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Queen Elizabeth The Queen Mother Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2016

The Queen Elizabeth the Queen Mother Hospital (QEQM) is one of five hospitals that form part of East Kent University Hospitals NHS Foundation Trust (EKUFT). The Trust provides local services primarily for the people living in Kent. EKUHFT serves a population of approximately 759,000 and employs approximately 6,779 whole time equivalent staff.

The QEQM hospital has a total of 388 beds, providing a range of emergency and elective services and comprehensive trauma, orthopaedic, obstetrics, general surgery and paediatric services.

Following our last inspection of the Trust in August 2015, we carried out an announced inspection between 5th and 7th September 2016, and an unannounced insection on 21st September 2016.

This is the third inspection of this hospital. This inspection was specifically designed to test the

requirement for the continued application of special measures to the trust. Prior to inspection we risk

assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment has led us to include four services (emergency care, medical services, maternity and gynaecology and end of life care) in this inspection.

Overall we rated the Queen Elizabeth, the Queen Mother Hospital as Requires improvement

Our key findings were as follows:

Safe

We rated The Queen Elizabeth, Queen Mother Hospital as Requiring improvement for safe because:

  • There was a shortage of junior grade doctors and consultants across the medical services at the hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service, particularly out of hours and at night.

  • The trust did not use a recognised acuity tool to assess the number of staff needed on a day-to-day-basis.

  • In Maternity, a lack of staffing affected many areas of service planning and the care and treatment of women. This included not meeting national safe staffing guidelines, meaning 1 in 5 women did not receive 1:1 care in labour.

  • We found poor records management in some areas. Staff did not always complete care records according to the best practice guidance.
  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance. The trust did not have adequate maintenance arrangements in place for the 483 medical devices used in maternity and gynaecology.
  • Mandatory training rates for topics such as adult safeguarding and information governance were low.

However

  • We saw robust systems in place for reporting and learning from incidents both locally and trust-wide.

  • Ward and departmental staff wore clean uniforms and observed the trust’s ‘bare below the elbows’ policy. Personal protective equipment (PPE) was available for use by staff in all clinical areas.

  • The hospital was clean and met infection control standards.

Effective

We rated The Queen Elizabeth, Queen Mother Hospital as Requiring improvement for effective because:

  • Documents and records supporting the learning needs of staff were not always competed and there were gaps in the records of training achieved.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision

  • Appraisial rates across the hospital needed to be improved.

  • There was poor compliance in the use of the end of life documentation across the wards we visited which was reflected in the May 2016 documentation audit undertaken by the SPC team.

However,

  • Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • Comfort rounds had been performed and audited. These provided good assurance that pain assessments had been performed, analgesia administered.

Caring

We rated The Queen Elizabeth, Queen Mother Hospital as Good for caring because:

  • Staff treated patients with kindness and compassion.
  • Patients and relatives we spoke with were complimentary about the nursing and medical staff.
  • Patients were given appropriate information and support regarding their care or treatment and understood the choices available to them.

Responsive

We rated The Queen Elizabeth, Queen Mother Hospital as requires improvement for responsive because:

  • Performance indicators such as patients being seen within four hours in A&E remained below trust target and national averages.

  • Delayed discharges remained a concern. However, as part of this response we observed an operational communications meeting, which showed the trust was addressing patient flow through the hospital.

  • The hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.

  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.
  • Services did not always meet people’s needs, for example, women had to divert to another hospital on 22 dates between January 2015 and June 2016. Also, the trust did not monitor the percentage of women seen by a midwife within 30 minutes and a consultant within 60 minutes during labour.

However,

  • The trust employed specialist nurses to support the ward staff. This included dementia nurses and learning difficulty link nurses who provided support, training and had developed resource files for staff to reference. Wards also had ‘champions’ who acted as additional resources to promote best practice.

Well led

We rated The Queen Elizabeth, Queen Mother Hospital as requires improvement for well led because:

  • In some areas risk management and quality measurement were not always dealt with appropriately or in a timely way. Risks and issues described by staff did not correspond to those
  • Where changes were made, appropriate processes were not always followed and the impact was not fully monitored in maternity and gynaecology services
  • No separate risk register was available for palliative /end of life care. A separate risk register would allow the risks to this patient group be discussed regularly at the end of life board, and allow plans to be made to alleviate any identified risks.
  • Changes in leadership in end of life care and maternity services had only recently been realised and as a result had yet to fully
  • address the issues relating to these services

However

  • The hospital had well-documented and publicised vision and values. Their vision was to provide ‘Great healthcare from great people’, with the mission statement ‘together we care: Improving health and lives’. These were readily available for staff, patients and the public on the trust’s internet pages, posters around the hospitals and on the trust’s internal intranet.

We saw some outstanding practice including:

  • Improvement and Innovation Hubs were an established forum to give staff the opportunity to learn about and to contribute to the trust’s improvement journey.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure the number of staff appraisals increase to meet the trust target. So that the hospital can assure itself that staff performance and development is being monitored and managed.

  • Ensure the trust’s agreed audit programme is completed and where audits identify deficiencies that clear action plans are developed that are subsequently managed within the trust governance framework. To have assurance that best practice is being followed.

  • The trust must ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes medical, nursing and therapy staff.

  • Ensure there are systems established to ensure there are accurate, complete and contemporaneous records are kept and held securely in respect of each patient.

  • The trust must ensure that all staff have attended mandatory training.

  • The trust must ensure that there are adequate maintenance arrangements in place for all of the medical devices in clinical use.
  • The trust must take steps to ensure the 62-day referral to treatment times for cancer patients is addressed so patients are treated in a timely manner and their outcomes are improved.
  • Ensure there are sufficient numbers of midwives to meet national safe staffing guidelines of 1:1 care in labour.
  • Ensure maternity data is correctly collated and monitored to ensure that the department’s governance is robust.

In addition the trust should:

  • Review the physical environment within maternity services to ensure it meets the needs of the patients. Specifically temperature control
  • Ensure that the trust programme to improve overall culture also focuses on individual cases of bullying and harassment.
  • Continue to reduce the number of bed moves patients experienced during their stay.
  • Monitor ambient room temperatures where medication is stored.
  • Review the maintenance of medical devises.
  • Include venous thromboembolism data on the department dashboard.

There is no doubt that further improvements in the quality and safety of care have been made since our last inspection in July 2015. At that inspection there had been significant improvement since the inspection in March 2014 which led to the trust entering special measures. In addition, leadership is now stronger and there is a higher level of staff engagement in change. My assessment is that the trust is now ready to exit special measures on grounds of quality, However, significant further improvement is needed for the trust to achieve an overall rating of good.

Professor Sir Mike Richards Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 December 2016

Effective

Requires improvement

Updated 21 December 2016

Caring

Good

Updated 21 December 2016

Responsive

Requires improvement

Updated 21 December 2016

Well-led

Requires improvement

Updated 21 December 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 21 December 2016

We rated this service as requires improvement because;

  • Lack of staffing affected many areas of service planning and the care and treatment of women. This included not meeting national safe staffing guidelines, meaning 1 in 5 women did not receive 1:1 care in labour.
  • The physical environment was not conducive to the safe care and treatment of women. The department was intolerably hot, with patients visibly struggling with the heat. The trust rated unworkable temperatures as ‘low severity’ when reported by staff.
  • Hospital management did not ensure robust governance, for example, hospital data of the number of surgical abortions was incorrect as figures included women who had miscarried and had a surgical evacuation.
  • On our previous inspection, we found there was an ingrained bullying culture within women’s services. This had since improved, however, the trust focused on overall culture rather than tackle individual cases.

However;

  • Staff provided a caring, empathetic environment for women during their pregnancy and labour.
  • Care and treatment was evidence based and patient outcomes were in line with other trusts in England.

On this inspection we have maintained the rating as requires improvement from the last inspection

Medical care (including older people’s care)

Good

Updated 21 December 2016

We found the medical services at the QEQM Hospital good because;

  • The trust had a robust system for managing untoward incidents. Staff were encouraged to report incidents and there were processes in place to investigate and learn from any adverse events. The hospital measured and monitored incidents and avoidable patient harm and used the information to inform priorities and develop strategies for reducing harm.
  • The trust prioritised staff training, which meant staff had access to training in order to provide safe care and treatment for patients.
  • There were systems in place to maintain a clean and therapeutic environment. Staff effectively managed infection control and maintained the environment appropriately.
  • Medical care was evidence based and adhered to national and best practice guidance. Management routinely monitored that care was of good quality and adhered to national guidance to improve quality and patient outcomes.

  • Patients were supported through consultant led care and effective delivery of care through multidisciplinary teams and specialists. There were clear lines of accountability that contributed to the effective planning and delivery of patient care.

  • Staff treated patients with kindness and compassion.
  • The trusts average length of stay for both elective and non-elective stays were better than the England average for the majority of medical specialities.
  • There was good provision of care for those living with dementia and learning difficulties. There were support mechanisms and information available to take individual patients needs into account.
  • The trust had clear corporate vision and strategy. The trust included the opinions of clinicians, staff and stakeholders when developing the strategy for medical services. Staff felt engaged with the direction of the trust and took pride in the progress they had made to date.
  • The trust had clearly defined local and trust wide governance systems. There was well-established ward to board governance, with cross directorate working, developing standard practices and promoting effective leadership. The trust acknowledged they were on an improvement journey and involved all staff in moving the action plan forward.

However

  • There was a shortage of junior grade doctors and consultants across the medical services at the QEQM Hospital. This meant that consultants and junior staff were under pressure to deliver a safe and effective service particularly out of hours and at night.
  • We found there were nursing shortages across the medical services. The situation had improved due to the use of agency and bank staff. Although the trust had recruited overseas nurses, there remained staffing shortages on the wards.
  • Staff did not always complete care records in accordance with best practice guidance from the Royal Colleges. We found gaps and omissions in the sample of records we reviewed. The trust did not have a robust system in place to audit, monitor and review care records to ensure they always gave a complete picture of the assessments and interventions undertaken.
  • The trust did not have adequate maintenance arrangements in place for all of the medical devices in clinical use. This was a risk to patient safety and did not meet MHRA (Medicines & Healthcare products Regulatory Agency) guidance.

  • The trust had not completed its audit programme. This meant the hospital was not robustly monitoring the quality of service provision. The hospital performed poorly in a number of national audits such as the stroke and diabetes services.
  • We found that the hospital was not offering a full seven-day service. Constraints with capacity and staffing limited the responsiveness and effectiveness of the service the hospital was able to offer.
  • Patients’ access to prompt care and treatment was worse than the England average for a number of specialities. The trust had not met the 62-day cancer referral to treatment time since December 2014. Referral to treatment within 18 weeks was below the 90% standard as set out in the NHS Constitution and England average for six of the eight specialties from June 2015 to May 2016.

  • The hospital had improved the number of bed moves patients had during their stay. However, a fifth of all medical patients moved wards more than once during their stay. This meant the hospital transferred some patients several times before they had a bed on the right ward, which put additional pressures on the receiving wards.

At our last inspection, we rated medical services as Requires improvement. On this inspection we have changed the rating to good because of improvements in incident reporting, staff training, infection control, staff engagement and ward to board governance.

Urgent and emergency services (A&E)

Requires improvement

Updated 21 December 2016

  

We rated the urgent and emergency services provided at QEQM Hospital as requires improvement because:

  • Some systems and processes were not always reliable, such as monitoring training implementation. Mandatory training rates for topics such as adult safeguarding and information governance were low.
  • Major incident training rates were low although we acknowledge that another training session had been booked for later in September.
  • Staff appraisal rates, although better the other A&E locations, were still below the trust target. Lower completion rates make it difficult for the department to assure itself that staff performance and development is being monitored and given sufficient attention.
  • Auditing had improved since our last visit, although we found that action plans were not always submitted in a timely manner and where there was an action plan the actions were not always fully implemented or communicated throughout the department. This meant the department did not have full assurance that best practice was being followed or that problems were being identified quickly enough.
  • Delivery of performance indicators such as patients being seen within four hours remained below trust target and national averages.
  • Delayed discharges remained a concern due to the impact on the A&E. However, as part of this response we observed an operational communications meeting, which showed the trust was addressing patient flow through the hospital and monitoring closely for risks that affected beds available for receiving patients from the department.
  • A range of positive initiatives have been implemented in this department along with others we observed at similar sites in the trust. Further harmonisation and sharing of best practice between all A&E locations would benefit patients and staff.

However,

  • We found ambulance handover breaches exceeding 60 minutes averaged 43 per month over the last four months (July – October 2016). This represented 2.4% of the total number of patient handovers and was better than the regional average of 3%.
  • We saw significantly improved figures for children’s safeguarding training for all staff groups, including doctors, and there were robust safeguarding systems in place for children.
  • Apart from adult safeguarding and DoLs/MCA, the figures for mandatory training had improved since our last visit and were near or above trust targets for all staff groups, including doctors.
  • We saw improvements in the way the department and the wider trust managed incident reporting and complaints. Lessons learned were widely communicated using a number of information systems.
  • Patients’ treatment and care was delivered in accordance with their individual needs. Patients told us they were treated with dignity and respect. People’s concerns and complaints were listened and responded to and feedback was used to improve the quality of care.
  • Medicines were stored safely and checks on emergency resuscitation equipment were performed. Incidents and adverse events were reported and investigated through robust quality and clinical governance systems. Lessons arising from these events were learned and improvements had been made when needed.
  • The leadership, governance and culture within the departments were generally strong and we saw examples of good practice regarding visibility of supervisors, rounds and communication. Staff were supported by their managers and were actively encouraged to contribute to the development of the services.

On this inspection we have maintained the rating as requires improvement since the last inspection.

Surgery

Requires improvement

Updated 18 November 2015

Whilst most areas in which surgical services were provided were suitable, the day-care theatre environment was not wholly safe. Fire safety arrangements within the main theatres was not sufficient, and there was a lack of risk assessment and consideration with this regard. Evacuation equipment was not available and staff had not been trained to the required standards. Some of the required safety checks were not being undertaken.

Although recruitment continued to be difficult, staffing arrangements did not always reflect the requirements, particularly when additional surgical beds were opened above the funded capacity. 

Staff had not completed all the required mandatory training, which supported the delivery of safe treatment and care, and there was no formal evidence of ward staff having been trained in safeguarding vulnerable adults.

Arrangements for reporting adverse events and for learning from these had been improved.

Theatre utilisation was not always maximised and referral to treatment times were not always achieved.

Patient flow through the surgical services was adversely affected by availability of beds. This was linked to delayed discharges associated with provision of on-going support, rehabilitation and delays in take home medication. 

Consent was sought from patients prior to treatment and care delivery. Consultants led on patient care and specialist staff and allied healthcare professionals participated in the delivery of treatment and care.

Procedures were in place to continuously monitor patient safety and surgical practices and patient care reflected professional guidance. Surgical outcomes were generally good and results were communicated through the governance structure to the Trust Board.

Patients commented positively on their experiences. They said they received kind and compassionate care, which maintained their dignity and respected them as individuals.

The surgical staff spoke positively about the leadership at departmental level and felt respected and valued. Staff understood the trust's values and recognised that there had been many changes, which had contributed positively to the change in culture they now experienced.

The governance arrangements supported effective communication to staff and the Trust Board. Identified risks were continuously reviewed and discussed and information was communicated with respect to service delivery and performance. The views of the patients and staff were sought with a view to improving and developing the services.

Intensive/critical care

Good

Updated 18 November 2015

We found appropriate and effective reporting and learning from incidents and Morbidity and Mortality (M&M) meetings. Patients were cared for in a clean, well maintained and safe environment. Staff demonstrated good awareness of infection control and there were systems in place to minimise the risk of health acquired infections.

Staffing levels were sufficient to meet people’s needs and consultants provided cover in line with the national recommendations. There was also adequate access to diagnostic and screening services out of hours. The care delivered in the unit reflected best practice and national guidance. There were systems in place to measure patient outcomes and the quality of the service provided. Care needs were risk assessed and the unit could demonstrate a track record of delivering harm free care. The CCU had procedures in place to ensure the safe storage, handling and management of medicines. Documentary evidence demonstrated that patients received their medicines in a timely manner and reasons for omission were clearly documented. Pharmacy support was provided as well as regular reviews and internal audits. Safety thermometer data was collected and collated and used to improve and drive service change. Data was displayed in a public area which meant it could be accessed by those who wished to view it. We found an adequate supply of serviced equipment to enable staff to care for their patients.

Staff demonstrated an established approach to multidisciplinary working with other specialists in the Trust and showed us how they could obtain treatment and care for patients with complex needs, including psychology assessments. The needs of people with delirium or dementia were met by well-educated staff but the Confusion Assessment Method for ICU (CAM-ICU) was not routinely used as an assessment tool. Training was provided on a rolling basis for nursing staff and a dedicated team ensured that trainees and new students were well supported and had the opportunity to develop. Leadership on the unit was found to be strong and effective.

Services for children & young people

Requires improvement

Updated 18 November 2015

The children’s and young people’s service at Queen Elizabeth The Queen Mother Hospital (QEQM) requires improvement.

We found the safe and well-led domains required improvement. We identified some potential risks to children’s safety due to an insufficient number of nursing staff in Rainbow ward and in the Special Care Baby Unit (SCBU).

We noted a large number of incidents reported on Datix had not been investigated in a timely manner and there were concerns that themes from these incidents had not always been examined so that lessons could be learnt.

Paediatric early warning score charts had not always been completed correctly. This was a serious concern because these charts were used to identify patients in urgent need of medical intervention. This meant that critically ill patients might not have received appropriate care and treatment in a timely manner.

There had been no never events and two serious incidents over a one year period. The latter had been thoroughly investigated and lessons had been learnt. The second of the serious events was attributed to a rare complication of an infection and was not caused by suboptimal care.

The environment was reasonably clean and tidy. There had been no incidents of C. difficile or MRSA infection. However, the building was not always kept in a good state of repair.

Staff had received mandatory training. However not all medical staff had received level 3 training in safeguarding, which was a statutory requirement.

We found gaps on the checklist for the resuscitation trolley in June and July 2015. The trolley had not always been checked daily and this had potentially exposed patients to the risk of serious harm, if an apparatus required for resuscitation had gone missing or was not in good working order.

There was consultant cover seven days a week and all acute patients saw a consultant within 24 hours.

Staff had yearly appraisals and felt supported by their line managers, including newly qualified staff and junior doctors. Mentorship was in place for student nurses, who had good learning opportunities.

Staff had access to trust policies and procedures, which were in line with national guidance. Some national clinical audits had been undertaken and improvements had been made in clinical practice as a result.

There was effective multidisciplinary working, both within the trust and with external services.

Patients had open access to the Child Care Unit, once they had been referred by the family doctor. This meant patients did not have to wait long to be seen and parents felt there was continuity of care on the children’s ward.

Mothers of babies in the SCBU were complimentary about the medical and nursing staff and felt their baby had received appropriate care and treatment. Staff treated patients and their family with respect and dignity and were compassionate in providing care.

In view of the various concerns raised, such as a prolonged period with insufficient staff numbers, delay in reviewing incidents reported on Datix and slow response in addressing issues raised, we considered senior managers had not acted fast enough to rectify the shortfalls and to ensure patients received safe and appropriate care at all times.

End of life care

Requires improvement

Updated 21 December 2016

Overall, we rated the end of life care services at the trust as requires improvement, because:

  • The trust’s Specialist Palliative Care (SPC) team demonstrated a high level of specialist knowledge. A strong senior management team who were visible and approachable led them. The SPC team provided individualised advice and support for patients with complex symptoms and supported staff on the wards across the hospital. However, the SPC team were small and there were concerns regarding the sustainability of the service. We noted the planned improvements and the implementation of the end of life strategy would be difficult to apply due to the current available resources.
  • We found an array of service improvement initiates had been introduced across the trust since the last inspection. This included end of life care plan documentation, the appointment of an end of life facilitator, identification of end of life care link nurses, a decision making end of life board with a membership of healthcare professionals from a variety of specialties within the trust and external stake holders. There was a slot at QII hub to spread the work and raise the profile of end of life care. All service improvements were based on national guidance. However, we found changes were recently implemented and more time was required to embed the changes into clinical practice, upskill staff and provide a robust training and education programme to ensure end of life care was delivered following national recommendations.
  • Since the last inspection, we found the training of junior and speciality doctors had improved with the SPC team invited to divisional meetings to present and raise the profile of the importance of good end of life care conversations and symptom control. We saw clinical leads championed end of life care. However, further work was required to strengthen the collaboration of working with consultants.
  • Staff told us that since the last inspection end of life care had a much higher profile across the trust. However, we found on the wards that ceiling of treatments were not generally documented, poor completion of nursing notes which made it difficult to access if patients were being reviewed regularly. There were no mental capacity assessments in place for vulnerable adults who lacked capacity. Where a patient was identified as dying it was often confusing for staff as in many cases interventions were still being delivered.
  • End of life training was not part of the mandatory training programme. We found some nursing staff on the wards had received training whilst others had not. Wards struggled with staffing levels and there were no extra staff in place to support end of life care.
  • 100 link nurses had been identified as leads on end of life care at ward level. By November 2016, training of the link nurses was expected to be complete. However, more time was required for the link nurses to settle into their new roles, to support their colleagues, and improve quality. We found the end of life resource folders were available on the wards. These folders contained the necessary documentation for staff, which was an improvement since the last inspection.
  • The trust had access to the Medical Interoperability Gateway (MiG) system that enabled the trust to view, with consent, patients’ GP records meant that this information was available 24/7.However, this system did not allow the trust to update records or input care plans. No electronic palliative care record system was in place where providers shared information.
  • A fast track discharge process was in place. However, staff told us the process was not fast with some patients taking weeks to be discharged to their preferred place of care (PPC). Whilst work had been undertaken to improve the process since the last inspection, further work was required to ensure patients could be discharged within hours to their PPC.

On this inspection we have maintained a rating of requires improvement.

Outpatients

Good

Updated 18 November 2015

The Outpatient department was well led and had improved since implementing an outpatient improvement strategy. Despite the strategy being relatively new, the department was able to evidence improvements in health records management, call centre management, referral to treatment processes, increased opening hours, clinic capacity and improved patient experience through structured audit and review.

Although there was still improvement required in referral to treatment pathways, the outpatients department and trust demonstrated a commitment to continuing to improve the service.

As a part of the strategy, the trust had reduced its outpatient services from fifteen locations to six. We inspected five of these locations during our visit.

Managers and staff working in the department understood the strategy and there was a real sense that staff were proud of the improvements that had been made. Progress with the strategy was monitored during weekly strategy meetings with the senior team and fed down to department staff through staff meetings and bulletins.

Outpatients and diagnostic imaging departments at Queen Elizabeth Queen Mother Hospital were providing safe care to patients. There were systems in place, supported by adequate resources to enable the department to provide good quality care to patients attending for appointments.

Evidence based assessment, care and treatment was delivered in line with National Institute for Health and Care Excellence (NICE) guidelines by appropriately trained and qualified staff.

A multi-disciplinary team approach was evident across all the services provided from the outpatients and diagnostic imaging department. We observed a shared responsibility for care and treatment delivery. Staff were trained and assessed as competent before using new equipment or performing aspects of their roles.

We saw caring and compassionate care delivered by all staff working at outpatients and diagnostic imaging department. We observed throughout the outpatients department that staff treated patients, relatives and visitors in a respectful manner.

Nurse management and nursing care was particularly good. Nurses were well informed, competent and went the extra mile to improve the patient’s journey through their department. Nurses and receptionists followed a ‘Meet and Greet’ protocol to ensure that patients received a consistently high level of communication and service from staff in the department.