Case Study

The ULHT 2013 Keogh Review concluded that our complaints process was not fit for purpose. This damning report resonated with both complainants and staff and a full service review was undertaken that led to the development of See it My Way.

• The approach was transformational; with patients involved at the centre through the review, redesign, implementation and evaluation. It embodied the 6Cs; with courage through change being key.
• Support and leadership came from the Trust Board and senior managers and where hesitancy was encountered drawing back to what our patients had told us kept us on track with our vision. Powerful outcomes have been seen including an almost complete elimination of complainants returning dissatisfied, monthly increases in PALS enquiries, a corresponding fall in formal complaints and extremely positive feedback from complainants on evaluation.
• The model and approach were shaped to be sustainable, building into the design and evaluation. Significant training was developed and the implementation of a patient peer review panel ensures patients continue to be involved and hold us to account.
• Championed under the umbrella of patient experience to ensure governance, reporting and monitoring, the transformation has been significant. Implemented across three hospitals; careful planning and robust communication ensured wide dissemination.

Patients and relatives gave ULHT clear messages that the complaints process was not working. Staff also voiced difficulties and dissatisfaction with the systems and that there was an urgent need to design and implement a structure for sharing and learning from complaints. A number of milestones were set which included:

1. Undertake a full service review.
2. Implement executive oversight of all complaints and responses as this was not in place.
3. Implement a PALS service.
4. Engage with key partners and stakeholders.

Our aim was to use the experience of our complainants and staff to design a patient centred approach to handling concerns and complaints that was responsive, compassionate, caring, open and honest and by doing so to regain public trust and confidence.

The overarching review needed to be thorough and we knew there would be some tough moments on the journey as our patients told us about their experiences alongside the organisations cultural challenges that had also been highlighted within our Keogh review; we knew radical change would be difficult to achieve. The key was to ensure genuine consultation and involvement of our patients and staff at every step.

The review and development of See it My Way is a great example co-design with patients central throughout the process.

Other key factors include:

• The existing complaints process and systems were systematically and completely dismantled; we literally started from the ground up working from what our patients told us and built See it My Way based on their requirements.
• We have implemented this significant change at a time of huge challenge for the organisation, being in special measures and under considerable scrutiny and pressure.
• We have implemented within an, at times, defiant and resistant culture; a number of the proposals such as clinical directors leading and senior managers contacting complainants met with initial resistance and hesitancy.

There are three key reasons for its success:

1. The tenacity of the patient experience team in pushing, supporting and leading the changes.
2. The unwavering support of the Trust Board and senior management especially when controversial decisions needed to be made.
3. It was the right thing to do, our patients told us this and our staff told us too.

• Setting up the PALS service was the first step and 15 patient representatives helped us to design the service model and recruit the staff.
• The Patient Association facilitated a listening event where 25 ex-complainants worked through their experience of the complaints process. This event was incredibly powerful and hard hitting with some very painful messages for us to hear.
• We held staff workshops exploring their involvement with and handling of complaints.
• We undertook a postal survey of 300 Trust members (26% response rate).
• We reviewed national reports and best practice.
• We triangulated the above evidence to clearly demonstrate where our focus was needed:

• A range of proposals were developed; every proposal tracked directly to what our patients had told us. These proposals were then presented back to patients and staff through workshops to consult and consider. From this �See it My Way� was designed and included the following key elements:
  • The development of 3 site based complaints from a central customer care service that was viewed as remote: Aim = local ownership and accessibility.
  • On receipt of a complaint a deputy director calls the complainant to acknowledge, apologise and explain next steps: Aim = senior ownership and accountability.
  • Clinical directors and consultant staff to act as case managers for medical complaints: Aim = individual ownership and accountability.
  • Development of quality metrics within business performance dashboards. Aim = service ownership and accountability.
  • Development of innovative new documentation templates that demand transparency: Aim = thorough investigations, all concerns addressed, compassionate responses.
  • Development of a change register and process for sharing lessons learned: Aim = learning identified, implemented and shared.
  • Development of a prospective survey of complainants to understand their experience and enable continuous improvement: Aim = listening and learning.
  • Development of a patient peer review process: Aim = open and transparent evaluation.
  • Completion of a training blueprint and comprehensive training programme: Aim = all staff confident and competent in managing complaints.

See it My Way is centred around 6 principles drawn from national best practice:

1. Getting it right
2. Being patient focused
3. Being open and accountable
4. Acting fairly and proportionately
5. Putting things right
6. Seeking continuous improvement

These were then translated into five pathway steps as shown in the logo below:

• The new documentation was developed to move away from defensive and corporate responses to being open and honest and apologetic. An investigation template was designed that demands an answer to each issue raised and forces staff to think about actions and learning against these. This template once merged and formatted is sent with the response letter to the complainant.

A detailed implementation plan was developed with milestones and clear measures of achievement. Led by the Deputy Chief Nurse progress was reported monthly to Patient Experience Committee and Quality Improvement Board and regularly featured on governance and service forum agendas.

Quantitative and qualitative data has been used to measure progress and impact. Over the last 12 months we can see the following from the graph below:

• Complaints peaked following inspections
• Fall in complaints on introduction of PALS
• Significant reduction of reopened complaints; (complainants not happy with the response or outcome) since the introduction of executive sign off.

Staff feedback has been extremely positive with them finding the ownership at individual and service level a key improvement and the new documentation easy and intuitive to use.

A survey of complainants was undertaken.

Whilst this survey was small, equating to 10% of complainants in an average month, one aim was for us to test the survey process for continuous surveying going forward. All complainants will be contacted within a month of receiving their final response to ascertain whether they were satisfied with the outcome and to understand their experience of the complaints process as a whole and enable continuous improvement plans.

A patient peer review panel has been developed with a keen group of patient representatives, three of whom were involved from the very beginning at the listening event. Terms of reference, sampling methodology and a review tool have all been developed with acknowledgement to The Patient Association complaints review programme.

The development of the PALS service has also been a critical component of See it My Way as there had been none at the Trust for many years. The graph below demonstrates the effectiveness in its first full year with a 93% resolution rate.

• Be brave; C for courage is essential for challenging historical practice and old behaviours and for listening to what your patients are telling you; it may hurt, but you must listen and be committed to making a difference.
• Achieve Trust Board support; the drive for achievement must be led from the top.
• Find your champions and get them to help you deliver the change. For us, our champions were our patients. The reality is that you cannot argue when your vision is centred on the patient experience.