Quality Accounts 2013/14

Quality

Accounts

2013/14

Section

Content

Page

Statement on Quality – A letter from our Chief Executive 4

Section 1 Priorities for Improvement in 2014/15 5

Section 2 Review of Quality Performance 2013/14 8

2.1 Patient Experience 9 2.1.1  Patient‐led assessments  9 2.1.2  Patient Experience Walk rounds  10 2.1.3  Same Sex Accommodation  11 2.1.4  NHS Choices, Patient Opinion and I Want Great Care  12 2.1.5  Maternity Survey  13 2.1.6  In‐patient survey  15 2.1.7  Friends and Family Test  17 2.1.8  Expert Patient Programme    18 2.1.9  Dementia Carers Survey  20 2.1.10  Compliments    21 2.1.11  Concerns  21 2.1.12  Complaints    23 2.1.13  Claims    27 2.1.14   National Cancer Patient Survey  30 2.2 Safety 31 2.2.1  World Health Organisation (WHO) Checklist    31 2.2.2  Venous thromboembolism (VTE) Risk Assessment    33 2.2.3  Theatres and Delivery Suite Ventilation  34 2.2.4  Serious Incidents Requiring Investigation  34 2.2.5  Safety Alerts: Central Alerting System (CAS)  36 2.2.6  Reportable Injuries Diseases Dangerous Occurrence Regulations  (RIDDOR)  37 2.2.7  Pressure Ulcers  38 2.2.8  Incident Reporting  40 2.2.9  Infection Control  43 2.2.10  Medication Errors  44 2.2.11  Mortality and Care Bundles    45 2.2.12  Never Events    48 2.2.13  National Early Warning Scores (NEWS)  49

2.2.14  Patient Falls  50 2.2.15  Fire Compartmentalisation  52 2.3 Effectiveness 53 2.3.1  Re‐admission Rates  53 2.3.2  Clinical Audit    54 2.3.3  Commissioning for Quality and Innovation (CQUINs)  55 2.4 Staff Engagement 57 2.4.1  Staff Survey  58 2.4.2  Recruitment in Maternity, Health Visiting and Nursing  58 2.5 External Reviews 59 2.5.1  West Midlands Quality Review Service  ‐ Acquired Brain Injury    59 2.5.2  Rapid Response and Care Quality Commission Review  60 2.5.3  Royal College of Obstetricians and Gynaecologists    (RCOG) Review  61

Section 3 Mandatory Statements Relating to Quality of NHS Services Provided 62 3.1  Review of Services  62 3.2  Participation in Clinical Audit  62 3.3  Participation in Clinical Research  76 3.4  Use of the CQUIN Payment Framework  76 3.5  Statements from the Care Quality Commission (CQC)    76 3.6  Statement on Relevance of Data Quality and Your       Actions to Improve Your Quality  78 3.7  NHS Number and General Medical Practice Code  Validity   79 3.8  Information Governance Toolkit Attainment Levels    79 3.9  Clinical Coding Error Rate    79

Statement on Quality –

A Letter from Our Chief Executive

Dear Patients, Relatives, Carers and Colleagues of Wye Valley NHS Trust

Welcome to the Quality Accounts 2013/14 for Wye Valley NHS Trust. Each NHS organisation publishes Quality Accounts every year. The document sets out areas where we have made improvements over the past 12 months and our priorities for the forthcoming year.

This document is set out into 3 areas; 1. Priorities for Improvement

Our three key areas for improvement over the coming financial year 2. Review of Quality Performance 2013/14

Our quality performance over the past financial year. 3. Mandatory Statements Relating to Quality of Services

The Department of Health mandates statements we must produce in relation to the quality of our services.

There have been a number of headlines in the local media about theatre ventilation and fire compartmentalisation. We continue to be open about these challenges and our work to improve them and you can read about what we are doing in Section 2.

We took part in a number of reviews during the last year, including a ‘Rapid Response Review’, carried out by NHS England (NHSE) and the Care Quality Commission (CQC). A number of recommendations were made (please see page 59). The Trust welcomes these reviews and has taken swift action to improve services. There are a number of areas that are still under development and these have been included in our priorities for 2014/15.

We welcome feedback on our Quality Accounts as well as any feedback on our services (positive or negative). If you do have any feedback please do not hesitate to contact the Quality & Safety Department on 01432 355444 x5820 or via email at [email protected].

To the best of my knowledge the information in this report is a true and accurate reflection of the current position of Wye Valley NHS Trust.

Yours sincerely

Richard Beeken Chief Executive

Section 1: Priorities for Improvement in

2014/15

Introduction

The key to improving our services is recognising and acknowledging where we have not performed well and where focussed efforts will truly benefit our patients. The Trust has developed a new Quality Strategy in 2013/14 and within this focussed priorities have been chosen for 2014 to 2017.

In developing the priorities for the Quality and Safety Improvement Strategy, which are echoed as part of the Quality Accounts, a significant amount of consultation was undertaken with the organisation’s stakeholders i.e. patients, staff members and external agencies. The Trust has utilised feedback from surveys, focus groups and national reports to determine its priorities for the quality and safety as set out in the Quality and Safety Improvement Strategy. Appendix 1 details the comments made by external agencies.

The Trust’s priorities for the forthcoming year are;

Priority

Responsible Officer Deadline

To achieve an improvement into the top quartile for acute Trusts for the CQC National Inpatient Survey.

Director of Nursing and Quality

31st March 2015 To aim for 100% harm free care with a

minimum acceptable level of 94% harm free care

Director of Nursing and Quality

31st March 2015 To achieve an annualised HSMR and

SHMI of 100 or below (by March 2015) To achieve a SHMI less than 100 (by March 2015)

Medical Director 31st March 2015 (It is important to note that rebased data in relation to this time period will not be available until August 2015)  

Patient Experience

Priority 1

To achieve an improvement into the top quartile for acute Trusts for the CQC National Inpatient Survey.

Rationale

The CQC National Inpatient Survey is a national tool used to gather patient feedback on the service they receive when admitted to an acute hospital as an adult inpatient. Using this national tool will enable the Trust to benchmark not only against its previous performance but also against other Trusts.

Baseline

Please refer to section 2.1.6.

Our Goal

The Trust aims to be within the top quartile of Trusts for the 2014 CQC National Inpatient Survey.

A number of key actions and areas for improvement have been identified following the 2013 CQC National Inpatient Survey. The Trust will focus on these areas to improve services and experience for patients and in turn improve the scores for the CQC National Inpatient

Survey.

Monitoring and Reporting

This priority will be monitored and progress reported to the Quality Committee on a quarterly basis through the Patient Experience quarterly report.

Responsible Officer

Patient Safety

Priority 2

To aim for 100% harm free care with a minimum acceptable level of 94% harm free care

Rationale

The Safety Thermometer is a national tool used to measure harm free care. The four key harms measured are;

 Pressure ulcers  Falls

 Catheter/UTIs  VTE

Using this national tool will enable to the Trust to benchmark not only against its previous performance but also against other Trusts.

Baseline

Harm Free Care – April 2013 to March 2014

Our Goal

The Trust aims to increase harm free care to a minimum of 94% this year.

How the goal will be achieved

A number of improvements have been made which will have a positive impact on the harm free care delivered by the Trust. This includes;

 A visual tool has been developed to be used to identify patients who are at risk of pressure damage and at risk of falling. This is placed at the head of the bed in order that staff can see at a glance which patients are more at risk.

 The SSKIN bundle tool and booklet have been used widely across the Trust and the booklet has helped consistency of care once the patient is transferred/discharged from hospital.

 A large purchase of new mattresses and other pressure redistributing equipment to ensure that patients have access to the right preventative equipment as soon as they

 The purchasing of alarms that are fitted to beds and chairs to alert staff that a patient is trying to stand unassisted.

 Continued monitoring of timely VTE risk assessments with all hospital acquired VTEs being subject to an RCA investigation.

Monitoring and Reporting

Safety thermometer data will be monitored and progress reported to both the Quality Committee and also the Herefordshire Clinical Commissioning Group as part of the Trusts CQUINs for 2014/15. Reporting will occur on a quarterly.

Responsible Officer

Clinical Effectiveness

Priority 3

To achieve an annualised HSMR and SHMI of 100 or below (by March 2015) To achieve a SHMI less than 100 (by March 2015)

Rationale

This priority links to the harm free care aspects of the Safety Thermometer however using mortality rates as an indicator for areas where quality of care needs to be improved has been an ongoing priority for the Trust and this has been reflected in previous Quality Accounts.

Baseline

Our Goal

The Trust aims to achieve an annualised HSMR and SHMI of 100 or less. This would be in line with the national average.

How the goal will be achieved

A number of key areas of improvement have been identified and acted upon over the past 12 months and the continuation of these will see an improvement in the services provided for patients as well as mortality rates. These improvements include the introduction of care bundles and NEWS. 2014/15 will see improved usage and knowledge of both the care bundles and NEWS with audits being undertaken to monitor the effectiveness of these tools.

Monitoring and Reporting

Both HSMR and SHMI will be monitored and progress reported on a monthly basis at Quality Committee.

Responsible Officer

Section 2: Review of Quality

Performance

2013/14

This section sets out our quality performance from 1 April 2013 to 31 March 2014 under the following five areas:

 Patient Experience  Safety

 Effectiveness  Staff Engagement  External Reviews

This year we have standardised how we display this information and under each sub heading you will find a brief introduction, the performance data, where we have performed well and where further work is required.

Also included in this section is the progress we made against our priorities from our previous Quality Accounts. These were:

Progress Against Our Priorities in 2013/14 Priority Goal

1 To eliminate all avoidable category 2, 3 and 4 pressure ulcers.

Although the Trust did not achieve its target to eliminate category 2, 3 and 4 pressure ulcers, a 14% reduction in category 3 pressure ulcers was achieved. This goal will continue to be monitored and reported on a monthly basis as part of the Quality Overview Report to Quality Committee and Trust Board. Further information is available in section 2.2.7.

2 To achieve a reduction in the Hospital Standardised Mortality Rate (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) in line with the national average.

The Trust did not achieve this target in 2013/14 and to this end this goal continues to be a priority for the Trust for the forthcoming year. A number of actions have been put in place, including the introduction of care bundles, which will contribute to the reduction in both HSMR and SHMI in 2014/15. Further information is available in section 2.2.11.

3 To reduce diagnostic waiting times for patients waiting over 5 weeks.

The Trust did not achieve this target in 2013/14 and to this end diagnostic waiting times for patients continues to be a focus for the Trust and this is reflected in the Trusts Quality and Safety Improvement Strategy.

Diagnostic waiting times for patient will continue to be monitored and reported as part of the monthly KPIs to Trust Board.

2.1 Patient Experience

2.1.1 Patient-led assessments of the care

environment (PLACE)

PLACE is a patient-led, annual snapshot that gives hospitals a clear picture of how their environment is seen by those using it, and how they can improve it. It includes assessing buildings and non-clinical services.

This new assessment replaces PEAT and reflects the move to give patients a real voice in assessing the quality of healthcare and the environment it is provided in.

At least 50% of those people taking part in the PLACE assessment must meet the definition of patient – in other words a user of, rather than a provider of, services. There are, however, some exceptions;  

 Former employees of the organisation who have left employment within the preceding 2 years.

 Anyone with a professional relationship with the organisation – e.g. as a facilities service provider.

 Members of the Trust Board of Governors and Trust Members can also act as ‘patient representatives’ because their primary role is to represent the interests of patients and the public

Performance

The following table sets out how the Trust was assessed across all its sites.

Site Name Site Type Cleanliness Food and

Hydration Privacy, Dignity and Wellbeing Condition Appearance and Maintenance Leominster Hospital Community 97.11% 85.46% 88.47% 96.01% Bromyard Hospital Community 98.79% 86.57% 75.42% 89.67% Ross Hospital Community 95.00% 84.96% 87.96% 93.39% Hillside Intermediate Care Centre Community 99.09% 85.13% 90.00% 88.60% County Hospital Acute 95.29% 78.42% 87.03% 91.30% National Average 95.74% 84.98% 88.87% 88.75%

Key  Better than average  About average (within 2%)  Below average 

Key Achievements

An action plan has been developed following the PLACE audits which took place in May and June 2013, all identified actions were completed by February 2014

Lessons Learned/Areas identified for further improvement

We have worked with staff to ensure that service environment checks become a routine part of our day-to-day work.

2.1.2 Patient Experience Walk Rounds

Patient Experience Walk Rounds have been carried out twice a month in outpatient, inpatient and community areas. The walk round

team is made up of an Executive Lead, a Non-Executive Lead, a Quality & Safety representative and an Infection Control representative. The team speaks with both staff and patients and gathers views about how services can be further

improved.

Performance Data

In 2012-2013, 18 walk rounds were undertaken. This year we have increased the number of walk rounds to 22.

Key Achievements

In June 2013, the programme changed so that walk rounds are unannounced, this is to ensure that the walk round team are able to experience what the patient sees on a day-by- day, hour by hour basis.

In addition, each team member focuses on a particular area. The Executive Reviewer focuses on patient experience, the Non-Executive Reviewer focuses on staff performance, the Quality & Safety Reviewer looks at documentation and equipment and the Infection Control Reviewer identifies any Infection Control issues.

Also, each participant is asked to consider their first impressions and to look at certain aspects of care and the environment.

Lessons Learned/Areas identified for further improvement

Volunteers Surveys

Volunteers visit the wards in the Hospital on a weekly and monthly basis asking the patients to complete Hospital Feedback Forms, once completed they are given to the PALS Department for recording.

Examples of where we have improved include:

 Variation in collecting and recording medication fridge temperatures was identified. Now, a new standard format has been developed and implemented in all areas.  Differences in supply of SSKIN bundle booklets (pressure area care information) to

patients were identified. Now there is a much greater focus on maintaining stock levels to make sure that all patients can easily access the information.

 A patient raised a concern regarding the disruptive noise the bin lids on the Intensive Therapy Unit. This was particularly disruptive when patients are aware of their surroundings but still critically ill. New bins with soft close lids have been installed. Some examples of good practice identified:

 The Non-Executive Director reviewer attended a ward staff meeting on Monnow Ward. The positive, open nature of the meeting, where staff were actively encouraged to ask questions and raise any concerns was noted. The Service Delivery Manager was also in attendance at the meeting.

 The Executive Reviewer spoke to a parent on Special Care Baby Unit (SCBU). The parent was extremely happy with the care she had received, not only on SCBU, but also on Delivery Suite. She commented that she felt very well taken care of and would score the unit 10 out of 10 and would not want anything to be done differently. As a result a member of staff was nominated and awarded our ‘Going the Extra Mile’ award.

 A patient in A&E commented on the good nursing care received and how well the medical staff kept them informed of what was happening during an anxious time.  

2.1.3 Same Sex Accommodation

The NHS Operating Framework 2013/14 requires all providers of NHS funded care to comply with the national definition ‘to eliminate mixed sex accommodation except whether it is in the overall best interests of the patient, or reflects their patient choice’.

The Trust monitors compliance with this national indicator daily and reports on its performance monthly to Service Units and the Trust Board.

Compliance is monitored via the Clinical Site Management Team, Ward and Department Teams and regular patient surveys. If a breach or potential breach is identified, it is escalated immediately to senior managers and the Chief Operating Officer, action is then taken to avoid or address the breach.

Sharing with members of the opposite sex will only happen when clinically necessary in our critical care areas.

Performance Data

In October 2013, the Trust took part in a Rapid Responsive Review. Fifteen mixed sex breaches were reported. These were all within the Day Case Unit.

Key Achievements

Following the Rapid Responsive Review’s findings, immediate action was taken by the Trust:

 Number of in-patient beds reduced to a maximum of 12 in the Day Case Unit only to be used in times of exception.

 Complete risk assessment to include mixed sex issues, patient experience, infection control and patient flow has been undertaken.

 New patient pathways to and from Theatre have been put in place to prevent passing through an opposite sex area.

 The use of the day case recovery area (recliners) has been reviewed and actions to maintain privacy and dignity have been taken.

 A Standard Operating Procedure has been introduced for the use of the Day Case Unit.

Lessons Learned/Areas identified for further improvement

The Rapid Responsive Review (RRR) and Care Quality Commission (CQC) visit identified an urgent need for the Trust to take action to improving the privacy and dignity of our patients in our day case area. Immediate action was taken and the layout of the department has been changed to ensure the privacy and dignity of our patients. 

2.1.4 NHS Choices, Patient Opinion and I Want

Great Care

The NHS Choices feedback page is linked to the Patient Experience Team (PET) which acknowledges, receives and actions any feedback logged on NHS Choices.

Patients using the site are encouraged to contact the team with any feedback, positive or negative. The majority of comments received via NHS choices are positive. Comments received by the PET are shared with the responsible managers. When postings are made anonymously we reply thanking them for their comments and ask if they would like to contact the PET to discuss their comments, this allows us to address concerns.

The majority of comments received are positive and complimentary - it is as important to use information about where we are doing well, as well as where we need to improve.

In addition to comments relating to the Trust, we regularly receive comments relating to services provided by other organisations such as West Midlands Ambulance Service,

General Practice and our Private Finance Initiative partners who are responsible for some of the environmental issues, such as car parking and catering. These concerns are forwarded to the correct organisations who send a reply back to PET and/or contact the person directly.

Performance Data

The table below demonstrates an increase in the use of NHS Choices over the past 12 months to log concerns; a possible cause is the increase in IT awareness and the use of the NHS Choices site.

2014 2013 2012 2011

NHS Choices 8 44 - -

Key Achievements

We receive, on average, more compliments through these sites than we receive concerns. An example of a comment posted on NHS Choices can be seen below:

Lessons Learned/Areas identified for further improvement

An emerging theme in comments received is around communication, behaviour and attitude. We are currently reviewing our Customer Care training with the aim of ensuring the areas identified are addressed and our patients and their family/carers have the best possible experience.

2.1.5 Maternity Survey

The CQC’s Maternity Survey was carried out by Patient Perspective on behalf of the Trust between March and September 2013. The questionnaire was mailed to mothers that gave

The Trust replied on 30 December 2013

On behalf of the Wye Valley NHS Trust thank you for your complimentary comments with reference to your recent experience here at the County Hospital,

Hereford.

We will pass your compliments on to the department mentioned in your email in order for them to share with their staff and we hope that you have made a full

recovery.

Patient Experience Team

Superb service - I was referred to Ophthalmology late on a Friday afternoon between Christmas and New Year so I was appreciative of any appointment.

This was my first visit to Hereford and I could not be more impressed by everything I experienced - from the clean modern hospital to the friendly and

efficient registration at A&E. I was sent to Ophthalmology and attended to immediately by the most pleasant nursing staff and later a thorough examination by the Ophthalmologist and a surgeon a short while later. I have

lived abroad for many years and experienced excellent facilities (private and state funded) but I can truly say Hereford is as good as you will find anywhere.

Something to be truly proud of. Congratulations! Posted on 28 December 2013

birth in February 2013. This is a national survey and all NHS maternity services in England take part in it.

The Maternity Survey attempts to measure mothers’ experience of maternity services by capturing quantitative and qualitative data. As a summary measure for each question, the researchers followed the approach adopted by the CQC in England for the National Patient Experience Survey. This allows us to compare our results with existing data and results from the previous survey, which was carried out in 2010.

Performance Data

The survey report was divided into six main areas:

 Response rates  Mean rating scores  Frequency tables  Trend charts  Patient Comments  Questionnaire

There were 146 direct questions relating to aspects of care throughout the antenatal, intra-partum and postnatal periods. The response rate for this Trust was 45.6%.

Responses to evaluative questions were then ranked accordingly:

 14 responses scored highly 90% - 100%  20 responses scored 80% - 90%

 10 responses scored 70% - 80%  2 responses scored 60% - 70%  3 responses scored less than 50% Scores were then set out by sections of care. There were some wide variations in scores within one or two sections of care. However, some sections of care scored consistently high on each aspect measured.

49 trend charts compared scores from this Trust’s survey with the scores from the 2007

and the 2010 survey, the 2013 survey results can be found at http://www.cqc.org.uk/survey/maternity/RLQ

Some scores were compared with 2010 scores only as the questions were new in 2010. Also, some questions were new for 2013 and are represented by a single dot on the line chart.

None of the comparisons with the surveys carried out in previous years were significantly different. Some were slightly improved and some were slightly worse.

The second part of the report displays patient comments – qualitative data. The Trust scored

Caesearan Section Rates

The promotion of normal births is a high priority for the Trust and as part of this we monitor our caesarean section rates closely. For 2013/14 the Trusts

emergency caesarean section rate was 17%, this is a 0.1% decrease from the previous year. The Trusts elective care caesarean section rate was 14.5% , this is a 3% increase from the previous year. The Trust has undertaken audits of caesarean sections using the

nationally recognised Robson Ten classification in order to identify any areas where improvements can be made. The results of these audits so far have led to a number of actions being taken to reduce caesarean section rates in Wye Valley NHS Trust. These actions include the introduction of working groups to specifically focus on the Robson Groups and also the

presentation of the results of the audits to specific groups such as Service Unit Governance meetings, Clinical

Excellence Group and Quality Committee.  

 Ensuring new mothers had contact numbers for a midwife or the midwifery team when they returned home.

 Reminding women that they needed to arrange a postnatal check up with their GP, for their own health.

 Giving new mothers information about their own recovery after the birth and help and advice from a midwife or health visitor about feeding their baby.

Key Achievements

The Trust scored very highly (80% -100%) in the following areas:

 Communication and, in particular, that staff listen and are sensitive to the needs of women.

 Partners of women felt able to be involved as much as they wanted during labour/birth.

 Women felt involved in their care and felt that they were treated with kindness and respect.

 Providing alternative access to care, including postnatal clinics in Children's Centres on weekdays and at the hospital at weekends.

Lessons Learned/Areas identified for further improvement

The Trusts maternity service has responded positively to the areas where improvement can be made.

The areas highlighted by the survey requiring improvement, have already been identified and are set out in the Service Unit’s improvement plans. These are monitored through the clinical governance structure.

Areas specifically highlighted for improvement by low scoring questions are:  continuity of postnatal care

 continuity of antenatal care  choice of venue for antenatal care

Addressing areas such as continuity of care has well documented benefits and leads to better outcomes for women and babies.

Provision of choice of venue for antenatal care is related to access to care and also leads to better outcomes for mothers and babies.

We are working towards a fully established Midwifery Service, which will improve continuity of care. It will also free up midwifery time to focus on provision of continuity of care.

The Maternity Unit is making progress with the development of communication pathways with users of the service, through virtual media, face-to-face meetings and real time feedback following comments in the Friends and Family Test.

2.1.6 Inpatient Survey

The results of the National Patient Survey were released by the CQC on 16April 2013. The benchmarking report can be found here.

A full report has been presented to the Trust’s Quality Committee. The key points are:

 Performance is ‘About the Same’ as other Trusts nationally in all areas with the exception of the questions in relation to emergency and A&E. Specifically, the Trust scored below average in providing patients with information about their condition and treatment in A&E.

 The Trust has been named in the top 20% of Trusts in eight key areas including privacy and dignity, providing help to patients at meal times, shorter waiting times, and providing clear information about patient medication

 Overall performance has improved significantly with the majority of results being better than last year and the remainder at the same level, ranking it 54 out of a total of 161 NHS trusts.

Performance Data

Trust Performance Comparisons

Compared to our 2011 survey results, we have improved significantly in relation to the following 10 questions:

 Were you ever bothered by noise at night from other patients?  Did you get enough help from staff to eat your meals?

 Did doctors talk in front of you as if you weren't there?

 Did you have confidence and trust in the nurses treating you?  Did nurses talk in front of you as if you weren't there?

 Were you given enough privacy when being examined or treated?

 Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

 Did a member of staff tell you about medication side effects to watch for when you went home?

 Were you told how to take your medication in a way you could understand?  Were you given clear written or printed information about your medicines? Compared to our 2011 survey results, we have not performed significantly worse on any questions.

National benchmarking

Compared to 2011/2012 a combined national result, we feature in the top 20% of Trusts on 8 questions:

 How do you feel about the length of time you were on the waiting list?  Did you share a room with opposite sex patients?

 Did you ever use the same bathroom or shower area as patients of the opposite sex?  Did you ever feel threatened during your stay in hospital by other patients or visitors?  Did you get enough help from staff to eat your meals?

 Were you given enough privacy when discussing your condition or treatment?  Were you given enough privacy when being examined or treated?

 Were you given clear written or printed information about your medicines? Compared to the 2011/2012 combined national result, the Trust is in the bottom 20% of acute and specialist NHS trusts in England on the following2question(s):

 Were hand wash gels available for patients and visitors to use?  Were you offered a choice of food?

The Trust is working with its Private Finance Initiative (PFI) partners to make sure that these are both improved.

Lessons Learned/Areas identified for further improvement

 Cleanliness of rooms and bed spaces  Pain control

 Being able to talk to someone about hopes and fears

Reviews of these areas now form part of the regular ward walk rounds undertaken by Ward Sisters who spend time talking to patients and their families/carers.

2.1.7 Friends and Family Test

The Friends and Family Test was introduced in Acute Inpatient Wards and A&E on 1 April 2013 and in Maternity Services on October 2013. It is the national tool for measuring patient experience.

The question posed to Friends and Family is:

“How likely are you to recommend this ward / service to your Friends and Family should they require similar care or treatment?”

There are five available responses:  Don’t know

 Extremely likely (Promoter)  Likely (Passive)

 Neither Likely or Unlikely

 Unlikely or Extremely Unlikely (Detractors)

If a patient answers ‘Don’t know’ then their result is not included in one of the three categories above BUT is included in the total number of responses a Trust has received when calculating the overall response rate.

 The Trust takes the total number of all responses (includes Detractors, Promoters,

and Passive)

 It then calculates the proportion of Detractors in the total number of responses and the proportion of Promoters in the total number of responses

 The proportion of Detractorsis then subtracted from the proportion of Promoters to calculate the NHS Friends and Family Score

There is a free text option for completion by patients to give the reasons why they gave the score, which is shared with staff in order to highlight where improvements can be made.

Performance Data

The roll out of the Friends and Family Test and achieving a combined response rate of 20% by year end was a quality indicator set by NHS Herefordshire Clinical Commissioning Group for Inpatients and A&E.

Key Achievements

 Rolled out the Friends and Family Test in Maternity Services in October 2013 and achieved one of the highest response rates nationally.

 Rolled out the Friends and Family Test in community hospitals as a measure for patient experience - this is now included in our monthly performance data.

 Recruited volunteers, particularly young volunteers from colleges, to help us promote the Friends and Family test.

 Introduced Friends and Family Test T-shirts to raise awareness.  Improved response rates month on month.

 Introduced “You Said, We Did” posters to promote improvements that have been made.

 Introduced a recognition scheme in January 2014 to reward wards that receive the highest response rates, highest and most improved scores.

Lessons Learned/Areas identified for further improvement

Areas with low response rates tend to be where there is a quick turnround of patients, such as A&E and Frome Ward (Acute Admissions Ward), or where patients are unable to

participate, such as Wye Ward (Stroke Ward).

A&E had a relatively low response rate compared to inpatient wards, but nationally our response rates for A&E are above average.

2.1.8 Expert Patients Programme (EPP)

EPP is a generic self-management course for patients 18 years or over living with one or more long-term or chronic health conditions. It consists of six weekly sessions lasting two and a half hours per week.

Course sessions cover key topics such as managing symptoms, relaxation techniques, dealing with stress, depression and low self-image, healthy eating, safe exercise, communication skills, goal setting and problem solving. Participants are encouraged to share experiences, learn from each other and develop ways of overcoming specific difficulties. The course works on the principles that the patient knows best how their condition affects them and, with proper support, can take the lead in managing their condition.

The course is facilitated by trained volunteer tutors who live with long-term conditions themselves and have attended the course prior to becoming a tutor. They understand the challenges that participants face on a day-to-day basis. The tutors are fully trained and accredited and are assessed annually to ensure compliance to the EPP quality framework. In 2009, the Department of Health produced a six month study of feedback from 1000 participants of EPP which showed evidence of a 7% decrease in visits to GPs, 10% to Outpatients, 16% in A&E attendances and 9% to Physiotherapists. Local evaluation supports

EPP is a copyrighted and scripted course developed by Stanford University, USA. It follows the Stepping Stones to Quality framework, an audit tool developed by the Department of Health for lay led self-management programmes to ensure courses are delivered to the same standard nationally under the Stanford University Licence.

Performance Data

In 2013/14 16 courses comprising 177 participants on were run in different locations across the county

Key Achievements

 An increase in the number of courses being provided.  One of our volunteer

tutors was shortlisted for the Pride of Herefordshire award in. 2013. This was positively reported in the media and also featured other success stories of EPP participants.

 Courses have been held with local work-match organisations such as JHP/Learn Direct and Pertemps to help people on long term sickness absence get back into work.

 Working with independent living organisations and GPs to promote the programme, increase number of courses and ensure courses are available to a wider selection of patients

Lessons Learned/Areas identified for further improvement

We would like to increase the number of volunteer tutors so that we can run more courses. Potential tutors are required to have a long-term condition and have attended at least four sessions of the course before applying to become a volunteer tutor. They also have to attend an interview to assess suitability, attend a four day training course and undergo a CRB check.

To help us realise this ambition we are:

 Using current tutors, Co-ordinator and Assessors to identify potential tutors  Working with the Trust’s Communication team to promote the service  Working with local volunteer centres

 Holding information and recruitment days for potential tutors

 Writing to previous course participants to invite them to become volunteers and to attend the information/recruitment days

 Using promotional stands at various local events

Comments from EPP Users

“When I look back I realise I had given up hope of ever being able to live a normal life…now thanks to

EPP I have a life!”

“I found the course enlightening, positive and very beneficial. An empowering process for people struggling to cope with a long-term condition. I’m now active and have taken back control of my life” “Before EPP my long term health condition used to limit me. I now manage a short bus ride to visit my eldest son whose home I have not been in for 2

2.1.9 Dementia Carers Survey

As part of the national CQUIN targets for 2013/14, we have developed a survey aimed at carers of patients with a confirmed diagnosis of dementia. This survey seeks to test the support services we provided to carers. The results from the surveys are collated monthly and we have now developed an action plan to improve the services we offer.

Performance Data

We worked with partners to create the Dementia Working Group in April 2013. The group agreed the content of the carers’ survey in May 2013. It was agreed that the best approach was to initiate a two-stage process. Firstly, a short survey, made up of four questions to be carried out when the patient was in hospital. It was acknowledged that carers' time was precious and that asking them to commit to completing a more detailed survey at this point was unlikely to be successful.

In an attempt to elicit more comprehensive data, an option was added to the short form survey asking if carers would be willing to participate in a more detailed extended survey. Both surveys ask for feedback on how supported the carers felt and how we could improve services. It also signposted carers to attend the Trust’s “Looking After Me” course.

Working with Herefordshire Council and Herefordshire Carers Support, we have been making sure that information about our services, and those in the community are distributed with the extended survey. This is to highlight support services available across the county for carers.

The questionnaires were distributed around wards in the County Hospital and handed directly to carers of patients with a confirmed diagnosis of Dementia/Alzheimer’s on admission.

Questionnaires Returned

The number of short questionnaires returned during this time was 128. Out of the 44 longer questionnaires handed out, the number returned was only 12 which equates to 27.2%. The initial results were disappointing as carers appeared reluctant to complete the questionnaires whilst patients are in the hospital setting. A revised approach to the collection of the data which involves telephoning carers has improved the number of responses the Trust has received and has also helped the Trust to initiate some important changes.

Lessons Learned/Areas identified for further improvement

 Development of a Dementia Working Group in May 2013  Improved literature for carers.

 More joint working with local care homes.

 A carer has joined our Patient Involvement Group.

The development of a robust feedback process in relation to the support Wye Valley NHS Trust provides to carers will formulate part of the national CQUIN targets for 2014/15.

2.1.10 Compliments

The Trust receives hundreds of compliments each month, mostly about staff and care received. Each ward and department provides the number of compliments received each month to the Patient Experience Team (PET), together with some examples of the type of compliments received. This information is included in the Service Unit performance data. Compliments are often sent directly to the PET or through the website ‘feedback’ page. Compliments received through the Chief Executive’s office are also forwarded to the PET. Compliments data is displayed in each ward as part of their quality dashboard.

Performance Data

 From 1April 2013 to 31 March 2014, the Trust has received 5026 compliments.  The vast majority of compliments relate to quality of care and helpfulness of staff.  The Wards and Departments receiving the most compliments during the year were:

- Teme Ward (364) - Monnow Ward (321) - Ross Community

Hospital (301)

 Compliments data forms part of the quality dashboard, which is visible in all ward areas.

Key Achievements

The number of compliments collected has increased from the previous 12-month period.

Key messages from compliments are used to identify good practice and are regularly reported in the Trust’s

Team Brief, which is delivered to staff directly by the Chief Executive.

Lessons Learned/Areas identified for further improvement

Although the Trust records number of compliments received by area, there is little analysis of the data. It is important that wards and departments learn from positive feedback as well as negative and further work will be taken to share and learn from the data more widely across the Trust.

An increased focus on collating this form of feedback from our community teams is planned.

2.1.11 Concerns

Patients and service users often wish to give feedback in an informal way or require advice or assistance to help them. The PET provides on the spot assistance and advice and is based at the main reception at the County Hospital, Hereford making the service very visible and accessible.

Ward Metric Posters

New ward posters have been introduced this year to provide more detail to staff and the public on ward metrics. These metrics include; complaints, compliments, medication errors, patient falls and pressure ulcers. In addition, the posters include any action taken by the ward to make improvements following incidents and feedback from patients and the public. The Trust is looking to further develop these

throughout 2014/15 and introduce the use of ‘huddle boards’.

Patients and the public can access PET through a variety of methods, including face-to-face, telephone, letter and through the website address ‘Making Experiences Count’. The service covers the whole of the Trust, including community hospitals and community services.

   Often patients contact PET with concerns but do not wish to make a formal

complaint. They wish to feedback their experiences to those involved and ultimately improve services for other patients or may require ‘real time’ assistance to improve the situation they are in

 The service is patient centred and the PET will work with the individual to agree an outcome and timescale for resolution

 The main difference between PET and formal complaints is the method used – all formal complaints are in response to letters, which only account for 10% of PET contacts.

Performance Data

Between 1April 2013 and 31 March 2014, the PET has dealt with 796 concerns, and 319 comments about services.

The top 5 topics of concern are:  Communication

 Information

 Quality and Safety of Care  Access

 Relationships

The A&E Department received the highest number of concerns, mainly due to length of wait and the effect of capacity issues on the department. Following the introduction of a Clinical Assessment Unit in December, the number of concerns has steadily reduced.

Concerns with respect to communication and information, mainly around issues with outpatient appointments accounted for 37% of all contacts received during the year. Issues dealt with through the PET service with respect to Quality and Safety of Care accounted for 21% of contacts. Wherever possible, PET are involved at an early stage and provide support to patients in order to resolve their concerns on the spot.

Key Achievements

 During the year 30 concerns could not be resolved through the PET service and went on to become formal complaints, this represents just 3.7% of all contacts.

 Developing links with the Learning Disability Nurse has helped with inpatient care.  Following concerns from patients, we co-ordinated a review of all appointment letters

to ensure correct information was included.

 Introduction of the Noise at Night Charter following concerns raised by patients.  Continued to develop good working relationships with staff.

 Problems have been experienced where patients find it difficult to get through to departments with questions about their appointments. Additional staff have been recruited in peak flow areas to specifically answer telephones.

 Following comments received about lack of wheelchairs in the main reception area, further chairs have been provided.

 Developed the interpreting provision service to accommodate increasing demand.

Lessons Learned/Areas identified for further improvement

 Lean assessment of processes for dealing with concerns.  Greater visibility in the community.

 Employment of specialist interpreters to support patients whose first language is not English.

 Development of e-learning package for customer care, in conjunction with the Professional Development Team.

 Patients being able to speak with staff about their areas of improvement.  The introduction of a Clinical Assessment Unit has resulted in a decrease in

concerns relating to waiting times in Accident and Emergency.

2.1.12 Complaints

On the 1st May 2013 a revised complaints process was introduced within Wye Valley NHS Trust. The revised process encourages more Service Unit ownership in relation to the formulation of open and appropriate responses to a complaint.

When a complaint is received it is reviewed and assigned a grade (red, amber or green) through a triage process concerning seriousness. The complaint is logged on an electronic risk system called Datix and sent to the relevant Service Unit in accordance with agreed timescales. The complainant receives a written acknowledgment with anticipated timescales for a full response to their complaint. This is within 25 working days for red and amber complaints and 10 days for green. If the complainant feels that the timeframe is not

acceptable, they are asked to contact the Complaints Team to discuss an alternative date. The complainant receives a written response from the Chief Executive. All complainants are provided with information on how to access the Independent Complaints Advocacy Services (ICAS) and details of the Parliamentary Health Service Ombudsman (PHSO) who they can contact for a review of their case should they be unhappy with the Trust’s response.

A complaint is defined as an expression of dissatisfaction that takes longer than 48 hours to resolve or where the individual clearly states that they are making a complaint. A formal complaint is an expression of dissatisfaction usually in writing to the Chief Executive and the complaints wishes to receive a written response through the NHS complaints procedure. General concerns are those that take longer than 48 hours to resolve or where the individual clearly says that they do not wish to make a complaint.  

Performance Data  

The Trust has received 242 complaints as compared to 266 in the period 2012/13.

Service Unit Comparison

The number of complaints received by other Trusts in the Arden, Herefordshire and Worcestershire areas.

18 complaints have been referred to the PHSO of which two have been upheld and three have been partially upheld. The PHSO felt that there was not enough evidence to proceed with an investigation with regard to one complaint and the Trust is currently awaiting the outcome of twelve cases.

Trust Complaints received 2012/13

Worcestershire Health and Care NHS Trust 295 South Warwickshire NHS Foundation Trust 214 George Eliot Hospital NHS Trust 293 Worcestershire Acute Hospitals NHS Trust 707 University Hospital Coventry and Warwickshire 483

Top 5 Themes

The table below demonstrates the top five themes highlighting the highest number of complaints received is with regard to the quality and safety of care.

Wards and departments that have received five or more complaints April 2013 to March 2014

  The Trust is working to address those areas which have been highlighted as areas of concern, noting its values include:

 People First

 Passion for excellence  Personal responsibility  Pride in our team

Particular areas of concern include Accident and Emergency Department and Maternity. The Trust also received a high number of complaints regarding Car Parking

 A new compassionate caring vision for nurses launched nationally, is being rolled out across the Trust. The vision is based around six values – care, compassion, courage, communication, competence and commitment. The vision aims to embed these values, known as the Six C’s, in all nursing, midwifery and care-giving settings throughout the NHS and social care to improve care for patients. This was launched at the annual public meeting in July 2013.

 Accident and Emergency developments include: - Improved feedback to patient waiting times

- Greater utilisation of television screens to provided up to date information to patients

- Clinical Team providing records to patients as opposed to Reception staff.  Opening of the new Clinical Assessment Unit to aid the flow of patients requiring

urgent assessment, diagnosis and treatment

 Delivery of the implementation plan following the National Maternity Engagement Survey

Key Achievements

The Trust has worked hard to embed the new complaints process which has included the appointment of a new Patient Experience Officer to manage the process. Training sessions regarding the production of draft response letters has been offered to all staff who may potentially be involved in providing complaint responses and meetings.

A patient-led forum held on the 20th November 2013 sought to identify what were the most important factors to delivering a service that patients would wish to recommend to their friends and family. The feedback from this session was considered in the delivery of the Quality and Safety Strategy for 2014 -17.

Specific examples of learning from complaints include:

Ward/Department Complaint Actions Taken

Accident & Emergency Poor attitude of receptionist All reception staff have been

reminded of correct procedures whilst at the reception area and additional training has been provided to the team.

Accident & Emergency Locum junior doctor had not

picked up the fracture to neck when reviewing x-rays.

Introduction of a priority in-tray for returning x-rays to ensure they are processed in a timely manner.

Paediatrics Child’s operation cancelled

at the last moment due to undetected allergy.

A review of the Children’s ENT pathway in regards to preoperative assessments has taken place. The patient literature is being reviewed to ensure all information is captured in advance to avoid cancellations on the day of surgery.

Surgical Admissions Unit

Concerns about

environment pre-operatively in Surgical Admissions Unit

Pre-operative assessment team to review and amend current

information provided to patients and their families for admission, including the environment and purpose of the Surgical

Maternity Failure to identify urine retention following birth of baby

The postnatal management of the bladder will be considered at staff up-date sessions to raise the awareness of this condition.

Lessons Learned/Areas identified for further improvement

formulated from telephone conversations, emails and letters sent to the Complaints Manager from a number of sources which was often disjointed and defensive in nature.

The Trust must continue to encourage Service Units to take ownership of complaints to include personal contact with complainants to discuss their concerns in a more patient centred way. Assurance must be given to complainants that their complaint has made a difference in preventing reoccurrence. The complaint process must strive to be as independent as possible.

2.1.13 Claims

Claims Background

Claims fall into four categories, which are as follows:  Clinical Negligence (patient claims)

 Employers’ Liability (staff claims)

 Public Liability (visitors, contractors etc.)

Car Parking

Car Parking charges at the County Hospital Site were increased January 2013. The car parking charges at the County Hospital are set within the schedule of rates (Schedule 10) as part of the PFI Contract that is managed by Mercia Healthcare, sub-contracted to CP Plus.

These parking charges cover the cost of managing and running the car parks, which includes parking attendants to prevent shoppers and commuters taking up parking spaces intended for use by patients and visitors attending the hospital. The Trust has urged the company to keep down the costs and has tried to influence this by continuing to offer a range of concessions to help cover the additional cost incurred to the patient attending the hospital for treatment. To ensure the public are aware of the concessions available they are published on the hospital web site and notices by all pay and display machines. Also the public are informed to speak to staff on hospital receptions desks they have been fully briefed on what concession is available and whether they are eligible to receive them.

The Trust is also committed to sustainable travel and operates a travel plan which ensures and encourages alternative methods of travel to the hospital

.

 Property Expenses (anything related to Trust property)

NHSLA Risk Pooling Schemes

The Trust is a member of the following National Health Service Litigation Authority (NHSLA) Schemes:

 Clinical Negligence Scheme for Trusts (CNST)

 Liabilities to Third Parties Scheme (LTPS) and Property Expenses Scheme (PES) [known collectively as the Risk Pooling Scheme for Trusts (RPST)]

The costs of the scheme are met by membership contributions. The projected claim costs are assessed in

advance each year by professional actuaries. Contributions are then calculated to meet the total forecast expenditure for that year. Individual member contribution levels are influenced by a range of factors, including the type of Trust, the specialities it provides and the number of “whole time equivalent” clinical staff it employs.

Performance Data

CNST Claims:

There has been a systematic increase year on year of NHSLA clinical negligence claims. The table below shows the number of claims opened in the financial year (April 2013 to April 2014) with a breakdown by Service Unit.

This year we received 36 CNST clinical negligence claims compared to 17 in 2012/13.

Service Unit Total

Elective Care 22

Integrated Family Health Services 7 Urgent Care/ Care Closer to Home 7 Total for Wye Valley NHS Trust 36  

You can see from this table that the Elective Care Service Unit received the highest number of Claims this year.

Of the Elective Care claims 6 had been classified as diagnosis failed or delayed, 15 had concerns with their treatment/procedure and 1 involved treatment from a medical device.

NHSLA

2013/14 saw the NHS LA change its

approach to the risk management standards and assessment process and as a result of this, undertook a limited assessment programme during the period of 1st April 2013 to 31st March 2014.

However they have continued to work with their members, to ensure that any revised process is focused on helping organisations reduce harm to patients and the number and cost of claims they receive.

Comparison of the Trust against the National Average Relating to Clinical Negligence Claims              

Key Achievements 

Within the Trust there has been improved triangulation of data between Claims, Complaints and the Incidents. This eliminates some unnecessary duplication (for example clinician’s comments) and the sharing of information between departments can lead to a more thorough and timely investigation particularly relevant for Claims.

A bi annual report is produced and presented to the Quality Committee to provide assurance in respect of the Trusts compliance with National Health Service Litigation Authority

(NHSLA) guidelines and Pre-Action Protocol for Resolution of Clinical Disputes.  

Clear and concise documentation in relation to the information written in medical records has been identified as an area which needs to be improved to enable thorough investigations into Claims.

2.1.14 National Cancer Patient Experience

Survey

The National Cancer Patient Experience Survey (NCPES) is one of the largest cancer survey programmes in the world.

The 2012/13 NCPES Survey follows on from the successful implementation of the 2010 and 2012 NCPES, designed to monitor national progress on cancer care. The 2013 survey is congruent with the National Operating Framework (NOF) for the NHS 2012/13, which measures performance against: safety, effectiveness and patient experience. The NCPES provides information that can be used to drive service improvement, delivery and

commissioning and is consistent with the objectives of NHS policy.

The NCPES survey includes all adult patients (aged 16 and over) with a primary diagnosis of cancer who had been admitted to an NHS hospital as an inpatient or as a day case patient, and had been discharged between 1 September and 30th November 2012. The three-month eligibility period for data capture purposes is identical to that for the 2010 and 2012 NCPES. Postal surveys were sent to patients’ home addresses following their discharge. Up to two reminders were sent to non-responders. A freepost envelope was included for their replies. Patients could call a free telephone line to ask questions, complete the questionnaire verbally, or to access an interpreting service.

We sent out surveys to 214 eligible patients and 135 questionnaires were returned. This represents a response rate of 66%. The national response rate was 64% (68,737

respondents). In 2012 the national response rate was 68%.

Performance Data

 The Trust was ranked 35of the 155 Trusts surveyed. In 2011/12 we were ranked 70 of the 160 Trusts surveyed

 The Trust was in the top 20% of Trusts in 20 areas

 The Trust was in the bottom 20% of Trusts on 11 out of 63 scored questions in the survey

Key Achievements

Key areas of improvement against the 2011/2012 survey are:  Overall rating of care:

“excellent/very good” = 91% (5% lower than the highest ranking Trust nationally and a 1% increase on the previous survey)

 Clinical Nurse Specialist (CNS) definitely listened carefully last time spoken to: 97% which was a 6% increase on the previous survey and equalled the highest score of any Trust nationally.

 Patient’s family definitely had an opportunity to talk to the doctor: An improvement from 64% to 81%.

 Hospital and community staff always worked well together:

A significant improvement on the previous two surveys = 73% only 8% below the highest-ranking Trust nationally.

Lessons Learned/Areas identified for further improvement

 Information and communication: on tests, bringing a friend/family member with them, information on side effects.

 Sensitively communicating the diagnosis.  Information on free prescriptions.

 Involvement in cancer research.  Respect and dignity.

 Information given on discharge.

 Availability of the correct information for review appointments in the Outpatient Department.

 Communication and information about the patient’s condition and treatment pattern for the patients GP.

 One of the most striking findings of the 2010, 2012, 2013 surveys is that those patients with a CNS report significantly better overall patient experience (following a recent review of CNS provision in the Trust, a business case has been developed to address a shortfall in Urology).

Following receipt of the survey results, an action plan was developed and presented to the cancer board and service user group

Due to the limited time between publication of the results of this survey and the dates from which the sample of patients for the next survey are drawn it is possible that some of the improvements put in place as a result of this survey will not be demonstrated until the 2014/2015 report is published.

2.2 Safety

2.2.1 WHO Checklist

The aim of the Surgical Safety Checklist is to ensure safe surgery for all patients and aid communication between all members of the clinical team. It was launched by The World Health Organisation (WHO) in response to an identified global risk of patient safety. The checklist includes a number of safety checks, which have to be undertaken at the following stages:

 Before anaesthetic

 Before the surgical operation begins

 Before the patient leaves the operating room

Performance Data

We monitor completion of a checklist on all surgical operations in all of our operating theatres on a continuous basis. Results have shown high levels of completion at 99 -100% throughout 2013/14. Results for each month are shown below:

Month Checklists fully completed

April - 2013 99.18% May - 2013 99.7% June - 2013 99.5% July - 2013 99.7% August - 2013 99.4% September - 2013 99.4% October - 2013 99.5% November - 2013 99.7% December - 2013 100% January - 2014 99.7%  

Results are reported on a monthly basis to heads of relevant departments, clinical directors, the Trust Board and to NHS Herefordshire Clinical Commissioning Group.

Key Achievements

Although levels of completion of the checklist have been high, the aim is to improve wherever possible.

 A World Health Organisation (WHO) “WHO Shield”, showing the number of days with fully completed checklists, is displayed within Theatres and is updated on a daily basis.

 During 2013/14 the Trust developed and implemented a new policy on the use of the WHO Safer Surgery Checklist. The policy requires that any failure to complete the safety checks be reported as a serious incident. This is followed by a full

investigation by a senior member of theatre staff of the circumstances leading to the failure, so that lessons can be learned and actions can be taken to prevent further failures to complete the checklist appropriately.

 A Standard Operating Procedure was developed to provide further guidance to staff on how to undertake the WHO checklist and appropriately report any instances where checks have not been fully performed.

 If the WHO checks are not fully performed, the incident is escalated to the appropriate senior manager through the Trust’s incident reporting system.  A Practice Development Facilitator was appointed within Theatres in 2013/14.

Following a review of WHO Safer Surgery checklist training and competencies, she has rolled out a robust training programme focused on the new policy and

procedures.

 Human factors training has been provided to staff. This is designed to help staff in challenging other members of the team who may not be supporting the WHO process.

Lessons Learned/Areas identified for further improvement