Compliance Plus Report Customer Service Excellence

Compliance Plus Report

Customer Service Excellence

The Royal Marsden NHS Foundation Trust

21 December 2012

Successful

15418/125059 4 December 2013Page 1 of 25

The Royal Marsden NHS Foundation Trust Compliance Plus Report

Assessment Summary

Overview

Overall Self-assessment Strong

Overall outcome Successful

10RP2 The Royal Marsden evidenced improvement across all Criteria. It continues to develop its insight,

continues to be very strong in engagement and consultation and continues to record very high levels of

customer satisfaction. Customer focus is still led from the top and 2010 feedback on patient privacy and

dignity warrants a new Compliance Plus in Element 2.1.5. The Trust continues to value staff input to its

customer focus ethos. Chargeable services are well-publicised and the organisation always checks that

patients receive and understand all its information, interaction methods are continually monitored and

improvements made accordingly and clear lines of accountability are set down for arrangements with its

partners. The Trust generally meets its operational standards and publishes data on this. Customer

satisfaction remains very high on promises delivered and planned outcomes achieved. The complaints

procedure was reviewed in 2010 and remains effective in driving improvement although it needs to publicise

these effectively to fully comply with Element 4.5.4. It showed its customer service outcomes are timely and

of high quality, it responds promptly to those making contact, explains delays and takes action on them. The

organisation now monitors performance against all customer service standards, shows it generally meets

them and publicises data.

11RP3 In the last year RMH has demonstrated improvement across all Criteria. It has improved its Customer

Insight, widened its customer focus culture, improved its information, learned from benchmarking and Best

Practice, and showed how it is regarded very highly, nationally and locally, for its quality of customer service.

The organisation cleared the Partial Compliance in the last report under Element 4.3.4, has maintained

Compliance Plus in all reviewed elements and has demonstrated Compliance Plus in two additional

Elements, 3.2.3 and 3.4.3. Further evidence is needed under Elements 2.2.3 and 5.3.3.

12RP1 You have continued to demonstrate improvements across all Criteria during the last year. With action

taken to clear previous Partial Compliances in Elements 2.2.3 and 5.3.3 you are now fully compliant with the

Standard. With the strengthening of existing initiatives and development of new ones you demonstrated

Compliance Plus in four new Elements: 2.1.1, 3.3.1, 4.3.1 and 4.3.4.

1: Customer Insight

Criterion 1 self-assessment Strong

Criterion 1 outcome Successful

10RP2 The organisation has used its insight to seek detailed patient feedback, determined to better support

patients with learning difficulties and appointed a Clinical Research Fellow in Psychosexual Practice to

identify and help appropriate patients to maintain Compliance Plus in 1.1.2. It again evidence improvements

made through consultation with customers and through its range of survey feedback, and continued to

improve customer experiences and journeys.

11RP3 The Trust has continued to engage with disadvantaged groups, showed it reviews all customer

engagement mechanisms on an ongoing basis, as with PCAG, and asked survey questions on all key drivers

and on specific subjects generated from its customer insight.

12RP1 You showed how you have continued to collect information for your customer identification and also

continued to warrant Compliance Plus with regards to your effective engagement and consultation, including

your Board, PCAG and a range of committees, groups and surveys. You are now operating monthly 'Real

Time Surveys' to gather more up to date and effective feedback on inpatient satisfaction and you showed your

performance against challenging and stretching targets for customer satisfaction continues to improve.

2: The Culture of the Organisation



15418/125059 4 December 2013Page 2 of 25


11RP3 Its Customer Service Policy and standards remain in place and evidence showed staff are continually

encouraged to promote its customer service culture. Although the Trust has the required mechanisms in

place to set and monitor targets on Customer Focus within its performance management system, further

evidence is needed in Element 2.2.3.

12RP1 With your stronger evidence of your corporate commitment to putting customers at the heart of service

delivery including how your Chief Executive, Chief Nurse, Directors, Consultants and Governing Body support

this you now demonstrate Compliance Plus in Element 2.1.1. Feedback shows that all customers feel they

are treated fairly by your staff and you demonstrated your ongoing commitment to delivering customer

focussed services through your recruitment, training and development of staff. You provided evidence of your

performance management process guidance and completed performance appraisal forms that show you

prioritise customer focus at all levels, clearing the Partial Compliance in Element 2.2.3. Evidence and verbal

feedback to the assessor showed that staff insight and experience is incorporated into internal processes,

policy development and service planning.

3: Information and Access



11RP3 The degree of improvement in improving verbal, documented and web-based information now warrants

Best Practice in 3.2.3 and evidence shows information updating customers remains accurate. The Trust

continues to improve facilities when finances permit and customer feedback confirms they find them clean,

comfortable and confidence building. It continually extends its community interaction and the extent of

worldwide take-up on Cancer advice and information now warrants Best Practice in Element 3.4.3.

12RP1 You continue to develop effective information that customers need and value and present it in ways

that meet their needs and preferences. Improvements to the ways patients, carers and families can access

your services now demonstrates Compliance Plus in 3.3.1 and your ongoing commitment and endeavours to

develop partnerships, including the ICR, GPs and for the offsite production of chemotherapy, to benefit cancer

patients, continues to warrant Compliance Plus in Element 3.4.1.

4: Delivery



11RP3 RMH again involved stakeholders in standards reviews and used benchmarking feedback to improve

services. It continues to use best practice within and outside the Trust to improve services and publishes

them locally and nationally. Staff continue to be trained in complaints handling and staff confirmed they

remain empowered to address them. Successful complainants are asked if they are satisfied with outcomes.

12RP1 A wide range of operational standards for the treatment and care of cancer patients remains in place

and you continue to agree at the outset what customers can expect from your services. Your detailed Action

Plans, as to address problems with your waiting times, and speed of action to address such dips, now

demonstrate Compliance Plus in Element 4.3.1 and, similarly, the extent to which you use formal and

informal complaints to generate improvements warrants Compliance Plus in 4.3.4.

5: Timeliness and Quality of Service



15418/125059 4 December 2013Page 3 of 25


11RP3 RMH's effectiveness at identifying and dealing with customer needs at first contact still warrants Best

Practice in 5.2.2 and it continues to share information to enhance the service to patients, whenever

practicable, and updates customers on progress and care plans on an ongoing basis. Although the Trust

compares well with others regarding the quality of customer care, additional evidence is needed in Element

5.3.3 to show it also compares well with regards to the timeliness of customer service.

12RP1 You showed you operate standards for the timeliness of response and quality of customer services on

an ongoing basis and you continue to monitor your performance against them. You also showed that you

take action when problems arise, as with keeping appointments. You provided evidence that your

performance with regards to the timeliness, as well as quality, of customer services compares well with other

organisations, clearing the previous Partial Compliance in Element 5.3.3.

15418/125059 4 December 2013Page 4 of 25


1: Customer Insight

1.1: Customer Identification

1.1.2: We have developed customer insight about our customer groups to better

understand their needs and preferences.

StrongApplicant Self Assessment:

Compliance to Standard: Compliance Plus

Active Evidence

This survey of patients across SW London Cancer network shows where patients are diagnosed and highlights

differences in responses between patients with different tumour types.

10:02: SW London Cancer Network patient survey 2009 Assessor Acceptance: Yes

The Trust asks subsets of its patient population for their views, for example patients being treated with

radiotherapy. Once the needs and preferences of patients are known improvements are made to services to

reflect them.

10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes

An annual patient survey is run by a contractor to Care Quality Commission guidelines. The results can be

reported against characteristics of the Trust's patient population including age, gender, ethnicity, ward or

hospital site as here.

10:04: National inpatient survey, 2009, Chelsea results Assessor Acceptance: Yes

The Trust runs a comprehensive clinical audit programme which is based upon the clinical units. Each unit is

responsible for identifying its own audits. These audits provide an insight into patients with particular tumour

types for example experience of specific support groups.

10:05: Clinical audit programme 2009/10 Assessor Acceptance: Yes

The new medical day unit in Chelsea has been designed around the needs of its patients. Improvements

based on the experience of patients using the old unit include provision of electronic entertainment systems to

help pass the time while the infusions are given.

10:06: New ambulatory care centre, Chelsea Assessor Acceptance: Yes

Process mapping identified when colorectal cancer patients should be approached to join the programme (p2).

It was also discovered that not all patients wish to discuss their concerns (p4).

10:57: Cancer Survivorship Programme, colorectal cancer case study Assessor Acceptance: Yes

15418/125059 4 December 2013Page 5 of 25


1.1.2.1: We have developed customer insight about our customer groups

T08 You have developed a range of focus groups to obtain the views and insight into different tumour patients,

and include those for teenagers and for younger children. This was evidenced through the work carried out with

gynaecological, lung and prostate patients and through surveys to ascertain needs on, for example, a

geographical basis. You also carry out a range of surveys, operate the Viewpoint comment system and hold

one-to-one discussions with patients.

09RP1 Add EvSUR24 and IG7. Evidence shows your insight has led to consideration of palliative care patients,

the relatives of people with cancer and those who suffer psychological effects after cancer treatment.

10RP2 A range of focussed initiatives, such as for Colorectal Cancer patients, Day Care patients, and

Radiotherapy patients, and analyses of survey feedback, such as by tumour type, demonstrate your ongoing

developments in customer insight,

Fully MetEvidence Value:

1.1.2.2: to better understand their needs and preferences.

T08 The depth of your customer insight has enabled you to understand and respond to their needs and

preferences. These have included the adaptation of treatments, reduction in travelling, provision of less-invasive

surgery and reductions in hospital stay durations.

09RP1 In addition to previous year initiatives you have enhanced 'End of Life Care'; are designing 'Care for

children whose parents have cancer'; and provide 'Support around issues affecting sexuality, sensuality and

intimacy following disease and treatment'. This demonstrates Compliance Plus in this Element.

10RP2 The Trust's aims continue to include to better understand patient needs and preferences and in the past

year you have opened the new Ambulatory Care Centre in Chelsea, designed the new Sutton Children and

Young People's facility and identified a preference for Radiotherapy appointments between 9.00 and 12.00.

These ongoing initiatives continue to demonstrate Compliance Plus.

Evidence Value: Fully Met

15418/125059 4 December 2013Page 6 of 25


1.2: Engagement and Consultation

1.2.1: We have a strategy for engaging and involving customers using a range of methods

appropriate to the needs of identified customer groups.



New Evidence

The Patient and Carer Advisory Group held a workshop in June 2012 to identify how it could recruit members

and represent patients receiving care from Sutton and Merton Community Services, following its merger with

the Royal Marsden.

12:03: Patient and Carer Advisory Group - community service workshop Assessor Acceptance: Yes

Includes greater emphasis on making the Foundation Trust membership more representative of the

communities served, especially young people and black and minority ethnic groups. The Council of Governors

has a patient experience sub-group; lay Governors work to improve patient experience (12:87).

12:06: Foundation Trust Membership recruitment, engagement and involvement strategyAssessor Acceptance: Yes

The Trust website lists many ways that patients and their families can feed back to the Trust including on-line

feedback forms, writing a review at NHS Choices and joining a patient/carer group.

12:07: Compliments, complaints and feedback section of Trust website Assessor Acceptance: Yes

Trust website users are asked to complete an on-line form to suggest ideas for future cancer research.

12:08: Website - suggestions for research Assessor Acceptance: Yes

PCAG, with patients and carers as members, reflects the views of patients to the Trust. At this meeting a

patient survey (52/12) and the Listening Post comment collection scheme (55/12) are reported as well as

feedback from a member who sits on Trust Equality and Diversity Committee (55/12).

12:09: Patient and Carer Advisory Group notes, July 2012 Assessor Acceptance: Yes

An example of an action plan that is developed to remedy shortfalls identified by patients in a survey.

12:10: National outpatient survey 2011, action plan Assessor Acceptance: Yes

15418/125059 4 December 2013Page 7 of 25


1.2.1.1: We have a strategy for engaging and involving customers

T08 Your comprehensive consultation strategy remains in place and is supported throughout the Trust and

includes the Clinical Audit Committee (CAC) and the Membership Council.

09RP1 The Consultation Strategy is still in place and operates on a continuous basis.

12RP1 Your Foundation Trust Membership recruitment drive, internet developments and engagement and

involvement strategy initiatives demonstrate your continued compliance here.


1.2.1.2: using a range of methods

T08 You have continued to consult using a range of methods including through the Patient and Carer Advisory

Groups, the Viewpoint comments scheme, the Listening Post monthly forum, emails and complaints.

09RP1 Your range of methods includes: meetings, surveys, (now also monthly by ward), and Focus Groups (as

for patients with pancreatic or hepatobiliary cancers), Listening Post sessions, and more Viewpoint stations are

programmed at the Chelsea site. This range of methods represents Compliance Plus here.

12RP1 Your range of methods remains in place for engaging with patients, carers and relatives across all sites,

and additions such as use of the internet and the PCAG Workshop held in June 2012 show you continue to

warrant Compliance Plus in this Element.


1.2.1.3: appropriate to the needs of identified customer groups.

T08 The Trust encourages lay representatives, patients and carers to become involved in consultation and

comprise over 50% of the Councillors on the Membership Council, which acts as the Board of Governors.

In-patients and outpatients take part in focus groups to cover all ages and the Viewpoint comments scheme is

available throughout the hospital. Complaints and emails can be used by discharged patients.

09RP1 All methods take account of patients' and carers' needs, such as the range and scheduling of meetings,

carrying out of surveys and PALS advisors attending at patients' bedside. This was confirmed by group and

Council members who spoke with the assessor during the visit.

12RP1Your methods of engagement continue to be appropriate to the needs of identified customer groups,

taking account of such aspects as gender, accessibility, disability, age, ethnic groups and geography. You

survey Outpatients and Inpatients, and the latter by Ward and Cancer Group.


15418/125059 4 December 2013Page 8 of 25


1.3: Customer Satisfaction

1.3.5: We have made positive changes to services as a result of analysing customer

experience, including improved customer journeys.



Active Evidence

Improvements are listed (p5) following a survey of patients receiving radiotherapy including work around

appointment times and target for start of treatment.


After a review of pharmacy services (p14), involving patient surveys, a number of new initiatives are being

introduced to improve access including home delivery of drugs and pharmaceutical services closer to clinical

areas. A new haemato-oncology unit also offers improved patient experience (p10).

10:13: RM Magazine, summer 2010 Assessor Acceptance: Yes

A new larger, better appointed medical day unit has opened in Chelsea (p18). It has been designed around the

experience of patients using the previous unit. Each chair has more space and its own entertainment centre.

There is a refreshment bar and an area dedicated to fast track quick infusion.

10:14: RM Magazine, autumn 2010 Assessor Acceptance: Yes

The Trust is in the process of deciding whether to take over running Sutton and Merton community services.

The key reason for taking on these services is to ensure continuity of care for patients with long-term

conditions including cancer (p6) and a safe and speedy discharge to community services.

10:19: Board minutes, September 2010 Assessor Acceptance: Yes

The Trust is moving away from routine follow up for breast cancer patients to a system where the patient is

supported to take control of their own follow up. This will improve patient experience. Patients have been

involved in taking this project forward.

10:20: Open access follow-up project Assessor Acceptance: Yes

After reviewing patient experience of current services the Trust is introducing Cyberknife robotic radiotherapy

and considering managing Sutton and Merton community services to respectively improve patient choice and

cut waiting times (p10) and improve patient pathways (p6).

10:59: Board Minutes, April 2010 Assessor Acceptance: Yes

15418/125059 4 December 2013Page 9 of 25


1.3.5.1: We have made positive changes to services as a result of analysing customer experience,

T08 Positive changes to services in the last year include the 're-assessment of prostate cancer treatment at

early diagnosis' for men and 're-assessment of the number and size of radiotherapy treatments to women with

early breast cancer'.

09RP1 Add EvPEER4 Positive changes in the past year include: 'End of Life Care', treatments for prostate

cancer, and measures arising out of the Gynaecology Tumour Working Group.

10RP2 Customer experience drives changes to the Trust's services on an ongoing basis.


1.3.5.2: including improved customer journeys.

T08 You continually implement change to improve customer journeys. In the past year you have opened the

Rapid Diagnostic and Assessment Centre (RDAC) on the Chelsea site, usually providing screening, tests and

results on the same day. You have opened a new Chemotherapy Unit at Kingston Hospital and you review

radiotherapy pathways on an ongoing basis. I consider these initiatives warrant Compliance Plus.

09RP1 Add EvSUR21 and EvNHSSUR19. Further developments intended to improve customer journeys,

including Telephone Counselling, Ambulatory Service review, and the Operating Theatre suite design

(observed), continue to demonstrate Compliance Plus in this element.

10RP2 Improvements include the consideration of customer journeys, which in the last year include the Open

Access Follow Up project for breast cancer patients, taking over the running of Sutton Community Services and

home delivery of drugs.


15418/125059 4 December 2013Page 10 of 25


2: The Culture of the Organisation

2.1: Leadership, Policy and Culture

2.1.1: There is corporate commitment to putting the customer at the heart of service

delivery and leaders in our organisation actively support this and advocate for

customers.



New Evidence

The Trust Chief Executive makes the statement: 'The quality of patient and family care is at the centre of

everything we do at The Royal Marsden'. A corporate objective for 2012/13 is to 'Improve patient experience'

(p4).

12:18: Quality Account 2011/12 Assessor Acceptance: Yes

The Chief Nurse highlighted to other Board members a patient survey, where 100% of patients had described

patient transport as ‘excellent’ and an improvement in chemotherapy waiting times (p5; item 21/12).

12:19: Board minutes, March 2012 Assessor Acceptance: Yes

The importance that directors place on service delivery is shown by the decision to discuss complaints about

unsatisfactory customer service and remedy at this meeting of a Board sub-committee (p2; item 87/11).

12:20: Quality, Assurance and Risk Committee minutes, December 2011 Assessor Acceptance: Yes

The Trust actively recruits patients and carers as members of key committees and projects throughout the

Trust giving them the power to influence service delivery. The support that Trust leaders give to this

empowerment is demonstrated here (p2; 302/12). The patient group reports to IGRM (12:88).

12:21: Integrated Governance and Risk Management Committee (IGRM) minutes, October 2012Assessor Acceptance: Yes

Governors and Board Directors actively advocate on behalf of patients and promote the central position of

patients in the work of the Trust egs section 14.1, p8, September 2012 minutes and section 8, p6, May 2012

minutes.

12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes

One of the Trust's Governors describes his aims for the next year to include "to increase engagement with

carers who can offer many insights to improve standards and the patient experience" (p28).

12:83: RM Magazine Spring 2012 Assessor Acceptance: Yes

15418/125059 4 December 2013Page 11 of 25


2.1.1.1: There is corporate commitment to putting the customer at the heart of service delivery

T08 The corporate commitment to putting patients and carers at the heart of service delivery is set down in

'What you can expect from the RMH'.

09RP1 Your corporate commitment is well-documented and re-stated on an annual and ongoing basis by your

Board.

12RP1 Your Quality Account includes the statement 'The quality of patient and family care is at the centre of

everything we do at the Royal Marsden' and amongst your Trust Objectives is 'To improve patient experience'.


2.1.1.2: and leaders in our organisation actively support this and advocate for customers.

09RP1 Leaders, including your Chairman, Board and Chief Executive, actively support customer care on an

ongoing basis, and annually in Reports. All leaders seek ways to lead on this and advocate for customers as a

team and individually. The Chief Nurse has become involved through the PCAG to drive 'Support around issues

affecting sexuality, sensuality and intimacy following disease and treatment' for cancer patients.

12RP1 The Trust Chief Executive sets down your ongoing commitment in your Quality Account as your

'Statement' and it is one of your fundamental 'Trust Objectives'. This has been strengthened further by your

Chief Nurse, Directors, Governors, 'Quality, Assurance and Risk Committee' and your 'Integrated Governance

and Risk Management Committee'. The level of commitment and support that leaders in your organisation

demonstrate warrants Compliance Plus in this Element.


15418/125059 4 December 2013Page 12 of 25


2.1.5: We protect customers’ privacy both in face-to-face discussions and in the transfer

and storage of customer information.



Active Evidence

A committee has responsibility for ensuring that best practice in information governance is followed to protect

the confidentiality of patient records and other information. The Trust scored 71% against the national

information toolkit in 2010, which was second highest amongst London acute Trusts.

10:26: Information Governance and Medical Records Committee report Assessor Acceptance: Yes

Sets out the principles for protecting the privacy of patients. Each year the policy is reviewed to ensure it is

consistent with current best practice.

10:27: Patient privacy and dignity policy Assessor Acceptance: Yes

Outlines the security arrangements of information, information systems, software applications, networks, user

devices, the physical environment and information management staff. This is one of a series of policies about

information governance.

10:28: Information management and technology security policy Assessor Acceptance: Yes

All staff are required to undertake information governance training. This is a requirement of the national

information governance toolkit.

10:29: Mandatory information governance training e-mail Assessor Acceptance: Yes

Literature reminding staff of their responsibilities around data protection.

10:30: Data protection leaflet Assessor Acceptance: Yes

Procedures to ensure the confidentiality of patient information and data protection.

POL11: Confidentiality policy Assessor Acceptance: Yes

2.1.5.1: We protect customers’ privacy both in face-to-face discussions

T08 Trust policies set down the commitment to protect patients' privacy and the latest survey results show 95%

of patients (well above the national average of 88%) felt given enough privacy (Ev ANRPT3). This was confirmed

by patients who spoke with the assessor.

10RP2 Add Ev 10:4. Your Trust policies and procedures remain in place to ensure privacy is protected in

face-to-face discussions and all survey feedback shows it still happens. Customer satisfaction with regards to

this is so high (97/98%) you demonstrate Compliance Plus in this Element.


2.1.5.2: and in the transfer and storage of customer information.

T08 The Trust's Data Protection Policy and Confidential Policy ensure the privacy of customers is protected

with regards to the transfer and storage of customer information.

10RP2 The same evidence shows that you continue to comply with regards to the transfer and storage of

patient information.


15418/125059 4 December 2013Page 13 of 25


2.2: Staff Professionalism and Attitude

2.2.2: Our staff are polite and friendly to customers and have an understanding of

customer needs.



Active Evidence

100% of patients surveyed found reception staff in the radiotherapy department courteous and polite (p2;

question 9).


Over 93% of patients asked in the national outpatient survey (p93) said they were treated with respect and

dignity whilst visiting the Trust's outpatient department.

10:32: National outpatient survey, 2009 Assessor Acceptance: Yes

Training for staff about how to provide excellent customer service including identifying the skills needed to

understand service user expectations.

10:34: Putting people first - training outline Assessor Acceptance: Yes

A statement by a member of staff which shows an understanding of customer needs corroborated by

testimonials from customers.

10:35: Staff NVQ customer care testimonial Assessor Acceptance: Yes

Action plans to improve basic care have been coordinated by the Essence of Care Steering Group. They cover

privacy and dignity benchmarking, protected mealtimes and spiritual needs. A patient is a member of the

steering group.

10:73: Essence of Care initiative Assessor Acceptance: Yes

Patients and their families write over 800 letters of praise to the Trust a year. Often the letters identify

individual staff for particular thanks.

COMP10: Thank you cards/letters Assessor Acceptance: Yes

15418/125059 4 December 2013Page 14 of 25


2.2.2.1: Our staff are polite and friendly to customers

In addition to Induction training the Trust's commitment is set down in the Patient Privacy/Dignity Policy.

Survey results show that staff are polite and this was confirmed during the assessor's visit. - The Inpatient

Survey 2004 showed that 93.3% of respondents said they were always treated with respect and dignity. T08

Patient feedback during 2007/8 shows that staff follow Trust policies in being polite and friendly to

patients/carers/families. All people the assessor spoke with during the visit agreed that staff are polite and

friendly.

09RP1 Add EvNHSSUR19 Inpatient Survey results show that patients and carers find staff polite and friendly.

10RP2 Your commitment and mechanisms, including internal training and NVQ courses, remain in place to

encourage staff to be polite and friendly to customers. Patient feedback across the Trust and within discrete

services, such as Radiotherapy (100% satisfaction), shows that this continues to happen.


2.2.2.2: and have an understanding of customer needs.

T08 Patient feedback also confirms that staff at all levels have an understanding of customer needs. You

continually strengthen this through training provision, such as your 'Enhancing Customer Experience'. I

consider the Trust demonstrates Compliance Plus in this element.

09RP1 Add EvNHSSUR19 The Inpatient Survey results also show people feel that staff have an understanding

of patient and carer needs. This was supported by patients and carers spoken with during the visit who praised

staff so highly that it warrants Compliance Plus in this Element.

10RP2 Your evidence also shows that customers believe staff continue to have an understanding of their needs

and you continue to demon strate Compliance Plus here.


15418/125059 4 December 2013Page 15 of 25


3: Information and Access

3.2: Quality of Information

3.2.3: We have improved the range, content and quality of verbal, published and web

based information we provide to ensure it is relevant and meets the needs of customers.



Active Evidence

Describes the review, audit and evaluation of information materials as well as their production to ensure

patients receive information of the highest quality. The policy is reviewed and signed off by PCAG when revised

(eg January 2011; evidence 11:36).

11:31: Information for patients - provision and production policy Assessor Acceptance: Yes

The Trust is working towards having all the patient information it produces accredited against the Information

standard. When first accredited the Standard only applied to one series of booklets, at the second

assessment further literature was accredited. All will be covered by 2013.

11:32: Information standard accreditation Assessor Acceptance: Yes

Examples of entries in the patient information database, showing review schedule and patient comments

included in revisions.

11:33: Patient information database Assessor Acceptance: Yes

The guide, Directory Plus, was originally published with a questionnaire at the back. The feedback from this

questionnaire and patient group members was used to compile the revised version: Your guide to support,

practical help and complementary therapies.

11:34: Your guide to support, practical help and complementary therapies Assessor Acceptance: Yes

Patients, carers and members of the public are consulted in the production and review of patient literature. In

this case (item 20/1, p1) the leaflet 'Being open' was presented to the patient group for comment and sign off.

11:35: PCAG notes March 2011 Assessor Acceptance: Yes

The Patient and Carer Advisory Group reviews draft patient literature to ensure content is clear, relevant and

meets the needs of patients of the Trust. For example the smoking cessation and family psychology service

leaflets.

11:37: PCAG review of draft patient literature Assessor Acceptance: Yes

15418/125059 4 December 2013Page 16 of 25


3.2.3.1: We have improved the range, content and quality of verbal,

SV06 You launched your new website to meet patients', carers and the public's needs. Trust produced or

revised 115 patient information leaflets and two new booklets ('Cancer of the Prostate' and 'Clinical Trials'). Ev

308N. SV07 Patient and Carers Advisory Group minutes confirm you improved information regarding 'charges

for telephone calls using hospital equipment'. T08 The Information for Patients Policy sets down how staff

should communicate with customers and you continually compare the levels of verbal information given by

doctors to what patients want, to demonstrate continuous improvement.

11RP3 Your monitoring of patient feedback on clinical and administrative information continues through surveys

and questionnaires and improvements are evaluated. Your presentations to GP conferences continue to develop

and improve.


3.2.3.2: published

T08 You endeavour to improve published information by seeking feedback from patients, their families and

potential patients. As a result of feedback regarding the Clinical Governance Annual Report extra information on

pastoral care has been added to subsequent issues. Last year 15 leaflets/booklets were revised and an

Information Sheet has been changed to clarify how 'blood sample' and 'genetic influences' relate to DNA.

11RP3 You continue to improve published information on an ongoing basis, as evidenced through 'Being Open'

and 'Your Guide to Support, Practical Help and Complementary Strategies'. You are now a Certified Member

under The Information Standard and demonstrate Best Practice in this Element.


3.2.3.3: and web based information we provide to ensure it is relevant and meets the needs of

customers.

T08 In the last year you have added prominent links to your home page, such as for GP referrals, services

offered and using clearer, less NHS-centric language. You have created a simplified

comments/complaints/compliments area, incorporating a feedback form.

11RP3 You also continually improve your web based information in line with customer feedback, as

demonstrated in the Patient Information Database and addition of PCAG minutes.


15418/125059 4 December 2013Page 17 of 25


3.3: Access

3.3.1: We make our services easily accessible to all customers through provision of a

range of alternative channels.



New Evidence

Lists the Trust's telephone and fax numbers and address as well as information about clinical units. There is a

facility to contact the Trust by e-mail.

12:39: Trust's website Assessor Acceptance: Yes

Has tel numbers, maps of each site and public transport info. The Trust has a contract with a telephone

interpreting service. Hearing loops, amplifiers for earpieces and hearing aid compatible phones are available.

PALS is a service able to support patients in accessing services.

12:40: Your guide to the Royal Marsden Assessor Acceptance: Yes

The Trust has set up a social network site for its young patients where information can be disseminated and

the patients can socialise with their peers.

12:51: Teenagers' social network Assessor Acceptance: Yes

A system for patients to contact their specialist neuro-oncolgy nurse through texting is being set up in

response to patients' request. Patients can also reach the nurse by e-mail and telephone.

12:48: Texting protocol for neuro-oncology Assessor Acceptance: Yes

Under the new open access system patients attend for a mammogram once a year, but no other appointments

are booked. The patient can return to see the clinical team at any time. Most patients prefer this rather than

attend unnecessary routine appointments. The service review is also described.

12:52: Open access following end of treatment for breast cancer patients Assessor Acceptance: Yes

Following a review of services a Centre for Personalised Care is to be built to deliver treatments in new ways, to

more actively support patients returning to their work and home life and provide for currently unmet needs of

patients.

12:53: Centre for Personalised Care Assessor Acceptance: Yes

3.3.1.1: We make our services easily accessible to all customers through provision of a range of

alternative channels.

The Trust is accessible by phone, fax, letter, email and personal visit. Treatment requires personal attendance

and patient transport is available. There is a 'drop-in' service. SV A shuttle bus has been set up between sites.

09RP1 You make services easily available through delivery across three sites and accommodate private

patients as well as NHS. Contact can be made by phone, fax, letter, email and via the website, as well as

personal visit. Psychological Therapy advice is now available by phone and you have launched a new online

course on 'Malignant mesothelioma'.

12RP1 All your previous channels for gaining access to services remain in place and you now offer texting,

'Outreach' services, 'Open access arrangements following end of treatment for breast cancer patients' and you

are in the early stages of setting up Teenage Social Network arrangements. You now warrant Compliance Plus

in this Element.


15418/125059 4 December 2013Page 18 of 25


3.4: Co-operative working with other providers, partners and communities

3.4.1: We have made arrangements with other providers and partners to offer and supply

co-ordinated services, and these arrangements have demonstrable benefits for our

customers



New Evidence

The users of the non-emergency patient transport service provided by a partner have been surveyed. Questions

include one asking for an overall rating of experience of the service.

12:54: Non-emergency patient transport survey Assessor Acceptance: Yes

The organisation of cancer service pathways in London is being revised to improve care (p2, 63/12). London

performs less well than the rest of England. The London Cancer Alliance will cover half of the capital and

consist of 17 Trusts. The new arrangements will improve outcomes for patients.

12:55: PCAG meeting notes, September 2012 Assessor Acceptance: Yes

This response to a complaint made about the service provided by the Trust's non-emergency patient transport

partner led to improvements to the service with extra failsafes introduced to prevent bookings being missed.

12:56: Complaint patient transport Assessor Acceptance: Yes

This new initiative ensures that out-of-hours doctors, nurses and emergency services have important

information about the medical condition and personal wishes of patients nearing the end of their lives. Patients

are reassured that their wishes will be met for their end-of-life care.

12:57: Coordinate my Care Assessor Acceptance: Yes

The contract for off-site production of chemotherapy includes, key performance indicators, turnaround and

pre-ordering targets, monitoring and monthly meetings, guarantees and complaints arrangements. Having

production off site, delays for patients have reduced due to less pressure on the pharmacy.

12:58: Off site production of chemotherapy Assessor Acceptance: Yes

Five of seven below average findings in the national cancer patient survey (p5, item 8, September minutes)

relate to the patient's experience with their GP and primary care. The Trust is working with these partners to

improve the pathway.

12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes

15418/125059 4 December 2013Page 19 of 25


3.4.1.1: We have made arrangements with other providers and partners to offer and supply

co-ordinated services,

Arrangements made with many partners to provide a co-ordinated service. Include the Institute of Cancer

Research, SWLCN, the contract with the Primary Care Trust, Social Services, cleaning contractor, GPs and

District Nurses.

09RP1 The Trust has made more arrangements in the past year with other providers and partners to offer and

supply co-ordinated services. Partners who spoke with the assessor related how professional you are to deal

with, how the partnerships are valued and about the effectiveness from their point of view.

12RP1 You showed you continually seek partnerships to improve services to patients. Recent additions

include: the London Cancer Alliance; 'Co-ordinate my Care'; off-site production of chemotherapy; and enhanced

liaison with GPs.


3.4.1.2: and these arrangements have demonstrable benefits for our customers

09RP1 You seek new partnerships on an ongoing basis to benefit cancer patients. Recently you have extended

the cleaning contract due to its success, set up a joint palliative care service with the Royal Brampton

Foundation Trust, made joint appointments of Gastroenterologist and Consultant Radiologist with the Chelsea

and Westminster Hospital and with the Institute of Cancer Research and GlaxoSmithKline to enable funding to

help Inflammatory Breast Cancer sufferers. This demonstrates Compliance Plus.

12RP1 All partnerships are entered into to benefit patients, as evidenced through: improving experiences and

outcomes for patients across London; improving end-of-life care; reduced waiting times for chemotherapy; and

improvements to pathways between Primary Care and GPs. You continue to demonstrate Compliance Plus

here.


15418/125059 4 December 2013Page 20 of 25


3.4.3: We interact within wider communities and we can demonstrate the ways in which we

support those communities.



Active Evidence

Beyond the direct service it provides to patients referred to it for treatment the Trust presents to community

groups that are disproportionately affected by cancer, encouraging them to attend screening eg people with

learning disabilities and here minority ethnic groups.

11:05: Presentations to minority ethnic groups Assessor Acceptance: Yes

Staff are supported by the Trust to volunteer for work in the wider community (p7-8).

11:44: Special leave procedure Assessor Acceptance: Yes

The Trust is organising a 2011 Christmas Fayre at its Sutton site and is actively inviting local residents and its

neighbours to attend.

11:62: Christmas Fayre, Sutton Assessor Acceptance: Yes

92,128 visits to the cancer information section of the website came from 171 countries/territories between

October 2010 and November 2011. This is beyond the direct service the Trust provides for its patients. There

were 64,861 visits from UK 882 cities/towns in the same period.

11:63: Worldwide access to cancer information section of Trust website Assessor Acceptance: Yes

Work experience is arranged for students and staff give lessons/talk to schools.

11:89: Student placements and school talks Assessor Acceptance: Yes

Local residents can apply for a permit to park on the Sutton hospital site.

COMM3: Parking form for local residents, Sutton Assessor Acceptance: Yes

3.4.3.1: We interact within wider communities and we can demonstrate the ways in which we support

those communities.

SV07 The positive effect of initiatives was further evidenced through the Hospital Garden transformed by Blue

Peter (Ev 329) and by the operation and popularity of Radio Marsden (Ev 330). - Trust has been involved with

the community for many years, as evidenced by 40th Summer Fair in Sutton, staff giving talks to Rotary Clubs

and schools, and its annual 'celebrate a Life' event. T08 You have continued to be involved in the wider

community, as with the Belmont Community Ward Panel and Chelsea Fire Service.

11RP3 You continue to interact with communities around the Trust sites, including through school

presentations and work experience, links with ethnic groups and art promotions, and your Special Leave

procedure remains in place. The extent of countrywide and worldwide 'take up' in accessing the Cancer

information on your website, evaluated through 'hits', now demonstrate Best Practice in this Element.


15418/125059 4 December 2013Page 21 of 25


4: Delivery

4.3: Deal effectively with problems

4.3.1: We identify any dips in performance against our standards and explain these to

customers, together with action we are taking to put things right and prevent further

recurrence.



New Evidence

Describes the procedures to keep patients and relatives informed, including an emergency helpline (p12), in the

event of a major incident.

12:64: Major incident plan Assessor Acceptance: Yes

Actions to remedy shortfalls identified by the patient frequent feedback survey include improved information

about waits in the medical day unit (p15). Actions in response to complaints (pp90-95) and incidents (97-100)

are also included. The report is a public document widely available.

12:65: Integrated Governance Monitoring Report, July-September 2012 Assessor Acceptance: Yes

Actions in response to complaints and comments are available on the Trust's website as are the annual

Quality Account and quarterly Integrated Governance and Risk Management reports which include performance

monitoring data.

12:39: Trust's website Assessor Acceptance: Yes

Long waits for outpatients are being addressed by a comprehensive action plan.

12:66: Outpatient waiting time improvement action plan Assessor Acceptance: Yes

This committee which includes patient members, discusses action plans (p2) and receives reports about

inspections (p2) and other performance info eg about cleanliness (p2), complaints (p2) and recommendations

following incident investigations (pp3-4). The minutes are available on request.

12:67: Integrated Governance and Risk Management Committee minutes, July 2012Assessor Acceptance: Yes

Patient and carers are part of project groups that work to improve performance, in this case, for the outpatient

departments and Rapid Diagnostic and Assessment Centres. Improvements in informing patients, reducing

'did-not-attends' and controlling over running are a few of the aims.

12:68: Request for PCAG volunteers to join Trust outpatient and RDAC project groupAssessor Acceptance: Yes

15418/125059 4 December 2013Page 22 of 25


4.3.1.1: We identify any dips in performance against our standards

Dips in performance are identified immediately through ongoing monitoring of performance and 'complaints'.

SV07 You identify dips on an ongoing basis, as with 'in-clinic chemotherapy waiting times'.

09RP1 The Trust continues to identify any dips on an ongoing basis, such as on theatre usage.

12RP1 Mechanisms, such as your Major Incident Plan, complaints procedure, 'frequent feedback surveys', and

ongoing monitoring, such as for 'Outpatients Waiting Times', show how you identify dips in performance,


4.3.1.2: and explain these to customers,

Quarterly Monitoring Reports show dips and are made available to the public on notice boards. These were

observed by the assessor. Performance reports explain dips, as with 'Discharge delays' and 'Medication

Incidents'. SV06 You also explain dips in performance through letters, notices and in the annual Reports, as

with patients not seeing the same doctor at every visit. SV07 Explanations on in-clinic chemotherapy waiting

times were given to the Clinical Governance Executive, Patient and Carer Advisory Group and patients.

09RP1 You continue to explain dips to customers through groups, such as the PCAG, the Board,

noticeboards and reports.

12RP1 You explain any dips on an ongoing basis, through committees, groups, noticeboards, reports and your

quarterly magazine, as you did with regards to waits in the Medical Day Unit.


4.3.1.3: together with action we are taking to put things right and prevent further recurrence.

SV07 You also explained action taken. In this case you explained you have changed working methods at

Chelsea Medical Day Unit so that patients are given a time for treatment to begin rather than waiting an

indeterminate time.

09RP1 You showed you explain action taken to put things right and prevent further recurrence, such as through

the review of working methods within operating theatres to improve the percentage usage figures.

12RP1 You continue to communicate action taken, as with: the comprehensive Action Plan to address

Outpatient Waiting Times; reduction of Pharmacy Waiting Times; and improving diagnostic processes through

the development and building of the Molecular Diagnostics facility in partnership with the Institute of Cancer

Research. You demonstrate Compliance Plus in this Element.


15418/125059 4 December 2013Page 23 of 25


5: Timeliness and Quality of Service

5.2: Timely Outcomes

5.2.2: We identify individual customer needs at the first point of contact with us and

ensure that an appropriate person who can address the reason for contact deals with the

customer.



Active Evidence

Any patients identified with a learning disability prior to contact with the Trust or on admission, will be noted on

the electronic patient records system. This will enable all staff to support the patient’s specific needs.

11:01: Protocol for supporting people with learning disabilities Assessor Acceptance: Yes

Patients are asked to complete and bring this assessment form with them when they are admitted to wards so

that staff understand their needs and respect and support them appropriately. Clinical Nurse Specialists also

assess the holistic needs of patients living with/beyond cancer (11:95).

11:66: Cultural and religious needs assessment Assessor Acceptance: Yes

Patients with a learning disability are offered at registration a ‘buddy’. The 'buddy' acts as an advocate for the

patient and their carer ensuring they receive information in a way they can understand and that their additional

needs are met.

11:68: Learning disability buddy role requirements Assessor Acceptance: Yes

All patients are assigned a key worker on diagnosis. This member of staff coordinates the patient’s care and

promotes continuity, ensuring the patient knows who to access for information and advice in relation to a

cancer diagnosis.

11:69: Key worker operational policy Assessor Acceptance: Yes

Patients who may have cancer are assessed in the Rapid Diagnostic and Assessment Centre. Individual needs

are assessed before surgery in the Admissions and Pre-assessment Unit.

11:70: Unit specific literature Assessor Acceptance: Yes

The Trust audits the assignment of key workers. 60/60 of patient records audited showed a key worker been

provided.

11:92: Key worker audit Assessor Acceptance: Yes

15418/125059 4 December 2013Page 24 of 25


5.2.2.1: We identify individual customer needs at the first point of contact with us

T08 Individual needs are identified at the first appointment when attending the RDAC or Transitional Care Unit

(TCU) or at first admittance.

11RP3 Trust policies and procedures remain in place to identify individual customer needs at the first point of

contact and patients who spoke with the assessor confirmed this happens.


5.2.2.2: and ensure that an appropriate person who can address the reason for contact deals with the

customer.

T08 Patients are met by relevant members of staff, such as a Clinical Nurse Specialist, and all patients are

assigned a 'key worker' who acts as a link between the patient and hospital and will originate documents, such

as a 'written case note'. The Trust demonstrates Compliance Plus in this element.

11RP3 Ongoing initiatives and role development, as with receptions, Clinical Nurse Specialists, 'Buddies', 'Key

Workers', the RDACs and the Admissions and Pre-Assessment Unit ensure you continue to demonstrate Best

Practice in allocating an appropriate person to each patient. Audits show you achieve your targets here.


15418/125059 4 December 2013Page 25 of 25

Date post:	24-Feb-2022
Category:	Documents
Upload:	others
View:	2 times
Download:	0 times

Compliance Plus Report Customer Service Excellence

Documents