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QUALITYACCOUNT 2013/14

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Our Vision

Putting local patients and families at the heart of everything we do, we will ensure that on the journey towards the end of life, we provide the right care,

in the right place, at the right time

Our Values:

Care – We will provide 1st class care, delivered by competent people who put the patient at the heart of all we doCompassion – We will treat everyone with respect, dignity and empathy Collaboration – We will work with others to ensure that patients and families receive the best end of life care possibleCharity – We will provide care free of charge to patients and families and will connect with our local communities so that they continue to finance our present and our future

St John’s HospiceBuilt by the people, for the people

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Part 1

Chi ef Execut ive’s St at ement

It gives me great pleasure to present this Quality Account for St John’s Hospice. In this account our aim is to show how the Hospice measures quality, involves patients, carers and staff and strives to always look for areas where we can improve our care.

A Quality Account is an annual report to the public from providers of NHS healthcare about the quality of services they deliver. It is important to note that St John’s Hospice only receives around 30% of its funding from the NHS, the rest (£2.7million) is donated by the local community. The majority of services described in this document are funded by charitable donation rather than by the NHS.

Quality sits at the centre of all that the Hospice does. Our vision is that everyone in our catchment area of South Lakeland, parts of North Yorkshire and all of North Lancashire with any life-limiting condition will have high quality care and support at the end of their life in the right place, at the right time.

We asked patients, families, volunteers and staff to sum up in one word what St John’s

means to them. Their key words can be seen here:

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Our Corporate and Clinical Governance structures ensure that we have both the systems and processes in place to maintain a viable and responsible business, whilst ensuring that our services are of the highest quality and meet the aspirations of our vision. Our services are subject to unannounced inspections at any time.

On the 13th February 2014, the Care Quality Commission (CQC) conducted an unannounced inspection of the Hospice. A CQC Inspector and an “expert inspector” specialising in Governance attended. They spent a full day speaking to patients, families and staff and scrutinising records and documentation. The Hospice was judged to be fully compliant in all areas inspected. They said:

“We found there were good systems and processes in place to monitor the quality of the service being provided. Staff told us this was underpinned by an open reporting culture and

strong leadership.”

This year we are proud to have achieved:

An increase in the number of patients being cared for at home An increase in bed occupancy on our Ward A complete review of our policies and proceduresThe joint recruitment of a Palliative Care Consultant in partnership with the local Acute Trust

Our goals for future improvement include:

To move from paper to electronic records, using an IT system that our GP colleagues also useTo implement the findings of a review of food and nutrition throughout the Hospice To gather accurate data and information in order to demonstrate our value to commissionersTo extend our reach into South LakelandTo provide more Day Hospice opportunities for patients

I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information contained in this Quality Account is accurate and a fair representation of the quality of healthcare services provided by our Hospice.

Sue McGraw

Chief Executive

26th March 2014.

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Part 2

Priorities for Improvement 2014/15

The priorities for improvement we have identified for 2014/15 are set out below. These have been developed in conjunction with feedback from patients, carers, staff and stakeholders. We have expressed our priorities in terms of the three domains of quality:

Patient safety Clinical effectiveness Patient experience

Priority 1 – Patient Safety & Patient Experience

Develop a workforce that is “Fit for the Future”

Review of staff competencies, training and the structure of our nursing teams

How was this priority identified?Working with data from Cumbria and Lancashire North CCGs, it is clear that over the next 20 years the profile of the patients we care for will change. We will be faced with increased demand as the population ages, people’s conditions will be more complex as they live with co-morbidities and people’s expectations about the level of the service they receive will rise.

The Help the Hospices Commission into the future of Hospice care has produced a number of important reports for Hospices to consider. These will be reviewed and analysed to ensure that the Hospice is “fit for the future” by ensuring our team has the skills and abilities they will need to care effectively for future generations.

In short, the demand for care at the end of life will rise and the nature of that care will become more complex.

Whilst our workforce is skilled and extremely caring, we need to review whether the competencies we have are the ones we will need for the future. Indeed, we need to consider whether continuing with the current or increased level of employed staff is the right model or whether we can increase/extend the number of volunteers; our volunteer support is strong but volunteers are usually deployed in non-clinical areas, if we are to develop a sustainable model for the future, the potential contribution of clinical volunteers must be explored.

How will progress be monitored and reported?• Develop a “Future Nursing Strategy” which will be monitored by the Care & Quality

Committee• Volunteer roles and recruitment to be reviewed and reported to the Board• Working with partner Hospices, develop a competency framework for staff at all levels

to be applied across all clinical areas and to be monitored by the Board

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Work with the Help the Hospices Commission into the future of Hospice care by taking part in research activities and benchmarking exercises as they arise

Working with partner Hospices to develop a management & leadership programme

How was this priority identified?The demise of the Liverpool Care Pathway in 2013 prompted the hospice to review the provision of food and hydration to patients at the end of life. Reading Baroness Julia Neuberger’s report “More Care, Less Pathway”, it was clear that the withdrawal of food and nutrition from dying patients was a major and traumatic issue for people her team interviewed. We are confident that the poor practice described in Baroness Neuberger’s report does not apply at St John’s, however, the harrowing descriptions in the document led to the CEO commissioning a review of food and nutrition across the Hospice.

The research was conducted in January 2014 by a member of the Board, results and recommendations will be implemented over the coming year.

How will progress be monitored and reported? A food and nutrition steering group will be established, chaired by the Head of

Nursing & Quality with a direct line report to the Board Patient satisfaction surveys will be reviewed to ensure that issues regarding food

and nutrition are captured The Head of Nursing & Quality will ensure that the staff we employ have appropriate

skills training to deliver nutritional advice The Hospice will take part in a national food and nutrition in Hospices research

project

How was this priority identifiedThis was identified as a priority for improvement l a s t y e a r , h o w e v e r , t he pan-Lancashire project stalled and the Hospice’s ability to make progress was delayed by this.

Priority 2 – Clinical Effectiveness

Conduct a Food and Nutrition Review across the Hospice

Ensure that patients’ food and nutrition requirements are met and that staff have the skills and abilities to provide first class nutritional advice

Priority 3 – Safety

Adoption of an electronic patient record system to ensure patients receive safe, effective and consistent care

We will adopt the system used by GPs in both our Commissioning areas

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It became clear that our current team do not have the knowledge, skills and abilities to lead a major IT project so the Board agreed to create a new post, IT and Information Governance Co-ordinator. The Co-ordinator will be responsible for supporting the implementation of the new IT system and for ensuring that our team has the necessary skills to face the “brave new world” of electronic records.

As the hospice is a charity and not part of the NHS, we do not have access to the IT infrastructure that many of our colleagues in the wider healthcare community are currently using. When patients are transferred to us, we have to access paper documentation which is not always available in a timely manner. Equally, on discharge, our colleagues in the community have little or no information immediately. Clearly this has the potential for delay and mistakes in communicating key information which may affect patient safety.

We will adopt EMIS web, the IT system used across GP Practices in South Cumbria and North Lancashire.

How will progress be monitored and reported? A cross healthcare community project group will monitor and report on the

effectiveness of the new system Regular audits will be undertaken Staff will be consulted to ensure they are involved in the development of the project Surveys of partners will be undertaken to ensure that the project is effective Progress will be report to the Care and Quality Sub-Committee who, in turn will

report progress to the full Board

Review of 2013/14 Priorities for Improvement

Ward Improvements

Following a complete refurbishment of the Ward, we have gradually increased bed occupancy to put us in the upper quartile for bed occupancy as guided by the National

Council for Palliative Care Minimum Data Set

ReviewThis refurbishment has been achieved this year but will always be “work in progress”. New beds were purchased with state of the art pressure relieving mattresses – this was achieved by applying for charitable grant funding.

Patients and families have been involved in discussions regarding colour schemes for the refurbishment of the communal areas and ventilation and weather-proofing work has been undertaken.

Simple things such as ensuring the bird-feeders outside the bedroom windows are topped up providing endless interest and entertainment and the provision of well-presented trays at mealtimes, including cloth napkins and individual hand-wipes seem to make the biggest difference for patients.

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Our patient and family survey comments are extremely positive and the CQC inspectors, when they made their unannounced inspection on the 13th February 2014, included the following comment from a service user:

“I can’t fault any aspect. It’s faultless and I don’t say that lightly.”

However, from the staff point of view, space on the Ward is limited. Whilst we make every effort to ensure that patient care is not compromised, equipment is not stored close at hand. Indeed oxygen cylinders are stored in the yard at the back of the Hospice and can be cumbersome for staff to move when needed urgently. As the service gets busier, there is a need to store more large equipment such as beds and hoists. Another sign of a shifting

demographic is the demand for bariatric equipment – since the 1st April 2013, our team has nursed 3 bariatric patients . Our “standard” equipment is not always adequate and it looks likely that we will need to invest in more bariatric equipment in the coming months and years. Again, this is problematic for staff as there are no storage facilities on the Ward. The new Head of Nursing & Quality is working with the Ward team and our Facilities Co-ordinator to address these issues. We will apply for grant funding to support the costs of any building/improvement works that may need to be done to accommodate these changes.

Become the Palliative Care “Hub” for North Lancashire and share our learning with neighbouring commissioning groups

Provide a telephone “hub” and a 24/7 rapid response service in the community for end of life patients in North Lancashire

ReviewThe introduction of this service has been a major success for the Hospice. Patients in the North Lancashire CCG area now have access to specialist palliative care 24 hours a day, 365 days a year. This round the clock service is coordinated from St John’s Hospice and has been part funded by Lancashire North CCG.

The successful Hospice bid for capital bid funding from NHS England was used to support the development of a purpose built space to accommodate the new service. The 24 hour service offers:

Home nursing care and a rapid response service 7 days a week provided by St John’s Hospice nurses between the hours of 7am and 10pmRespite support for carers provided by St John’s Hospice nurses 7 days a week Urgent, “out of hours” care from 10pm to 7am 7 days a week provided by the Marie Curie rapid responseSingle point of access telephone support for referrers, patients and families Bereavement support provided by St John’s Hospice Family Support Team

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To be referred to the service the patient must:

Want to stay at home Be aged over 18Be registered with a GP in the Lancashire North CCG commissioning areaHave end of life needs (any diagnosis) and be experiencing a sudden deterioration in their condition

Have urgent palliative care needs (nursing, social or symptom management- physical or psychological)

Have a carer who is in crisis and needs support

The service was launched fully in June 2013. Since the 1st April 2013, the team have made more than 12,000 face to face visits and handled more than 10,000 telephone calls. Whilst difficult to quantify, we know that the team have helped prevent numerous unnecessary hospital admissions since the service began. A family member wrote to us to say:

“My dear ‘Team’ I can’t thank you enough for all your help, care, concern and support. I have an overwhelming feeling of thankfulness that my Husband was able to die so peacefully at home with all our familiar things around us. It was just as we had discussed and very much hoped would happen. An ending most of us would probably hope for. God bless all of you.”

The introduction of the 24 hour palliative care hub has been a great success in Lancashire North. We are working with Commissioners in South Lakes to identify gaps in end of life care provision. We hope Commissioners in South Lakes may recognise the value of this 24 hour, 7 days a week “hub” model for their area and patients too.

Part 2 (Continued)

Statements of Assurance from the BoardQuality Accounts have a series of statements that MUST be included. Many of these

statements do not apply to St John’s Hospice. Explanations of these statements are given

where appropriate and are prefaced by the words: “MANDATORY STATEMENT”.

During 2013/14, St John’s Hospice provided the following services: In Patient Unit – 17 beds (registered for up to 20) Hospice at Home Service Day Hospice Family Support and Bereavement Service

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COPD/MND/Parkinsons Support Groups Education and Training – Including 6 Steps to Success programme with Care Homes Education and Training – Including Lancaster University GP trainees, GPSTRs from the

Lancaster University Medical School, Nurses and Occupational Therapists from UCLAN and University of Cumbria

Out Patient Clinics Physiotherapy, Occupational Therapy, Social Work and Lymphoedema Services

Charitable donations support 70% of this work, the remaining 30% comes from the NHS.

MANDATORY STATEMENT – St John’s Hospice has reviewed all the data available to them

on the quality of care in all these NHS services.

Participation in Clinical Audits The Hospice audit calendar is led by the Head of Nursing & Quality, co-ordinated by the

Education department and overseen by the clinical team. Audits are a standing item on the

Care and Quality Committee agenda and are discussed monthly at the clinical management

meeting. The following are examples of audits conducted within the Hospice in 2013/14:

Pressure Ulcer Management

Discharge Summaries

Steroid Use on the Ward

End Stage Heart Failure Case Notes

Resuscitation Status Documentation

Drug Allergies

Bedrails Decision Record Documentation

Information Governance Compliance

The Hospice also took part in a North West Audit Group Fentanyl Patch review. This was a

multi-centre, regional audit covering Hospice, Hospital and Community sites.

Research

MANDATORY STATEMENT - The number of patients receiving NHS services provided or sub-

contracted by St John’s Hospice in 2013/14 that were recruited during that period to

participate in research approved by a research ethics committee was NONE

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Use of the CQUIN Payment Framework

For the first time the Hospice at Home Hub was asked to work on the CQUIN framework

below, results are indicated, all goals were achieved.

Goal Number

Goal Name Description of Goal

Goal weighting (% of CQUIN scheme available)

Expected financial value of Goal (£)

Quality Domain (Safety, Effectiveness Patient Experience or Innovation)

H@H Hub Response

1Friend and Family Test

Develop and pilot family & carer survey in year

50.00% £1,440.50 Patient Experience

Completed, although this will continue.

2NHS Safety Thermometer

Locally develop implementation of safety tools applicable to the service

0.00% £0.00 0 N/A

3Dementia

All staff undertake Dementia awareness training

50.00% £1,440.50 Effectiveness Completed.

4VTE

Training to identify, assess and manage treatment of VTE, where appropriate in year

0.00% £0.00 Patient Experience

N/A

Total 100.00%

MANDATORY STATEMENT - £2881.00 of St John’s Hospice NHS income in 2012/13 was

conditional on achieving CQUIN targets as outlined above. All targets were achieved.

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Statement from the Care Quality Commission (CQC)

St John’s Hospice is required to register with the CQC; we are registered to carry out the following regulated activities:

Treatment of disease, disorder or injury Diagnostic and screening processesTransport services, triage and medical advice provided remotely

St John’s Hospice has the following conditions on registration:

Only treat people over 18 years oldOnly accommodate a maximum of 20 in-patients

The CQC has not taken any enforcement action against St John’s Hospice during 2013/14.

On the 13th February 2014, two inspectors made an unannounced visit to the Hospice. The Inspectors’ overview of the Inspection was as follows:

“We spoke with a range of people about the hospice. They included the registered manager, staff members, volunteers, patients, relatives and visitors. We also asked for the views of

external agencies in order to gain a balanced overview of what people experienced using St John’s Hospice. We spoke with patients and relatives. They told us they could express their

views and were involved in making decisions about their care. They told us they felt listened to when discussing their care needs. Staff confirmed to us they also involved relatives, where possible to ensure people received the right care and support. We spent time in all areas of the hospice, including the day centre and in-patient unit. This helped us to observe the daily routines and gain an insight into how people's care and support was being managed. Staff

treated people with respect and ensured their privacy when supporting them. They provided support or attention as people requested it. We spoke with people about the care and

support they received. They said they were happy with the care and support being provided.We looked at how the service was being staffed and reviewed staff training and supervision. We saw there were sufficient staff on each shift with a range of skills and experience. Staff

told us they felt supported, had regular meetings with their manager, and their training was kept up to date. We found there were good systems and processes in place to monitor the

quality of the service being provided. Staff told us they felt this was underpinned by an open reporting culture and strong leadership.”

Areas inspected were:

Treating people with respect and involving them in their care

Providing care, treatment & support that meets people's needs

Caring for people safely & protecting them from harm

Staffing

Management

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All areas inspected fully met CQC standards. The full report can be seen here:

http://www.cqc.org.uk/sites/default/files/media/reports/1- 126938839_St_Johns_Hospice_INS1-674602270_Scheduled_06-03-2014.pdf

Data Quality

MANDATORY STATEMENT - St John’s Hospice did not submit records during 2013/14 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

However, St John’s Hospice does submit data to the Minimum Data Set (MDS) for Specialist Palliative Care services collected by the National Council for Palliative Care on an annual basis, with the aim of providing an accurate picture of Hospice and Specialist Palliative Care service activity. Data taken from the MDS is reported in section 3, Review of quality Performance.

Information Governance Toolkit

St John’s Hospice Information Governance Assessment Report overall score for 2013/14 was 76%. This is considered a “satisfactory” score. The % mark for compliance this year was 66%.

Clinical Coding Error

MANDATORY STATEMENT – St John’s Hospice was not subject to the payment by results clinical coding audit during 2013/14

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Part 3

Review of Quality Performance

In this section, we have chosen to provide data benchmarking St John’s Hospice with figures from the National Council for Palliative Care Minimum Data Set, (MDS.) The MDS is the only national benchmarking tool for Hospices.

Hospice at Home

2013/14 2012/13 2011/12

Total number of patients

541 315 250

Total number of visits face to face

12,327 4902 4155

Total number of telephone calls

10,302 4722 3858

% of people who died at home

85% 92% 93%

11.615.413.4Average length of stay( in days)

7 - Other9 - Other22 - Other

12 – Acute Hospital4 – Acute Hospital3 – Acute Hospital

14 – Care Home7 – Care Home16 – Care home(NB Figures do nottotal because some

patients were admitted more than

once.)

152 – Home 169 – Home 172 – Home

160 – Deaths161 – Deaths159 – DeathsLocation after end ofstay

67%74%77%% Occupancy

24825925824

Number of newpatients

286293295Total number ofpatients

2011/122012/132013/214

In Patient Unit

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Average length of care 43 days 25.9 days 38.4 days

Day Hospice

2013/14 2012/13 2011/12

Total number of patients

147 140 144

% new patients 66% 69% 74%

Average period of attendance

80.5 days 85 days 91.4 days

An annual staff satisfaction survey is conducted, benchmarking St John’s with 93 other Hospices nationally. The top three statements that staff agreed with were:

If a friend or relative needed treatment, I would be happy with the standard of care provided by the Hospice – 99% (95% national benchmark)

I enjoy the work I do – 98% (95% national benchmark)

I am proud to work for St John’s Hospice – 97% (91% national benchmark)

Feedback from Staff8445Aver 333Numb 444Total 202020Famil

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Feedback from Patients, Families and Carers

Feedback from patients, families and carers is one of the most important ways for us to understand and improve the services we provide. In the past 12 months, our patient user group have been put to good use! We invited a local GP to come to speak to them about the difficulties they face when they cannot get a GP appointment, they took part in a workshop with the “Better Care Together” communications team and most recently, they helped us to review our Hospice vision and values as we refreshed our Corporate Strategy.

We often receive comments and compliments by letter or email, here is a montage of some of them:

We never forget that the sign above the door here reads “built by the people for the people”. Putting patients and families at the heart of what we do is fundamental for the Hospice.

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Surveys

Our Vice-Chairman and Chair of the Care and Quality Committee conducts patient surveys on the Ward. This year, comments have been almost 100% positive.

For the first time this year, we conducted surveys with bereaved relatives who had used our Hospice at Home service. Again, feedback was overwhelmingly positive.

Complaints 2012/13

Complaints are all monitored by the relevant member of Senior Management Team, clinical complaints are discussed at the Care and Quality Committee and are reported to the full Board.

Complaints Number

Total number received 2

Total number of complaints upheld in full 2

Total number of complaints upheld in part _

Total number of complaints not upheld _

Opportunities to give Feedback on this Quality Account

We welcome feedback on our Quality Account. If you have any comments, please email:

Sue.mcgraw@sjhospice.org.uk

Or write to:

Sue McGraw

Chief

Executive

St John’s

Hospice Slyne

Rd Lancaster

LA2 6ST

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Annex

Comments from Healthwatch Cumbria

Healthwatch Cumbria is pleased to be able to submit the following considered response to St. John’s Hospice Quality Accounts for 2013/14. Our comments and questions have been developed in consultation with Healthwatch Board Members, lay representatives and the Healthwatch Manager.

Healthwatch Cumbria welcomes the opportunity to provide feedback in response to the Quality Account Report and would like to comment on the clear and concise presentation of the report. The responding group found the report gave a good account of the quality and safety of care, in an open and transparent manner in line with the Francis Recommendations also noted by the CQC along with strong leadership.We commend the Hospice on acknowledging the need for forward planning for future workforce and their competencies to best support the future needs of service users and the need to align itself with computerised systems used by GP’s that will ensure easier and safer access to patient information by both care providers to best support the patients in a timely manner, which demonstrates best practice.It is good to see the Hospice prioritising the views of both staff and patients although it is not exactly clear how feedback is used to gather this information. The Hospice is clearly working in partnership with its staff and patients as evidenced in the Chief Executives statement that includes testimonial phrases from both parties.Following the outcome of Baroness Julia Neuberger’s report it is good to see that St. John’s Hospice Chief Executive was proactive in the commissioning of a review of Food and Nutrition across the Hospice and will be able to demonstrate the findings through evidential data and training of staff.In the hospice’s priorities for next year (2014/15) it would be helpful to include some detail of the processes used for gathering feedback, specifically on how it is translated into chosen priorities.This concludes the response from the Healthwatch Cumbria’s responding group to St. John’s hospice Quality Accounts Report for 2013/14. Once again we would like to commend the Hospice on the presentation and content of this report and for the continued improvements across the Hospice’s services.

Signed for Healthwatch Cumbria

Sue HannahSenior Engagement Officer

Comments from Healthwatch North Lancashire

The hospice is to be commended for producing a Quality Account, as it is not entirely clear that they are obliged to do so. It is also apparent that the QA pro forma does not fit well with the services provided by the hospice. Presumably this is an issue of wider concern than St John’s and it may be that there is a role for Help the Hospices to develop a more useful format.We have no reason to doubt the accuracy of the information contained within the document. We received no comments – positive or negative – from the public regarding St

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John’s Hospice in 2013/14. They have had very positive local media coverage.We have some comments on specific issues raised by the Quality Accounts:• We believe that the hospice is right to prioritise workforce development. The health

and care sector in general is looking at very significant challenges to its future workforce in terms of enough people and the right skills. The hospice clearly has some advantages as a small organisation that people actively want to work for. A tightening labour market in the medium term may well threaten this and we urge the organisation to keep workforce development at the forefront of its efforts. The hospice already works very successfully with volunteers, who play a key part in delivering services. In the context of workforce development, it is likely that volunteering will become even more important to the hospice in the future.

• We welcome the Food and Nutrition Review and would appreciate seeing more detail about this in the future.

• The narrative of the document suggests a successful, empathetic organisation. The challenge for the Hospice, based on the document, is the provision of outcome data showing improvement in things like life quality, general health, and mental wellbeing, across the community. These outcomes are clearly a key part of the work of the Hospice and they should be a key part of its Quality Account. The test of inpatient care, the hub, hospice-at-home and the phone service is the impact they have on people’s lives.

• The Hospice is to be congratulated on having a loyal and highly motivated staff team.We understand that the dynamics of a hospice may make a complaints policy difficult to manage and we would be happy to assist the hospice in developing its thinking about this. We presume that the two complaints recorded in 2013/14 were formal written complaints and we wonder how informal complaints and comments are dealt with. Really important information about service quality can be gleaned from informal complaints and comments, and a learning organisation will want to capture this.

Comments from Cumbria CCG (South Lakes Locality)

“Cumbria CCG recognise the great work St John’s Hospice does in ensuring the best quality of care, for patients, which is so well reflected in this Quality Account. They continue to be great advocates for the improvement of those services and they and their staff should be commended on the services they provide.”

Senior Commissioner Cumbria CCG

Comments from North Lancashire CCG

“I think the report is an excellent reflection of the level of consideration you have given to leading and developing the Hospice and the staff are to be commended on their hard work and commitment.” Commissioning Manager, Lancashire North CCG

Comments from Lancashire County Council Overview and Scrutiny Committee

“The Lancashire Health Scrutiny Committee made no comment on the St John’s Hospice Quality Account”

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Comments from Cumbria County Council Health Scrutiny Committee

The Cumbria Health Scrutiny Committee welcomes the opportunity to comment on the St John’s Hospice Quality Accounts for 2013-14.

Councillors have highlighted how clear and well written the report is, clearly setting out the improvements you aimed to achieve, the rationale for these and the desired outcomes and monitoring procedures in place. It was felt that there was a good use of the CQC evidence and patient and others’ views.

In future it was suggested that the document could be further developed to include more like for like comparisons in the data section. It may also be useful to highlight if there were any areas for development arising from the surveys that you reference, and if so what is being done to progress these, in addition to the excellent feedback that is also coming out of these.

The overall picture is of a well-run and caring establishment and Health Scrutiny members appreciate the work that has taken place over the recent year and look forward to continuing to work with the Hospice.