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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
Patient Experience and Feedback Committee
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.
Patient Experience and Feedback Committee
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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%
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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%
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
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 :
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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
Patient Experience and Feedback Committee
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