Identify priority
bathrooms for
refurbishment
2b. Obtain quotes from
buildings contractors
2c. Project manage
bathroom refurbishment
programme to
conclusion
Timescales
Aug 2012
Task owner
October
2012
Jun 2012
Sarah Watts
Oct 2012
Les Apps
Patient feedback score
rises to 8.3/10 during
2012-13
Patient feedback score
rises to 8.7/10 during
2012-13
Les Apps
3a. All staff to complete
multi-professional
training to improve how
we work as a team
around the patient
Oct
2012Mar
2013
Sally Quinn
3b. re-launch productive
ward & use of ward
boards
April
2013
Hilary
Frayne
3
Executive
Lead &
Assurance
Hilary
Frayne
Hilary
Frayne /
Matrons
Mar
2013
Measure
Patient feedback score
rises to 7.9/10 in 2013
Zoe
Packman,
Patient
Issues
Committee
Mike Ralph,
Patient
Environment
Action
Group
(reports to
Patient
Issues
Committee)
Progress update
 Pain audits
completed for all
wards.
 Report & actions
presented at Nursing
and Midwifery Board,
Directorate Quality
Boards October 2012
 Priority facilities
identified
 Quotes being sought
 Bathroom
refurbishment
Duppas due March
2013

Michael
Burden,
People and
Organisational
Development Group
Leaders event
24th January with
positive feedback

Full programme
commenced 11th
February with
great feedback
Zoe
Packman,
Patient
 Recruitment to Nurse
Lead for Productive
Issues
Committee
Series expected
March 2013
 Patient Status at a
glance boards used
daily on all wards.
New symbols for
Learning Disability
and Dementia.
 Falls, C Diff and
Pressure Ulcer data
made available for
public and staff on
two beacon wards
(F1 & Duppas) “How
well are we doing
Boards” as part of
roll out plan
3c. Ensure the patient
summary screen in
Cerner Millennium
includes the right core
information
Too many inpatients
have low confidence
and trust in doctors
4. Develop best practice
guidance for
communication and
interaction with patients
on ward rounds, and set
and monitor
performance against
these standards.
4a. Develop best
practice guidance and an
audit tool
4b. 2-phased audit &
feedback process for
those 32 doctors that do
85% of our IP work
against these standards
4c. Enable all doctors
who want, or are
identified as needing
support, to take part in
Nov 2012
Emily
Andrews /
Paul Diggory
July 2012
Andrew
Cockayne
Aug 2012
Jane
Northedge
Mar
2013
Jane
Northedge
4
Tony
Leonard,
Patient
Issues
Committee
 Doctors responding
well to patient
questions (8.1/10)
 Not talking in front of
patients as though
they were not there
(8.3/10)
 Privacy when
discussing condition &
Tony
NewmanSanders,
Patient
Issues
Committee,
Commissioning Quality
Review
 Date for launch
revised to June 2013
 Training and testing
being undertaken
 Guidance & tools
finalised

The Ward
Communications
Project report due
to report to
patient Issues
Committee in
March 2013.
the world-class selfawareness and
communication skills
programme available
within the NHS
treatment (8.2)
 what the side effects of
new medication are
(4.7/10)
 who to contact if
worried after discharge
(7.7/10)
5. Develop best practice
guidance for dignity and
respect in nursing care,
Associate Medical
Director for
Clinical
Governance has
been appointed to
lead on the
project.

There is a current
Trust bid for a
Darzi Fellow to
build on the
communication
work already
undertaken on the
Ward Round and
in Outpatient
Clinics to combine
it with Clinical
Effectiveness and
Patient Safety so
that all three
components of
Quality are
incorporated in to
the Ward Round
process
 Involving the patient in
decisions about their
care and treatment
(7.1/10)
 what to look out for
when going home
(4.7/10)
Too many inpatients
have low confidence
and trust in nurses

4d. Ensure
comprehensive
participation of doctors
in action #3a (all-staff
training)
Mar
2013
Clinical
Directors
5a. Develop a coherent
programme of audits,
including action #1 (Pain
July 2012
Hilary
Frayne
5
 Communication plan
in development
 Nurses responding well
to patient questions
Zoe
Packman,
Nursing
 Tools developed
 Nursing Audit
and set and monitor
performance against
these standards.
Control) eliminating
mixed-sex
accommodation and
patient privacy and use
the learning to inform
the development of
nursing practice
(8.1/10)
 not talking in front of
patients as though
they were not there
(8.7/10)
 Being available to
discuss worries and
fears (6.3/10)
5b. Increase the practice
development resource
available for the nursing
workforce
5c. Ensure
comprehensive
participation of nurses in
action #3a (all-staff
training)
Dec 2012
Cynthia
Davis
 Giving patients enough
privacy when
discussing their
condition and
treatment (8.2/10)
 Telling people who to
contact if worried
about their condition
or treatment after they
leave hospital
(7.7/10)
Sept
2012Mar 13
Cynthia
Davis
Board &
Patient
Issues
Committee
Calendar Created for
2013-2014 with leads
identified. Monitored
at Nursing and
Midwifery Board
 Trust PD lead
appointed and in
post.
 PD leads for each
directorate
appointed with one
outstanding post.
Interview 3 March
2013
 A Practice
Development Nurse
forum has been
established
 New Induction
Programme to be
launched in April
2013, which includes
aspect of
communication
 See 3a above
 Communications plan
in development
5d. Re-launch Hourly
Aug 2012
6
Hilary
 Baseline audit of
Rounding
Frayne
state of play has
found a range of 3084% patient
recognition of hourly
rounds.
 Weekly spot checks
to be completed
from 01/09/12
onwards & results
presented in
matrons’ dashboard
 Target set: 90% of
patients to report
that they are visited
hourly by a nurse.
5e. Re-launch Productive
Ward
5f. Nursing Workforce
Review
5g. Introduce “how are
we doing?” posters,
giving better visibility to
who is accountable for
the quality of care on
each ward
5h. Invest in our training,
guidance and support to
staff on working with
people with learning
April
2013
Hilary
Frayne
Aug 2012
Cynthia
Davis
July 2012
Cynthia
Davis /
Andrew
Cockayne
June
2012
David
Feakes
7
 See 3b
 48 new registered
nurses and 60
healthcare assistants
started in April –
December 2012 in
response to removal
of the 20% coverline
 Completed.
 LD steering group
established
 Tools & resources for
staff issued on wards
disabilities
 Programme of staff
development
ongoing
5i. Re-launch dress code
policy
5j. Make better use of
volunteers at supported
mealtimes, providing
specific feeding training
June
2012
June
2012
8
Cynthia
Davis
Justine
Sharpe
 Completed
 Volunteers
development
programme in
feeding completed
Patient Experience plan: Summary of key priorities for outpatients
Issue & Current
Performance
Before your
appointment, did you
know what would
happen to you during
the appointment?
 CHS patient feedback
score 6.0/10
Did doctors and/or
other staff talk in front
of you as if you weren’t
there?
 CHS patient feedback
score 8.9/10
Were you involved as
much as you wanted to
be in decisions about
your care and
treatment?
 CHS patient feedback
Action
1. Improve
communication to
outpatients before their
appointment
2.Improving doctors’
communication and
interaction with patients
in clinic
Tasks
1a. New patient letter
templates are available
on the system, so
patients know what to
expect before they
arrive
1b.New IT system goes
live in late 2012 which
will improve the format
of all letters and create
standardisation across
the organisation
2a. Use expert
communication
specialists to review how
doctors interact with
patients in clinic and
give them
developmental feedback
2b. Make dedicated
communication skills
training available to
doctors in 2012-13
Timescales
Complet
e
Task owner
Measure
Nina Bensley
Achieve a patient
feedback score of 6.2/10
in 2012-13
June
2013
Mar
2012
Mar
2013
9
Jane
Northedge
Richard
Parker,
Patient
Issues
Committee
Tony
Leonard,
Patient
Issues
Committee
Emily
Andrews /
Paul Diggory
Andrew
Cockayne
Executive
Lead &
Assurance
Did doctors and/or other
staff talk in front of you
as if you weren’t there? Achieve a patient
feedback score of 9.1/10
Were you involved as
much as you wanted to
be in decisions about
your care and
treatment? - Achieve a
patient feedback score
of 7.8/10
Tony
NewmanSanders,
Patient
Issues
Committee
Tony
Newman
Sanders,
Patient
Issues
Committee
Progress update
 Work completed on
the current patient
records system
 To be implemented
in IT System in spring
2013
 Testing and training
being undertaken –
commencement date
revised
 Complete for 53% of
doctors (2011-12
target achieved)
 To be repeated in
2013
 See 4c above
 Some staff have
attended ICS
programme
score 7.6/10
Did hospital staff tell you
who to contact if you
were worried about your
condition or treatment
after you left hospital? Achieve a patient
feedback score of 6.2/10
Did hospital staff tell
you who to contact if
you were worried about
your condition or
treatment after you left
hospital?
 CHS patient feedback
score 6.0/10
3. Improve the customer
care skills of outpatient
staff
Sometimes in a hospital
or clinic, a member of
staff will say one thing
and another will say
something quite
different. Did this
happen to you?
 CHS patient feedback
score 8.6/10
4. Improve how we work
as a team & ensure the
right information is in
the right place at the
right time to enable staff
to communicate
effectively
3a. Provide all patientfacing clerical staff
Institute of Customer
Service training as part
of our ICS membership
to create a culture of
customer service and
problem solving
4a. All staff to complete
multi-professional
training to improve how
we work as a team
around the patient
Commen
ced
2012
Oct
2012Mar
2013
10
Sara Coles
Patient
Issues
Committee
Sally Quinn /
Karina
Malhotra
Sally Quinn
 Key learning
captured to inform
all staff training
(action #4a below)
Achieve a patient
feedback score of 8.8/10
in 2013
Michael
Burden,
People and
Organisational
Development Group
 Juice Learning
programme
commenced on 11
February to be
delivered to all staff
 Listening into Action
programme of staff
engagement has
seen 2000 staff
responding to the
‘Pulse Check’ and 400
staff attending
engagement
sessions, led by the
Chief Executive.
 Leaders event 24th
January with positive
feedback

Full programme
commenced 11th
February with
great feedback
Patient Experience plan: Summary of key priorities for maternity services
Issue & Current
Performance
Action
Tasks
1a. Women are provided
with information to
enable them to make
informed choices which
are clearly documented
in their birthing / care
plan
Did you get enough
information from a
midwife or doctor to
help you decide where
to have your baby?
 68% responded
positively in 2011-12
1. Improve the
accessibility of our
patient information, the
communication skills of
the practitioners
delivering this
information, and the
moment in the pathway
that relevant
information is provided.
1b. Develop a good
standards guide for the
28 week antenatal
assessment, better
clarifying the
expectations of
midwives
1c. Provide day-to-day
support to staff to
perform against these
standards of
communication and
manage performance
accordingly
Timescales
Task
owner
Measure
Executive
Lead &
Assurance
Progress update
 Core information on
where to have baby
is front page of
maternity website
Sept 2012
Nov 2012
Ann
Morling
Ann
Morling
Achieve the national
benchmark of 88%
positive responses to
this question in 2013/14
Zoe
Packman,
Patient
Issues
Committee,
Commissioning Quality
Review
 To work with General
Practitioners
regarding the choice
agenda and
adherence to the
generic SWL booking
referral form - in
2013
 Adhere to NICE
Antenatal Care
guidance.
 Principles of effective
communication
included induction of
midwives on rotation
Complete
& ongoing
Ann
Morling
 ‘Respect at work’
workshops have
been completed
 Communication
study day has
11
commenced – band
7’s and senior band
6’s if enough capacity
1d. Ensure learning and
development
opportunities are in
place for those staff who
are identified as needing
to improve their
communication skills or
self-awareness
2a. Develop a good
standards guide for
antenatal care, better
clarifying the
expectations of
midwives
Thinking about your
antenatal care, were
you involved enough in
decisions about your
care?
 90% responded
positively in 2011-12
2. Improve the
Communication skills of
our staff in maternity
services
2b. Provide day-to-day
support to staff to
perform against these
standards of
communication
2c. Develop good
practice guidance for
doctors for effective
communication in clinic.
Observe doctors in clinic,
and give developmental
feedback on the quality
of their interactions with
patients.
Complete
& ongoing
Nov 2012
Complete
& ongoing
Complete
12
 Kingston University
identified as training
provider
Beverly
ReyesRoberts
 Courses available and
staff attending
 All staff to will work
to and be monitored
against the Trust 5
Patient Promises and
to NICE guidance.
Beverly
ReyesRoberts /
Ann
Morling
Ann
Morling
Andrew
Cockayne
 Reinforce a culture of
individualised care
Achieve the national
benchmark of 96%
positive responses to
this question in 2013/14
Zoe
Packman,
Patient
Issues
Committee,
Commissioning Quality
Review
 New focus on key
principles of effective
communication in
induction of
midwives on rotation
 Completed for all
doctors in Women &
Children’s
Directorate by March
2012
Were you (and/or your
partner or a companion)
left alone by midwives
or doctors at a time
when it worried you?
 65% responded
positively in 2011-12
3. Set and work to
higher standards of
responsiveness
3a. Develop a good
standards guide /
operating procedure,
better clarifying the
expectations of
midwives
3b. Increase the number
of midwives, so that
there is more time to
care (1:30 midwife to
birth ratio)
Thinking about your
care during labour and
birth, were you involved
enough in decisions
about your care?
 87% responded
positively in 2011-12
4. Improve the quality of
patient interaction of all
staff in maternity
services
4a/3b. Increase the
number of midwives, so
that there is more time
to care (1:30 midwife to
birth ratio)
Nov 2012
On-going
Oct 2011 &
ongoing
Oct 2011
& ongoing
13
Beverly
ReyesRoberts /
Ann
Morling
Achieve the national
benchmark of 74%
positive responses to
this question in 2013/14
Zoe
Packman,
Patient
Issues
Committee,
Commissioning Quality
Review
Ann
Morling
Ann
Morling
Achieve the national
benchmark of 94%
positive responses to
this question in 2013/14
Zoe
Packman,
Patient
Issues
Committee,
Commissioning Quality
Review
 The Director of
Midwifery is holding
staff and monitoring
them against the 5
Patient Promises and
NICE guidance, rather
proposing alternative
standards.
 Promotion of 1-1
care in established as
per NICE guidance
 Continued support to
achieve 1:28 ratio in
line with Safer
Childbirth/CNST
guidance
 Robust recruitment
has resulted in 17
new midwives.
Recruitment
continues in
response to the
establishment uplift
to support
achievement of 1:29
ratio.
 New leadership posts
include:
Consultant Midwife –
to be recruited
Safeguarding Midwife
Matron for Maternity
and an uplift in
Obstetric Anaesthetic
PA’s
4b. Develop a good
standards guide /
operating procedure,
better clarifying the
expectations of
midwives
4c. Develop good
practice guidance for
doctors for effective
communication on ward
rounds. Observing
doctors on rounds, and
give developmental
feedback on the quality
of their interactions with
patients.
Thinking about the care
you received in hospital
after the birth of your
baby, were you treated
with kindness and
understanding?
 86% responded
positively in 2011-12
5a. Improving
information provision,
with the introduction of
the 11 o’clock stop
Nov 2012
Beverly
ReyesRoberts /
Ann
Morling
 Guidance and tools
developed
Dec 2012
March
2013
Andrew
Cockayne
 Launched 18th July
2012 – See 4c under
‘Inpatients’
Ann
Morling
Achieve the national
benchmark of 94%
positive responses to
this question in 2013/14
5. Set and work to
higher standards of care
and compassion
5b. Reinforcing the
standards of care we
expect of our staff
through a robust
approach to
performance
management.
 See 3a
Nov 2012
Ann
Morling
Zoe
Packman,
Patient
Issues
Committee,
Commissioning Quality
Review
 Investigating ability
to use Language Line
at short notice via a
mobile phone.
 Daily info provision
to women preparing
for discharge
 To be launched
among staff by new
DOM
 DOM reinforcing 5
promises to staff as
14
initial process –
liaising with labour
ward manager re
finalising agreed
standards of care.
15