Patient Advice and Liaison Service (PALS) Policy and Procedure
Responsible Directorate:
Corporate Services
Responsible Director:
Helena Corder
Date Approved Committee
8 August 2008 Governance Committee
Version Control Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible for revision Primary Circulation List Web address Restrictions
PALS Policy and Procedure 1 Kirsty Wayman 1 August 2008 August 2011 Kirsty Wayman
None
Standard for Better Health Map. Domain Domain 1 Safety, Domain 3 Governance Core Standard Reference C1a&b, C7a&b, C10a&b, C11a Performance Indicators 1. Exception reports 2. Performance Advisory Group Minutes 3. Decision Making Group Minutes (as necessary)
Contents Section 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Policy Statement Introduction Associated Policies and Procedures Aims and Objectives Scope Accountabilities Service provided by PALS Procedure for dealing with PALS queries Queries made in person or by phone Queries made in writing Concerns relating to other organisations Interagency PALS issue process Formal complaints Equality Impact Assessment Training needs analysis Monitoring and compliance Stakeholder involvement
Page 2 2 2 2 2 2 3 3 3 4 4 4 4 5 5 5 6
Appendices A Flowchart for dealing with PALS enquiries B Equality Impact Assessment Tool
Page 1 of 10
1. Policy Statement The Trust is committed to ensuring that patients, carers, relatives and members of the public have access to information about the provision of health services and that they are able to raise concerns about any services or individual and will not be treated any differently as a result. 2. Introduction. The purpose of this document is to detail the process for ensuring that patients, relatives and their carers have suitable and accessible information about, and clear access to, procedures to raise concerns informally via the Patient Advice and Liaison Service (PALS) which is managed as part of the Patient and Public Involvement Team (PPI). PALS and PPI is considered by the Trust to be an important tool used to listen to the views and concerns of patients and the public which in turn aids the process of continuous improvements to health care services and patient experience. 3. Associated Policies and Procedures. This document should be read in accordance with the following Trust policies, procedures and guidance. • • • • •
Complaints Policy Claims policy Records management policy Consent policy Communications Strategy
4. Aims and Objectives. The Patient Advice and Liaison service aims to: 1) 2) 3) 4)
Advise and support patients, their families and carers. Provide information on NHS services. Listen to patients’ concerns, suggestions or queries. Help resolve problems quickly.
5. Scope of the Policy &Procedure This policy and procedure is primarily aimed at PALS and PPI staff but must be followed by all NHS Kirklees employees and staff on temporary or honorary contracts as well as bank staff and students. The document is provided for contractor staff as a guide to best practice. 6. Accountabilities & Responsibilities The Chief Executive has overall accountability for ensuring that the Trust has in place an effective and robust PALS system in line with NHS guidance and best practice. The CE devolves the responsibility to the Director of Corporate Services who is supported by the Assistant Director of Communications and Public Relations . The PALS service is directly provided by two PALS Officers and a PPI Co-ordinator (PALS Lead) within the Patient and Public Involvement Team. The PPI Team sits in
Page 2 of 10
the Corporate Services Directorate and is managed by the Head of Public Involvement. The PALS and PPI team work on a regular basis with many different organisations and stakeholders to ensure the service is up to date and fit for purpose. 7. Service provided by PALS PALS act independently when handling patient and family concerns, liaising with staff, managers and, where appropriate, relevant organisations to negotiate immediate or promote solutions. If necessary, PALS can also refer patients and families to specific local or national-based support agencies. PALS ensure that patients, relatives and their carers are not treated differently as a result of raising a concern. The Patient Advice and Liaison Service for NHS Kirklees provides a service for patients public and staff from Monday to Friday 9.30am to 4.30pm with an answer phone being available outside these hours. The PALS team provide posters and leaflets, which are distributed to all independent contractors and key stakeholders. The PALS team can be contacted via the following routes: Telephone: Telephone: Email: Address:
01484 466172 or 01484 466214 0800 5872417 – Dental Registration Line (Automated response) PALS@kirkleespct.nhs.uk PALS NHS Kirklees St Luke’s House Blackmoorfoot Road Crosland Moor Huddersfield HD4 5RH Further information is also available on the Trust’s website: http://www.kirklees-pct.nhs.uk/public-information/patient-advice-liaison-service/
8. Procedure for dealing with PALS queries A PALS query can range from a straightforward request for a telephone number, to an enquiry about support groups or a problem someone has experienced with a service (providing that the problem is outside of the definition of a complaint which is handled through separate procedures). PALS queries are questions that get asked every day. PALS is a formalised approach to dealing with these queries (see appendix A – flowchart for dealing with PALS queries). 9. Queries made in person or by phone The PALS Officer deals with PALS queries made in person or by phone immediately. The PALS Officers make a note of the query and where possible a full response is given immediately. When further advice / information is required to resolve the query the PALS Officers will: Page 3 of 10
a. Gain verbal consent from the user to make enquiries on their behalf with the relevant departments or staff b. Explain to the user what action the PALS Officer will undertake on their behalf c. Agree with the user when and how the PALS Officer will contact them and whether this will be to provide either a full response or a progress report d. Contact an appropriate individual for advice e. Where possible a full response is provided within two working days. If this is not possible the person is advised what action is being taken and the PALS Officer will aim to resolve the PALS query within 25 working days of being logged. 10. Queries made in writing If a query is made by email / letter, a full response, where possible is provided within five working days. If this is not possible an acknowledgement is sent in two working days detailing what action is being taken and that the PALS Officers will aim to resolve the query within 25 working days of being logged. Full details of all queries are inputted onto DATIX system which is the primary recording system for managing PALS, complaints and claims for the Trust. 11. Concerns relating to other organisations Individuals are able to access PALS to raise concerns about any NHS organisation. If the concerns raised by an individual are relevant to other PALS (e.g. acute hospital trust/ambulance trust) a PALS Reporting Form will be completed and sent to the PALS Officer using the Inter Agency process noted below. The PALS Officers will be contacted if there are any queries. 12. Inter-Agency PALS issue process The following process has been developed and agreed by the West Yorkshire PALS teams in conjunction with NHS Yorkshire and Humber. The aim is to provide a process for dealing with PALS issues involving more than one agency and, where possible, to result in a single reply. • The lead will normally be taken, by agreement, by the agency against whom the major component of the PALS issue is made; • Each agency will have a contact officer for liaison, who will co-ordinate any requests for information within the protocol; • PALS issues will be acknowledged by the receiving agency, which will also give the details of who will respond (the caller should be asked if they want the receiving agency or the responsible agency to respond) • If, during the handling of the PALS issue, criticism of another agency is identified, then the way forward will be determined through consultation with that agency; • Issues of confidentiality (eg between agencies, or involving consent from a PALS caller) should be the responsibility of the liaison officers; 13. Formal complaints Whenever possible PALS staff will attempt to resolve any concerns from callers but there will be occasions when this is not possible and the caller may indicate that they wish to pursue a complaint.
Page 4 of 10
In these cases the caller can either be transferred to the Trust Complaints manager or the details of the caller obtained including the reason for the complaint (if known) and the details provided to the complaints manager who then calls the complainant back. Once an agreement has been made with the caller and the appropriate action taken including entering the details on Datix the role of the PALS officers ceases. The role of the PALS in formal complaints is to: • Offer alternative options instead of the formal complaints procedure • Advise on the local complaints procedure • Where appropriate refer to Independent Complaints Advocacy Service (ICAS) 14. Equality Impact Assessment. All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This Policy & was found to be compliant with this philosophy. 15. Training Needs Analysis. As part of the induction process newly appointed PALS Officers receive training on the following areas: • • • • • •
DATIX Filing system: electronic/paper Dental registration line Process for dealing with web based forms Promotion of service Process for undertaking monthly user surveys
On an ongoing basis PALS Officers are encouraged to attend relevant training courses to update their skills, for example: • Telephone skills • Customer care • Listening skills 16. Monitoring Compliance with this Policy & Procedure. Monitoring of the PALS and PPI system is considered to be extremely important to ensure that the quality of the service being provided is of a high standard and to ensure that changes are made as a result of concerns raised. As a result the Trust has in place a number of timed Quality Assurance programmes which are reported to the PPI committees ultimately leading to the Trust Board.
Page 5 of 10
Monthly user survey On a monthly basis all users of the service are sent a “Tell us what you think” questionnaire which provides feedback on the service provided by PALS. This enables PALS to monitor the levels of satisfaction, ensure that queries are dealt with efficiently and appropriately and if there is anything else the service can offer to them. A monthly report is produced and these are discussed at the PPI Team meetings. Any actions are noted within the PPI Team meeting minutes and included within the quarterly report. Quarterly reporting requirements A quarterly report is prepared by the PPI Co-ordinator (PALS Lead) and signed off by the Head of PPI for consideration by the Communications and Public Relations Committee. The quarterly report provides:
A summary of the PALS queries received
Details of any service improvements that have occurred as a result of a PALS query
Details of any promotional or engagement work that has taken place
Results of the monthly user survey “Tell us what you think”
The Communications and Public Relations Committee has responsibility for ensuring that any actions raised in this report are performance managed. Annual report The PPI Co-ordinator (PALS Lead) prepares an annual report on the PALS service to be included in the PPI Annual Report. The report is signed off by the Communications and Public Relations Committee and copies are sent to:
Trust Board
Local Involvement Network
Key stakeholders
Published on NHS Kirklees website
Policy review The PALS policy and procedure will be reviewed on an annual basis by the Assistant Director of Communications and Public Relations who will consider how the policy and procedure has operated and make recommendations for change. The recommendations will be discussed and agreed with the Director of Corporate Services who will performance manage the recommendations via an action plan monitored by the Governance Committee. 17.
Key Stakeholders consulted / involved in the development of the policy & procedure. PPI Steering Group Page 6 of 10
Communications and Public Relations Committee
Terry Service – Assistant Director of Corporate Services and Risk
Policy Development Group
Neill Macdonald - Assistant Director of Medicine Management.
Page 7 of 10
Appendix A Flowchart for dealing with PALS Enquiries Issue raised with PALS If identify issue is a complaint (see below)
Gain consent (verbal or written as appropriate) to make enquiries on their behalf with depts./staff etc
PALS liaise with appropriate staff/dept.
PALS response provided either verbally or in writing
If enquirer remains unhappy
If PALS can process outstanding issue - back to stage 2
If no more PALS can do, explain in writing or verbally option to pursue further via NHS complaints process Advise: • Option to pursue as a formal complaint. If so, advise Complaints Manager that a formal complaint may be received • Advise of ICAS for support – 0845 120 3734 • Time-scale in which to pursue complaint • Consent to pass issue to ICAS or Complaints Dept.
If a complaint • • •
PALS Advisor make contact with enquirer, Explain about role of PALS and NHS Complaints Procedure and give options for issue to be dealt with under either process Advise of ICAS for support – 0845 120 3734 Page 8 of 10
Equality Impact Assessment Tool Appendix B: To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)
2. 3.
4. 5. 6. 7.
(including
gypsies
and
Comments
No No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay and bisexual people
No
• Age
No
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?
No No
No NA NA NA
If you have identified a potential discriminatory impact of this procedural document, please refer it to Human Resources Dept together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources Department
Page 9 of 10