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Quality & Safety: Patient Experience

Annual Report

Presented by: Tracy Luckett

Director of Nursing and Allied Health Professions

Produced by:

Tim Withers, Patient Experience Manager

27th May 2014

Item 7

Action for Board: For information

For consideration

For decision

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1.0 Introduction This report reviews the patient experience at Moorfields between March 2013 and April 2014. It will inform the board of the work currently being undertaken to assess the views of our patients, what the trust is doing to address issues of concern to them and to outline future developments. The majority of feedback from patients remains positive expressing recognition of the professionalism and caring attitude of the staff, clinical outcomes and efficiency as strengths, whilst waiting times and issues around some aspects of communication and administration might still be improved and throughout the year steps have been taken to address these issues. The following comment captures the sentiment in much of the patient feedback received throughout the year: “Until I went to A&E two weeks ago I just didn't realise what a fantastic job the staff and doctors do at this specialist hospital. We are exceptionally lucky to have such a great facility here in the capital. I was referred to Moorfields’ A&E by my optician following a routine visit. I was seen right away by a triage nurse who was just wonderful - so reassuring, kind and helpful. Honestly, I don't think I could have wished for better. I then saw a doctor within ten minutes who made his diagnosis and advised what treatment would be necessary. He too was extremely reassuring, explained absolutely everything in language you could understand. His diagnosis meant I was seen in their outpatient’s clinic 10 days later and the problem is now being dealt with. Whatever time you have to wait is really worth it - you will get the best treatment for eye problems in this country and if you have a genuine emergency (like I did) you will not wait at all, you will be seen without delay” (NHS Choices comment: July 2013) Equally, where patients are not entirely satisfied the same themes are repeated, a typical comments being: “There are always issues with appointments and waiting times are almost always an issue. Appointments are booked and then cancelled and new ones given, then (one is told to) come in to be told your appointment is at a completely different time - very bad service.”(Friends and Family

test comment: December 2013) “I found one or two of the nurses unfriendly and unconcerned whilst others were quite charming. I would have appreciated someone holding my hand during the operation, and not being addressed as "mama" - I found the experience quite daunting and when led into the recovery room the nurses were not very friendly, just putting a cup of tea and a packet of biscuits in front of me without enquiring whether I was OK. In short, felt that some of the staff need to learn some "people skills" (Post-operative patient survey: October 2013) 2.0 Patient Experience Committee

The Patient Experience Committee (PEC) met on a six weekly basis throughout the year to discuss patient feedback and actions taken in response. The committee has functioned in its present form since 2009 and had become very operationally focussed with much of the agenda driving operational performance based on patient feedback. In 2013 the committee introduced a more formal reporting structure with directorate teams presenting their action plans which

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included addressing the patient experience strategic themes identified for 2013/14 and which are discussed in more detail below. The themes were:

Discharge information

Patients contacting the trust with appointment issues

The management of waiting times in clinic and on the day of surgery Towards the end of 2013, at the request of the Board the function and purpose of the Patient Experience Committee (PEC) was reviewed and though there was a high level of respect for the work that has been done, it was felt that the PEC was trying to simultaneously perform both a management and oversight and scrutiny function. With too broad a remit the focus has become blurred. As a consequence the following recommendations were made:

The PEC should become more strategic- setting the vision and agenda

It should be driven by quantitive and qualitative patient feedback

The PEC should focus on the delivery of the Quality snd Safety plan

The PEC should champion the patient experience at an organisational level

The will have a smaller and more focussed membership though this will continue to include patient representation

3.0 Notable achievements in 13/14

3.1 Patient Experience CQUINS Four patient experience CQUINS were achieved during the period. Two CQUINS around the implementation of the Friends and Family test (FFT) were achieved.

The response rate for accident and emergency and overnight admissions improved on Q1 results and was within the top 50% of all NHS England trusts.

There was a phased expansion of the FFT to day care and pre-assessment with a response rate of 15% or over.

A third CQUIN was achieved through the use of a child friendly “Fabio the Frog” tablet device for capturing the experience of a required number paediatric patients and developing an action plan in response. Following a review at Q2 it was required that a higher number of responses be achieved and that evidence for the meeting of the objectives set out in the action plan be demonstrated and a new action plan formulated. The fourth CQUIN cantered around the identification of patients who were smokers and the provision of smoking secession advice. Around 70% of the patients sampled were asked if they smoked and of those that did, all were offered cessation advice.

A further CQUIN related to a composite improvement on the score for nine key questions selected from the annual 2012/13 day care and outpatient survey questions compared to the previous survey from 2011/12. Unfortunately the trust failed to meet the required percentage improvement. This CQUIN was repeated for 2013/14 and more focus has been given to achieving these and the result will be available in June 2014

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3.2 NHS Friends and Family Test The trust continued to meet the NHS Friends and Family test requirement in A&E and overnight admission areas, the results of which are published nationally on the NHS England and NHS Choices websites. In November 2013 Moorfields inpatient care was rated the highest of all 156 NHS English trusts. Moorfields’ A&E has consistently been one of the two highest scoring ophthalmic A&E’s. With support from Performance and Information, a real time dash board for the Friends and Family was set up allowing manager almost immediate access to the latest patient response figures, scores and patient comments. This has been especially useful for ensuring CQUIN targets are met as they can easily identify the daily percentage response rate. 3.3 Care Quality Commission reports The CQC have undertaken three unannounced visits to Moorfields in the past twelve months, to the RDCEC (Feb 12013) Northwick Park (May 2013) and Ealing (September 2013). The reports were overall very positive, meeting all of the CQC standards. Noted at all sites was the good, positive and informative relationship between staff and patients, as was the staff’s satisfaction with working at Moorfields, the arrangements for the safeguarding of vulnerable patients and the clinical environments. The reports did highlight issues relating to patient information, including leaflets and consent forms, in languages other than English. These issues have been addressed with the ten most used leaflets translated into other languages and translations of consent forms are currently available upon request. 3.4 Dementia awareness training As a result of the government's mandate to Health Education England, Moorfields worked with UCL Partners and Health Education North Central and East London to lead a cultural change in dementia care across the partnership, by ensuring that 12,000 clinical and non-clinical healthcare staff have had introductory dementia awareness training. At Moorfields the target was to train around 250 staff by the end of March 2014. In the event, over 750 staff were trained, with further activities such as dementia awareness raising events at City Road and the satellite sites involving the Alzheimer's Society, Age UK, the RNIB and Islington Carers Hub as well as displays about how Moorfields supports dementia. Throughout dementia week in January there were daily emails to staff covering various aspects of dementia and links to organisations and information with which to support our patients with dementia and their carers. 4.0 Current sources of feedback

4.1 NHS Friends and Family Test Introduced in January 2013, the FFT, using a ‘Net Promoter Score’ methodology, is a simple test which is comparable between sites or over time. It provides a way of recognising good performance, acts as an ‘early warning’ for poor performers and can be an incentive to staff to develop and improve services. It is currently reportable to the DH and covers all A&E patients and those patients admitted overnight on Duke Elder, Observation Bay and NHS patients on

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Cumberlege Wing. The results are published on NHS England and NHS Choices websites. 15% of patients are required to respond but there is not, as yet, a minimum score to be achieved Patients are asked: “‘How likely are you to recommend our ward / A&E department to your friends and family if they needed similar care or treatment?’ and are asked to use a descriptive six point scale to answer the question: 1. Extremely likely 2. Likely 3. Neither likely nor unlikely 4. Unlikely 5. Not at all likely 6. Don’t know Subtracting the percentage of neither, unlikely or not at all likely to recommend the Moorfields responses from the percentage of those extremely likely to recommend the Moorfields responses gives a score of between +100 (everyone is extremely likely to recommend the trust) and – 100 (no-one is likely to). (Fig. 1)The results for the department of health reportable areas for 2013/14 are:

NHS FFT Score 2013/14 NHS FFT Pt response rate 2013/14

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Duke Elder Ward 62 90 85 93 29% 41% 85% 50% Observation Bay 88 93 96 88 61% 31% 40% 74%

Cumberlege Wing 91 85 92 85 61% 52% 56% 63%

A&E 76 73 79 76 12% 17% 23% 23%

A second question “Please can you tell us the main reason for the score you have given” invites a free text response. In A&E, despite overwhelming number of patients being seen and treated within four hours of attending, the majority of detractor patient comments cited waiting as the main problem, however, over the year the percentage trend of adverse comments about waiting times has been down, whilst an increasing number of patients mention the quick and fast service or not having to wait as their main reason for recommending the trust. Other themes predominated around the professionalism and caring nature of the staff.

(Fig. 2) A&E waiting time comments

74.0%

72%

78%

76%

71%

67%

12%

14%

7%

9%

8%

13%

14%

14%

14%

15%

21%

20%

0% 20% 40% 60% 80% 100%

Apr-13

Jun-13

Aug-13

Oct-13

Dec-13

Feb-14

Other comments Negative waiting time comments Possitive waiting time comments

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Typical of the comments from A&E are:

• “Waiting time was quite long and the three steps you needed to take was not explained i.e. triage, assessment, registration, etc.”

• “Courteous and friendly, staff efficient, rather long wait but kept well informed. • Seen as an emergency and due to my outstanding medical condition was moved up the

queue and treated with respect, dignity and well looked after.” • “In terms of process and time my expectations were continually well managed, I engaged

with many of your staff in the 2 hours here who were without exception very friendly” • “I am from America and think the NHS is brilliant. I've had a very positive experience, the

staff have been very friendly and informative and helpful, thanks very much for this excellent service”

4.2 Moorfields Friends and Family Test Moorfields has introduced the FFT to areas beyond what is required by the DH and follows the same methodology. 32 clinic and day care areas across the trust are included. As noted above, achieving a 15% response rate in all patient areas is a national CQUIN and Moorfields should be well placed to meet this. Actions are currently underway to address the poor response rates in City Road clinics and Moorfields South and the recent administrative staff review will hopefully bring a renewed focus on the importance of patient feedback in the staff groups involved. Options for introducing a process where patients can text, SMS message, send their FFT by post or go online are being explored to see if they are cost effective and capture the number of patients we would need to at Moorfields. A decision on this is expected around July 2014.

NHS FFT Score 2013/14

Q1 Q2 Q3 Q4

Day Care 80 87 86 88 OPD City Road 72 75 71 75 OPD MF North 77 75 76 75 OPD MF South 63 62 62 74

(Fig. 3) FFT response rate by directorate 2013/14

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Over the year, over 52,000 of Moorfields patients took the opportunity to comment on the service they received at Moorfields through the FFT. Of them, around 96% of patients said they would be likely or extremely likely to recommend Moorfields to their friends or family. (Fig. 4) FFT percentage results 2013/14

88.0%

79.0%

11.0%

18.0%

1.0%3.0%

0% 20% 40% 60% 80% 100%

Day Care sites 2013/14

Outpatient sites 2013/14

Extremely likely Likely Neither likely nor unlikely / Unlikely / Not at all likely

The comments and results are sent to directorate management teams on a monthly basis with the comments suggesting improvements highlighted. Again, where patients felt they could not recommend the trust, waiting times, either in clinic or for surgery was the primary reason given. Other comments suggest staff attitude, administration and communication could be improved but the numbers are too small to be judged to represent common themes. A full semantic analysis of the comments from 2013/14 is currently being undertaken; however, of the 6000 comments so far looked at the adjectives most commonly used are friendly, helpful (2000 mentions), excellent (750), efficient (553), professional (489), polite (277), happy (193), attentive / attention (283).

“First to arrive - second on list - third to be operated on - makes no sense - shame because everyone so nice.”

“Changed appt to 08:30 at short notice yet still wasn’t operated on until 13:00. The consultant did not operate as I was previously informed.”

“On my visit, terrible communication in every department. Doctor did not introduce himself. I asked for directions was told 'look at the board'.”

“Very poor communication and customer service at point of entry - main reception and clinic (X) reception. Terrible first impression - this is very important.”

“Because I found everything to be very efficient and felt comfortable during the whole operation.”

“Receptionists were very calm and knowledgeable - especially when dealing with difficult patients going out of their way to resolve any issues - well done.”

“First class professionalism efficient courteous very friendly. Everyone puts patient at ease - this applied to all from reception to theatre - very lucky to have this facility.”

It is expected that the administrative staff review, the focus of which is on making the backroom organisation of medical records, appointment handling and improved communication will address some of the issues commonly raised by patients. Part of the review is also to identify staff who are more suited to a patient facing role who, with closer management support and training, will be able to provide an enhanced customer service, especially keeping patients better informed. It is already notable the degree to which individual members of staff are mentioned in patient comments when patients receive a good service. This will be enhanced by the ‘Moorfields Way’ programme, which aims to identify the shared values and expectations of both staff and patients, will result in colleagues working better together but also give them a clearer understanding of what patients expect when they come to Moorfields. The day care comment regarding theatre waiting times is a common theme and all theatres now have a dedicated telephone so that they can better communicate with ward staff who can keep patients better informed of list orders and delays.

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4.3 Day Care and Outpatient surveys In July 2013/14 the Day Care and Outpatient surveys commissioned by the trust and carried out by the Picker Institute reported. These were not part of a nation NHS survey and the results were not published nationally. Overall, when the individual question responses are compared to the previous 2011/12 surveys, it shows that, on the whole, 90% respondents felt that a service was delivered fully e.g. ‘yes, completely/ all of the time’ etc. or partially e.g. ‘to some extent/ some of the time’ etc. The latter response making up between 20 -30%, suggests it is the degree and consistency to which the service is delivered to patients across the trust that is an issue, rather than whether or not the service is being provided. There were notable improvements around the questions relating to the discharge process reflecting the work undertaken in that area. Actions taken in response to the issues raised in the surveys included in the overall directorate patient improvements discussed below. 4.3.1 Day Care Survey 1000 (54%) surveys were returned compared to 61% the previous year. Where answered, 41% of patients were male; 56% were female and 82% were over 60 years of age. The survey consisted of around 70 questions of which the positive points were:

93% of patients felt they were treated with respect and dignity all of the time

92% of patients were told how to take their medication in a way they could understand

91% of patients felt they were offered the right amount of information about their condition and treatment

95% of patients felt that doctors and nurses spent enough time explaining about their health and care following discharge

Where room for improvement was identified:

43% of patients felt they had to wait a long time before surgery

25% of patients, who minded waiting, were not given a reason for the delay

23% of patients felt that doctors and nurses spoke in front of them as if they weren’t there

Only 73% of patients had the opportunity to talk to a nurse and 71% to a doctor, whenever they wanted to

27% of patients were not told about the side effects of their medication

22% of patients were not told about danger signals to look for following their discharge

4.3.2 Outpatient Survey 809 (47%) surveys were returned completed compared to 56% the previous year. Where answered, 43% of patients were male; 57% were female and 73% were over 60 years of age. 26% of patients were first time visitors to the trust. The survey consisted of around 70 questions of which the positive points were:

95% of patients gave an overall rating for their care as Excellent, Very Good or Good

87% of patients said they were treated with dignity, all of the time

97% of patients found the environment of the outpatients very or fairly clean with 95% saying the same of the lavatories

91% found the courtesy of the receptionists Excellent, Very good or good

72% of patients were seen within 30 minutes compared with 63% the previous year

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71% of patient s received copies of all their GP letters compared to 63% the previous year

Where room for improvement was identified:

Only 47% of patients were given a choice of appointment times and 21% had their appointment changed

If there was a delay, 68% of patients were not told how long they would have to wait, 79% were not told why and only 35% received an apology

36% of patients were not told about the possible side effects of their medication

35% of patients were not told of any danger signals to look for when home and 39% were not told who to contact if they had any concerns about their condition or treatment

4.4 Online patient feedback The importance of online patient feedback or social networking sites such as NHS Choices, Facebook etc. is that patient opinion is no longer solely between the patient and the trust but is on public view and will be an important pointer for patients as they (and commissioners) exercise choice by comparing providers. Comments or experiences left on sites such as these will become more important as use of such fora is increasing. Currently, appropriate staff are alerted when a post is left and a weekly summary is circulated to the management teams. A new service, Care Connect, of which Moorfields was a trial site in 2013/14, will facilitate this by allowing patients to email text or call in their concerns which, are then uploaded in real time onto a publicly accessible interactive map detailing what concerns are currently being addressed by the trusts and at what stage any resolution is at. The purpose is to allow staff to be alerted immediately should a patient have a concern so that it can be addressed there and then and allows for a personalised response to the patient. A Moorfields webpage based version of the Friends and Family test is being developed to give another avenue for patients to leave their comments and hopefully increase the trust response rate. It will also be interesting to see if the nature of the comments posted is different from the ones written on paper at the time of the patient’s visit. On NHS Choice in 2012/13 only seven comments were left. During 2013/14 this increased to 73 comments, 48 of which were positive, whilst 25 were negative. The tone of the comments posted tends to either fulsome in praise or harsh in criticism.

“For the second time in just over a year, I visited Moorfields A&E with concerns that I was suffering a retinal detachment. On this visit, I was slightly concerned to see that the dept. was undergoing refurbishment work as I thought this might affect the waiting time but not at all. From triage to consultation, I was in and out in little over an hour and at every stage was treated with courtesy and professionalism - something that I have unfortunately not experienced at times at other NHS hospitals. The medical staff were as welcoming, efficient and reassuring ….the hospital was spotless both within and outside the treatment areas and, perhaps most impressive of all, the receptionists were polite, friendly and informative to everyone who approached them. I can't thank the staff at Moorfields enough. It really is a beacon NHS hospital on so many levels and I wish that their managers could share their best practice and procedures with other hospitals in London, who could really learn from their

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approach to patient care, particularly in terms of how patients are spoken to and interacted with.” (NHS Choices, August 2013)

“I attended this hospital last September through to November. It was the worst experience I have ever had. Outpatients in clinic (X) are a disgrace. One queue for pm appointments forming at 13.15 at reception desk, as told to attend 15 minutes early, only for a new receptionist to come along and demand a new queue to form at her side of the department at 13.30, so those there early actually at end of queue. Receptionist’s argumentative and the most uncaring I have ever met. A Staff nurse was laughing at our annoyance until I told her I would report her callousness to the NMC. That shut her up and made her bring in a service manager who just said yes the clinic was always busy. Other patients confirmed to me that they always dreaded attending as the clinics were so badly run and shambolic. There was no attempt to manage the 80 odd patients at all. Cattle treated better than this clinic” (NHS Choices, November 2013) 4.5 Patient Engagement There were several examples of engaging patients to understand better the services we provide. These included focus groups and in your shoes events, patient involvement in inspections and open days and displays. A trust wide focus group was held in September to explore with around 35 patients and their carers how they felt about ‘How well supported do patients feel while at Moorfields or at home?’ Following a wide ranging discussion, where many positive things were raised, two themes arose that have not been noted in patient feedback in the past. Patients were unsure a lot of the time who was operating on them and there was a feeling that there was a lack of appreciation as to anxiety that patients underwent when coming into hospital, especially for surgery. This was fed back to the surgical services review group and a further study about how patients feel supported during surgery is currently underway. The Glaucoma service undertook an ‘in your shoes event’ in November. This involved one or two patients discussing with a member of the staff, including service leads, managers, admin staff and nurses, their experience and then feeding back to a wider group. From the issues discussed a wide ranging action plan was developed which included:

Work with clinicians and nursing staff to improve the process for calling patients into clinics and consider a process whereby patients can leave the waiting area for refreshments/toilet without concerns about missing their time slots

Ensure patients leave with a booked follow up appointment

Identify the best methods to contact patients on an individual basis and how this could feasibly be collected and implemented in practice. Involve PAS team

Re-establish departmental contact details on appointment cards

Produce a Glaucoma information leaflet/card providing tips, advice and practical guidance about the long term management of glaucoma

Review the nursing role in the clinic environment – consider patient education, information about drop insertion and possible side effects of prescribed medication

Review current process for booking patient appointments to satellite sites

Establish how we ensure that patients understand the clinical information given to them during a consultation and encourage clinicians to use simple, clear language and refrain from jargon and complex medical terminology

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Other involvement included participation on the annual PLACE assessment of the City Road site, where six patients are invited to join six members of staff to undertake a review of the environment, catering, cleanliness and signage etc. at Moorfields. Patient engagement activities were also undertaken such as the Low Visual Aid open day at St George’s, bringing charity and support groups together with visually impaired patients in South London and the glaucoma week held at City Road with advice, information and teaching available for patients with the condition. 4.6 Governor and membership week reports

Governors’ week was held in July 2013. During the week the governors talk to patients in the clinical areas and explain their own role and responsibilities and encourage those who are not already

Moorfields members to become such. Equally importantly, the governors get to engage with members, patients and staff to get their invaluable feedback as to how MEH is performing. Compliments, improvement suggestions, concerns and complaints are noted so that Governors are both informed of them and can then via Council ensure that they are acted upon. This year they focused on accuracy of clinic information provided on the screens/whiteboards for each clinic, observe the clinic clerk’s friendliness and courtesy and asked the reception staff if they had informed the patients of how long they could expect to wait and update them with any delays.

What they found was that over 98% of patients replied that the clerks were both friendly and courteous and this accorded with governors’ own observations. Indeed many patients specifically commented on the warmth and friendliness of many of the staff which was seen as a welcome improvement over previous years. Concerns centered on the length of wait times in clinics and the paucity of information about those waiting times, notably around the updating of waiting times on whiteboards and information screens. These issues were discussed at the PEC and were taken forward as part of the administration staff review.

4.7 Patient Observations Patient observation are conducted by patients who come in for an appointment, surgery or

telephone the trust and following their visit or call complete a questionnaire about their experience. Unfortunately uptake has been slow but in June it is planned to raise the profile and target specific groups starting with Day Care patients. So far nine patients have agreed to participate on their next visit and three have already done so. The preliminary feedback has reflected patient feedback from other sources and the questionnaire is being adapted to try and illicit more specific information about the patients visit rather than generic observations. It is hoped that a way of comparing patient expectation with their actual experience can also be incorporated. Though two of the feedback forms received so far expressed positive comments about their clinic experience, one, who was sent from A&E to PCC clinic expressed some dissatisfaction about the lack of information and attitude of the doctor who saw them. 5.0 Addressing patient concerns as a result of feedback Highlighted below are the main themes identified from patient feedback and how the trust is addressing them. Patients are informed of some of the changes made through ‘you said, we did’ posters across the trust and on the website.

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Booked in at 9.15am but not seen until 10.20am. Human error but every time we come here have to wait at least 2 hours. We were ticked off but the service needs to be better. (FFT May 13)

“Twice my appointment was changed - today I had appointment at 9.15am - I booked this appointment 7 months before and today I took off from work - I reached my appointment was told it was rescheduled for next month. I receive confirmation by text on 7.1.14 and without calling me or sending me text or message my appointment was cancelled. I think you should close your department if you cannot work properly.” (FFT Jan

14) 5.1 Patient journey times Waiting times have long been recognised as the main source of dissatisfaction among patients at Moorfields, evidenced by Moorfields minute and FFT responses, patient surveys, patient comment cards and complaints. It should also be noted however that more patients comment on the speed and efficiency with which they are seen.

In order to address the issue of patient journey times that include excessive amounts of waiting time in both surgical and outpatient journeys, the trust has focused on the following initiatives: 5.1.2 Transformational change At St. George’s, work was undertaken with Vanguard Consulting during 2012/13, to introduce a programme of transformational change, to completely re-evaluate clinic pathways without pre-conceptions and to establish novel ways of working. This programme is now being rolled out to other services and sites.

The new operating principles include:

Only do work that is valuable to the patient

Design against demand and ensure that patients see the right person with the right skills but be able to pull expertise when required

Minimise handovers between staff and ensure that clinics are prepared and start on time and when finished, all loose ends are tied up

Gather data about clinics and make change and decisions based on that and always have the right measures of capability

Challenge existing rules, regulations and practices How this looks in reality is that responsibility for specific clinic organisation is handed to named administration staff who take total ownership of preparing, receptioning and the scheduling of the clinics and oversee the management of follow up appointments, which should reduce lost to follow ups and see all patients leaving with either a follow up appointment or having been discharged but knowing how obtain a future appointment through their GP should they feel they the need to in future. Having personal commitment for clinics allows staff to offer a more informed and effective service for patients.

It also seeks to enhance the organisation of clinics on the day, the ‘clean start’, with emphasis being placed on medical records being fully prepared, with none missing, start times being strictly adhered to, and with a nurse identified to support and coordinate the clinic. This includes a more focused customer approach from staff which includes an emphasis on keeping patients informed of waiting times and delays and assurance that they can leave the clinic and not miss their turn in the queue. St. George’s are currently trialling a pager system whereby

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patients can leave the clinic area, for a coffee etc., and have the reassurance that they will be ‘summoned’ when their time is due. The complimentary ‘clean finish’ will ensure that medical records are tracked back to the appropriate location i.e. library, follow up clinic or surgery. The clean finish is a significant contributor to avoiding lost to follow-up and is much improved in many but not all clinics. A clinic co-ordinator role has been developed to assist and support the clerical staff in the scheduling of follow up appointments. They liaise with consultants to establish the urgency of appointments, and then book appropriately. This allows for better management of overbooked clinics and capacity issues. All clinics now have a template which demonstrates the number of doctors present and number of patients booked per doctor. This is presented daily in the clinics and projects six weeks in advance the number of patients scheduled for review. This aids the planning of future appointments and communication with patients on the day. This has a direct impact on patients and their perception that clinics are unnecessarily overbooked. To further support the clinical settings, a visible, managerial presence to support the admin and clerical team has been established. Having a ‘Manager of the day’ also allows for any concerns that arise during clinic to be managed in a timely manner and patient concerns to be resolved locally rather than redress to PALS or a later complaint. It also means that the other managers can concentrate on their remit and not be distracted. Manager of the day walks the floor and proactively works with clinic and day care teams to identify issues in advance and support clinics with difficult decisions around capacity. The MR and Glaucoma service have the highest number of patients and ways are being explored to increase capacity. The expansion of Saturday clinics and the trial of virtual clinics, were a very specific cohort of new patients presenting with only one risk factor are identified at referral specialist optometrist. In total it is anticipated that 30% of Glaucoma patients will be seen through these services at City Road and then replicates at other sites. This will play a significant role in freeing up templates in face to face clinics and therefore directly impacting on patient experience and capacity. Ultimately Saturday working will become part of the normal work schedule. Planning to establish Moorfields as six day service across the trust is currently ongoing. 5.1.3 Outpatient communication “Clinics seemed to be operating efficiently and providing excellent clinical care. Staff are all very welcoming and friendly, clean, pleasant, busy but uncrowded, not stressful environment. Issue of not communicating wait times on first arrival unfortunately means these clinics failed the customer care obligation as agreed by PEC. “(Governors’ week report Jan 2014) Communication with patients in the clinic setting in regard to delays and waiting times has been recognised as an issue for some time and although there have been some improvements we require more consistency in the approach. Clinic reception staff are encourage to keep patients informed of estimated waiting times through updating the clinic status white boards in each clinic, updating the patient information screens in a timely manner and to be more proactive in verbally communicating with patients in regard to waiting times and delays. Clinic reception staff have been issued with a prompt sheet reminding them to explain why there is a delay, apologise, estimate the likely time they will be seen and invite them to come and speak to the

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receptionist if they have any concerns. The changes outlines in 6.1.2 will go some way to enhance this as will the outcome of the administrative staff review which will identify those with customer service skills for patient facing roles. Patients have expressed concern that they feel unable to go for a cup of tea without the worry of losing their appointment slot. St. George’s are about to trial a pager system whereby patients can leave the clinic area, for a coffee etc. and have the reassurance that they will be ‘summoned’ when their time is due. 5.2 Telephone access regarding appointment and clinical enquiries “The patient missed his 1 week follow-up appt after surgery because the letter arrived on the day of the appt, too late to attend. His daughter has been unable to get through to rebook, and it is now outside the recommended follow-up time.”(PALS enquiry Sept 13) A project steering group was established to look at the issue of patients’ communication with the trust, especially with regard to appointment issues. 23% of PALS enquiries concern appointments suggesting that direct communication with the appropriate team is not always possible. The aims of the review are:

To provide a simplified and readily-accessible service to patients wishing to confirm/change/cancel their outpatient clinic appointments

Improve patient’s access to clinical information and advice via the telephone

Ensure long-term sustainability of improvements Following a patient survey and statistical analysis of unanswered calls, a business case has been approved to address some of these issues and changes will be rolled out through 2014/15. Some of the initiatives include each service having a single, manned telephone number for enquiries, improvements to the automated telephone system and a focus on known problem areas such as optometry and Medical Retina. This will lead to a simplified and readily-accessible service for patients wishing to confirm/change/cancel their outpatient clinic appointments. An expansion of Moorfields Direct, the nurse led helpline for clinical enquiries is also being proposed and the recently re-launched webpage and imminent ‘Moorfields Patient Booklet’, will also include clear and specific advice on how to access various trust departments. 5.3 Surgical services review and Day Care discharge information. “H16. Were you told about the danger signals to look for following discharge? No: 22% H13. Were you told about medication side effects to watch for? No: 27%” (Picker Day Care Survey: July

2013) Day care patient discharge information has been reviewed and re-designed to make it clearer for patients and includes specific advice on who to contact should the patient suffer pain, vision loss or feel unwell following their surgery. It also now contains sections which can be personalised for individual patient needs. All discharging nursing staff have been issued with discharge prompt cards stressing the importance of telling the patient who to contact in an emergency and their medication side effects. Day care areas also have laminated medication side effect cards to help explain to patients the side effects of commonly used eye drops. A programme of near patient dispensing has been partially rolled out, where by a pharmacist dispenses medication on the ward directly to the patient and can discuss fully any contraindications or side effects. A repeat day care survey, due to report in June 2014 will

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demonstrate any improvement compared to the survey results achieved prior to these initiatives. The work of the Surgical Services Review group continues with several miles stones achieved during the year:

Introduction of a new integrated care proforma (ICP) so that all surgical information is in one place

Extension of pre-assessment hours and introduction of a nurse led telephone query/telephone pre-assessment line allowing for more one stop assessment

Introduction of a biometry protocol enhancing patient safety

Telephone reminders 48-72 hours prior to surgery and pre-admission patient checklist

Mydriasert now PGD approved for dispensing on wards by nurses saving time on drop instillation. It is planned that patients will be given medication to self-administer so they are dilated prior to attending for surgery

Reduction in number of observations (e.g. Blood Pressure etc.) required post-operatively

Review of post IOP / AC checks – to be taken as an exception rather than routine.

Staggered arrivals with on-going pilot on cataract list

Utilisation of space on the wards with the introduction of reclining chairs for sedation patients

Introduction of patient status at a glance boards for patients on day care wards allowing staff to see the pathway status of patients quickly and efficiently

Ward opening from 7 am onwards so patients no longer have to wait on the front hall upon arrival

Introduction of colour coded areas per consultant/theatre on Sedgwick which saves time and enhances co-ordination

5.4 Patient information When the CQC visited the trust they found that patient information was not always distributed to clinics or available in waiting areas or that it was not available in other languages. “We saw there were leaflets relating to common conditions which the doctors handed out to patients. These were not translated into any of the languages that many patients who used the service spoke.”(CQC Report: Sept 2013)

A Patient information hub has now opened in City Road main reception. This is manned by a Friends Volunteer supported by the outpatient matron and contains information on ophthalmic conditions as well as more general health information for patients. In the coming months, interactive terminals and videos will supplement the written information

The Editorial Committee is overseeing the translation of the most commonly used patient leaflets into the most common languages used by Moorfields patients

The Editorial committee is also overseeing a complete review of patients letters to ensure they are clear, easily understood and do not confuse patients with too much information. The new Moorfields patient Booklet will contain much of the information currently included in the current letters

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‘YouTube’ style patient information videos are being developed for the new trust website, giving patients simple instructions, advice and information that can be accessed online. Commentary of these will be in different languages

Friends of Moorfields volunteers have enhanced the training process for volunteers to enable them to appreciate the needs of patients better. The ‘floor walker’ role has been established to support patients in clinics and assist in directing them.

6.0 Conclusion

As with previous years the, patient experience feedback at Moorfields is overwhelmingly positive with clinical outcome and the friendliness and professionalism of the staff to the fore. There remain issues with waiting times and communication, but much work has begun to address some of these issues and initiatives in place which will address these concerns in the coming year. In the coming year the priorities in terms of patient experience are:

Patient Experience Committee to be re-launched with a more specific remit around ensuring that patient feedback is being responded to

Engage patients in more face to face in your shoes events at satellite sites and within services

Explore more effective ways of collecting and disseminating the Friends and Family Test feedback though use of multi-media techniques

More in-depth analysis of existing patient feedback information to be undertaken to get a clearer understanding of what they are telling us and to measure improvements. More quality work to be done to identify the differences between patient expectation and experience

Roll out of the ‘Moorfields Way’ project aimed at identifying the behaviours of both staff and patients would like to see and embedding the results in practice, appraisal and recruitment across the trust

Development of the Moorfields website to deliver video patient information

Development of a trust wide agenda for dementia including training of staff and further engagement with community and patient support groups

Continuation of the Surgical Services Review and Transformation Projects

TPW/ /QSPE/5/14