patient experience and feedback committeeengagement ... · patient experience and feedback...

Patient Experience and Feedback Committee

SIRI Panel

Trust Board

Quality & Risk

Committee

Patient Experience

and Feedback

Committee

SIRI Review

Panel

Executive Team

Quality Board

Health Intelligence

Board

Strategic

Planning &

Delivery

Board

Patient

First

Board

Divisional Clinical

Governance

Review Meetings

Clinical Audit and

Effectiveness

Committee

Triangulation

Committee

Via Chief Exec

Infection

Control

Committee

Quality

Standards Group

Safeguarding Strategy

Committee

PatientEngagement

and Experience

Committee

Reducing Avoidable

Harm

Mortality

Steering

Group

Health and

Safety Committee

End of Life Board

CQUIN

Delivery Group

Medicines

Optimisation

Committee

Divisional

Integrated

Performance

Review

FallsTissue Viability

CAUTI

Joanna Crane

Bill Brown Bill Brown

Governors

http://m.westernsussexhospitals.nhs.uk/index.html


SIRI Panel

Purpose :

To provide assurance to the Board that the

Trust manages comments, compliments,

concerns and complaints, from patients and the

public, in a sensitive, open and effective

manner, and …

That a process of organisational learning is in

place to ensure that identified improvements

are embedded within the organisational

framework.




SIRI Panel

Authority

Has the delegated authority, within its

remit, to act on behalf of the Board

Empowered to investigate any activity

within its terms of reference and to seek

any information it requires from staff

Authorised by the Board to obtain

independent legal and professional advice

– in consultation with the Company

Secretary



SIRI Panel

Chair NED

Members Two further NEDs *

Director of Nursing and Patient Safety

Medical Director

Other Customer Relations Manager

PALS Manager

Head of Patient Experience

* Preferably one of whom should be Chair of the Quality and Risk Committee

Membership



SIRI Panel

Quarterly Proceedings

Quarterly Report

Actions taken as a result of formal complaints

in the quarter under review

Trend information of both formal complaints and

PALS enquiries:

by quarter over 2 years and 12 month moving

average

by patient category v. national benchmarks

by type of complaint/PALS, by sub-type, by

division, by site, by sub-type – last 18 months

For major complaint/PALS areas – deep dive

into department/process

Detail level report/management presentation on areas of

concern

By consultant and by ward - last 18 months



SIRI Panel

Agenda Item. : Review of each complaint graded “HIGH” in

the quarter

- reviewed for action status/learning and

linkage with prior complaints, PALS, SIRIs

Agenda Item. : Patient Experience Report : Lisa Ekinsmyth,

Head of Patient Experience : review of Real

Time Patient Experience surveys, Friends

and Family, local and national surveys, Sit

and See outcomes…………..

Agenda Item. : Review of outcome of Governors’ PEEC

committee against ongoing actions



SIRI Panel

NED Audit of Complaint Files

Prior to the quarterly PE&FC meeting,

NEDs select at random approximately

10 Formal Complaint files that have

been closed in the quarter under

review



SIRI Panel

Formal Complaints v National Benchmark

Average Last National

12 months Average

Inpatients per 1,000 admits 1.81 2.18

Outpatients per 10,000 OP attends 8.70 13.26

A & E – complaint level is below national average



SIRI Panel

Is this informal?

Customer Relations or PALS

PALS Yes

No

Same day

Immediate remedy

Generally verbal

Formal Complaint

Complaint or Concern

Management Process for Comments,

Concerns and Complaints

1,100 Per quarter 150

Per quarter



SIRI Panel

Formal Complaint

Acknowledge formal complaint within 3 days

Triage : High - Response 1 to 3 months

Medium - 25 working days

Low - 5 working days

Investigation

Chief Executive’s written response



SIRI Panel

Timeliness in response to Complaints

Average number of closed formal

complaints per month 54

Grade

Low 96%

Medium

standard :

< 25 days

April to Dec : only 10% closed within 25 days

January 2016 : 38%



SIRI Panel

Formal Complaints 2012-2016

0

10

20

30

40

50

60

70

80

90

A-J J-S O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M

12 12 12 13 13 13 13 14 14 14 14 15 15 15 15 16

Quarter

nu

mb

er

of

co

mp

lain

ts

Inpatient

Outpatient

A&E

Other



SIRI Panel

Analysis of cause of : Formal Complaints PALS

Clinical Treatment 63% 13%

Communication (verbal) 6% 24%

Communication (written) 6% 12%

Date for Appointment 4% 21%

Date of Admission/Attendance 3% 7%

Admission/transfer/discharge general 9% 2%

Staff Attitude 5% 6%

Test Results 2% 3%

Other 2% 12%



SIRI Panel

PALS concerns and Formal Complaints 2014-2016

0

200

400

600

800

1000

1200

1400

J-M A-J J-S O-D J-M A-J J-S O-D J-M

14 14 14 14 15 15 15 15 16

Quarter

nu

mb

er

of

co

mp

lain

ts/c

on

ce

rns

PALS

Formal Complaints



SIRI Panel

PALS Contacts 2013-2016

0

100

200

300

400

500

600

700

800

O-D J-M A-J J-S O-D J-M A-J J-S O-D J-M

13 14 14 14 14 15 15 15 15 16

Quarter

nu

mb

er

of

co

nta

cts

Other

Outpatient

Inpatient

A&E



SIRI Panel

PALS Contacts 2013-2016

0

50

100

150

200

250

300

350

400

450

2013 2014 2014 2014 2014 2015 2015 2015 2015

O-D J-M A-J J-S O-D J-M A-J J-S O-D

Number of Contacts

Communication (Verbal

and Written)

Date for

Appointment/Admission

Clinical Treatment

Staff Attitude

All Other



SIRI Panel

Medicine Surgery

Q3 Q2 Q1 Q3 Q2 Q1

Worthing 10.5 17.3 10.2 10.7 26.6 14.8

St Richards 2.7 8.4 3.8 7.7 17.7 11.9

Formal Complaints Analysis : Outpatients (42%) Per 10,000 first attends



SIRI Panel

Medicine Surgery

Q3 Q2 Q1 Q3 Q2 Q1

Worthing 2.3 2.5 2.5 2.0 3.1 3.0

St Richards 2.9 2.5 1.7 1.3 1.2 1.8

Formal Complaints Analysis : Inpatients (42%) Per 1,000 admissions



SIRI Panel

Clinical Treatment Sub-category :

“Co-ordination of Medical Treatment”

Formal Complaints concerning

Co-ordination of Medical Treatment

Average per Quarter : last 8 Quarters

Worthing 20

St Richards 7



SIRI Panel

SIRI Panel

Chair : NED*

Two further NEDs*

Medical Director

Director of Nursing and Patient Safety

plus :

Head of Clinical Governance

Risk and Patient Safety Manager

Representatives of Clinical Divisions as required

* One of these must be the Chair of the Patient Experience and Feedback Committee



SIRI Panel

“an adverse event where the consequences to patients,

families and carers, staff or organisations are so

significant or the potential for learning is so great, that a

heightened level of response is justified.

“The occurrence of a serious incident demonstrates

weaknesses in a system or process that need to be

addressed to prevent future incidents leading to avoidable

death or serious harm to patients or staff, future incidents

of abuse to patients or staff, or future significant

reputational damage to the organisations involved”.

SIRI Panel

Serious incidents requiring investigation were defined by the

Serious Incident Framework (NHS England, 2015), as :



SIRI Panel

DEFINITION OF A SERIOUS INCIDENT REQUIRING INVESTIGATION (SIRI)

An incident resulting in one of the following:

Unexpected or avoidable death of one or more patients, staff, visitors or

members of the public.

Unexpected or avoidable injury to one or more people that has resulted in

serious harm

(recently widened to include any FALL resulting in harm that requires surgical

intervention)

Unexpected or avoidable injury to one or more people that requires further

treatment by a healthcare professional to prevent death or serious harm

Allegations of abuse

One of the core set of NPSA ‘Never Events’

An Incident or series of incidents that prevents or threatens to prevent an

organisation’s ability to continue to deliver an acceptable quality of healthcare



SIRI Panel

SIRI Panel

Review SIRI RCAs brought forward on Tracker

Review all RCAs relating to closed SIRIs two

quarters back :

eg Dec SIRI panel looks at quarter ending June

Review SIRIs from 18 months prior for learning

and embeddedness



SIRI Panel

SIRI Panel

March Dec Sept

2016 2015 2014

Falls

(requiring Surgical Intervention) 11 10 7

Pressure Ulcers (Grade 3 or 4) 7* 0 2

Maternity 3 2 2

Other Clinical SIRIs 1 5 4

of which Never Event 1 0 0

* 6 at SRH of which 4 deemed avoidable


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