NHS BORDERS 2018 Annual Review Self Assessment 1 Progress against 2017 Annual Review action points There were 7 items highlighted in the Annual Review held on the 1st November 2017. Progress updates against these actions can be found throughout the self assessment. Action point 1: Make sustained progress in achieving smoking cessation targets. Please see section 3.1, page 17 Action point 2: Continue to review, update and maintain robust arrangements for controlling Healthcare Associated Infection, with particular emphasis on SABs. Please see section 2.1, page 14-15 Action point 3: Keep the Health and Social Care Directorates informed on progress towards achieving all access targets and standards, in particular for Inpatient and Outpatient appointments and Psychological Therapies. Please see section 1.1, page 9-12 Action point 4: Continue to make progress against the staff sickness absence standard. Please see section 3.2, page 19 Action point 5: Keep the Scottish Government Integration Partnership, Support and Development Team informed on progress towards reducing levels of delayed discharge. Please see section 1.1, page 9 Action point 6: In particular on elective access targets: as a minimum, the Board should achieve the same elective waiting times performance at 31 March 2018 as delivered on 31 March 2017. Please see section 1.1, page 9-10 Action point 7: Continue to deliver financial in-year and recurring financial balance, and keep the Health and Social Care Directorates informed of progress in implementing the local efficiency savings programme. Please see section 3.3, page 20 2 Contents 1: Person-Centred 1.1: Everyone has a positive experience of healthcare 1.2: People are able to live well at home or in the community 2: Safe 2.1: Healthcare is safe for every person, every time 3: Effective 3.1: Everyone has the best start in life and is able to live longer healthier lives 3.2: Staff feel supported and engaged 3.3: Best use is made of available resources 3 1 PERSON CENTRED 1.1 Everyone has a positive experience of healthcare NHS Borders has a workforce plan, covering 2016-19, in place which was developed using the NHS Scotland six step methodology and outlines the anticipated changes to the NHS Borders workforce over the coming years. Ensuring we have the right workforce in place is crucial to ensuring we can deliver high quality, person centred, safe and effective care. The plan also seeks to enhance our staff engagement, recognising that a positive staff experience will lead to the delivery of better quality care. Recruitment across NHS Borders is values based in line with our corporate values – Care and Compassion, Dignity and Respect, Openness, Honesty and Responsibility, Quality and Teamwork. A Clinical Governance and Quality Strategy has been drafted, which will go out for consultation by the end of 2018, and will be reviewed in light of the Quality of Care Approach (QoCA) publications by Healthcare Improvement Scotland (HIS) to ensure it aligns with all aspects of quality. NHS Borders closely monitors a number of clinical quality and patient experience indicators to assess the overall quality of care delivered through its services. These include staff reviewing patient stories on Care Opinion and sharing the top 5 themes for complaints at the NHS Borders Board at each meeting. Public Involvement and Patient Experience 2017-18 Through our public involvement networks and patient experience work streams NHS Borders has a strong person centred programme of work. Areas covered by this work are: the Patient Rights (Scotland) Act (2011), complaints, feedback, person centred care projects, advocacy, carer support, voluntary sector engagement, volunteering, public involvement and patient experience. We continue to improve and strengthen our public involvement and patient experience work streams by engaging with colleagues, external and third sector organisations to support and strengthen the inclusion of the service user in public involvement and patient groups. Consistent and high quality public involvement and patient experience work is achieved through the implementation of NHS Borders Process for Coordinating Public/Patient Engagement. Included in the process are monthly meetings with the Scottish Health Council, who support us to ensure that the public/patient engagement work carried out by NHS Borders is of a high quality. We report regularly to the NHS Borders Board, which includes patient feedback gathered with the support of our patient feedback volunteers and “Two Minutes of Your Time” feedback and suggestion boxes situated throughout our acute hospital, community hospitals and mental health units. Oversight of delivery of the Person Centred Care work programme is provided by NHS Borders Clinical Executive Operational Group and assurance is provided to the Boards Clinical and Public Governance Committees. Leadership of Public Involvement and Patient Experience sits with the Medical Director and Clinical Governance and Quality Department alongside responsibility for the workstreams of safety, clinical effectiveness and patient flow. 4 thepatient. mattered to providedunderstood thecare what Chart mannera timely with the care and treatment provided. Chart 1 visitors. the core questions asked by with us to improve the experience of patient our patients. The graphs below outline feedback the response from voluntee Our patient feedback volunteers continue to speak to patients, carers and relatives and work 2014/15. Sector Ombudsman reports and through its public proactive involvement,patient feedback patient system stories, introduced complaints and NHS Borders co PatientProactive Feedback 2 below below shows the percentage of patients, carers and relatives who thought the staff that below below demonstrates the percentage of patients, carers and relatives that were satisfied Patient/Carers/Family Members % Satisfied with the Care and Treatment Provided % Yes/Yes to Some Extent C LCL UCL Sigma Violation Shift trend collects patient feedback through many different means including nd mitigating actions are agreed going forward. actions going agreed mitigating are nd 100% 90% 80% 70% Percentage 60% 50% Comments received are fed back to the relevant area in a 15 16 17 15 16 17 15 16 17 15 16 17 18 15 16 17 18 15 15 16 16 17 17 18 15 16 17 15 16 17 15 16 17 15 16 17 14 15 16 17 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Jul Jul Jul Jan Jan Jan Jan Jun Jun Jun Oct Oct Oct Feb Feb Feb Feb Apr Apr Apr Sep Sep Sep Dec Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar Mar May May May Month mmendations, mmendations, surveys, Scottish rs of patients, carers, relatives and Patient/Carers/Family Members % That Thought Staff Providing Care Understood What Matters to the Patient % Yes/Yes to Some Extent C LCL UCL Sigma Violation Shift trend 100% 90% 80% Percentage 70% 60% care o 50% 15 16 17 15 16 17 15 16 17 18 15 16 17 15 15 15 16 17 18 16 16 17 17 18 15 16 17 15 16 17 17 15 16 17 15 16 17 14 15 16 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - pinion, pinion, Public Public Jul Jul Jul Jan Jan Jan Jan Jun Jun Jun Oct Oct Oct Feb Feb Feb Feb Apr Apr Apr Sep Sep Sep Dec Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar Mar May May May Month in in 5 Patient/Carers/Family Members % That Felt They Had the Information and Support Needed to Help Make Decisions About Their Care or Treatment C LCL UCL trend % Yes/Yes to Some Extent Sigma Violation Shift trend 100% 90% 80% ofwards programme. this evaluate feedback from the wards that The support role mealtime of volunteers mealtime volunteerand was inform created other in acute March 2018, a patients. volunteers and processesthe to ofat ensure thework safety with the Health & Safety and Training department devising risk assessments and safe systems We are piloting a volunteer driver programme inAgreements place. Service are volunteers within NHS Borders ensuring the same principle Voluntary Services of Manager is ‘duty compiling of a database care’ of all applies third and sector organisations that Volunteers recruited by NHS secure Borders and person The Clear Pathway document was released to NHS Boards as guidance the eLear orprovided classroom in completing a setting recruited prior to this date have completed Public Protection training either by attending training three years. The core volunteer shouldtraining be required day to undergo formalcommenced training / in refresher training in November safeguarding at 2015, all recommending volunteers that all NHS volunteers regardless ProtectionP of of how long they have been NHS volunteering Borders is committed to implementing otherBoards. NHS the recommendations from the title Volunteer Coordinator the was changed to Voluntary Services Manager in ‘Safety accordance with and NHS Borders has 268 volunteers volunteering in 39 Volunteering treatment. patient always had the information and support needed to make Chart decisions 3 about their care or Percentage 70% 60% 50% below demonstrates the percentage of patients, carers and relatives who thought the 15 16 17 15 16 17 17 15 16 17 15 16 15 16 17 17 14 15 16 15 16 17 15 16 17 18 15 16 17 15 16 17 18 15 15 16 16 17 17 18 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Jul Jul Jul Jan Jan Jan Jan Jun Jun Jun Oct Oct Oct Feb Feb Feb Feb Apr Apr Apr Sep Sep Sep Dec Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar Mar May May May atients, Staff and Volunteers in NHSScotland’ letter from the Scottish Government from NHSScotland’Scottish Government Staff letter and Volunteers in atients, the Month - centred involvement of volunteers from the third sector in NHS setting. are are subject t within within our different volunteering roles. o clear polici ning module. ning Dialysis Dialysis Unit case case study was produced to es and procedures.