Measurement of quality to drive improvement is one of the hallmarks of a high performing healthcare system. The RCSI Hospital Group recognises the importance of a common relevant set of metrics and key performance indicators and their active usage in measuring, tracking and generally guiding performance in various dimensions of care across all clinical services. Their usage also helps identify where improvement is required and the impact of purposeful quality improvement initiatives when introduced.

The RCSI Hospital Group is committed to maximal transparency in relationship to performance measurement and in order to enable patients, relatives and the general public to see and understand current performance these metrics are now published on a cumulative basis on its web site (www.rcsihospitals.ie). Therefore focus of this Report is a statement of performance rather a description of actions to improve performance. All data presented is anonymous and necessary, patient confidentiality is and will be maintained at all times.

 

IAN CARTER

CHIEF EXECUTIVE

RCSI HOSPITAL GROUP

Selection methodology

The performance metrics are organised within 7 core dimensions:

  • Access and Patient Flow
  • Infection Control and Management
  • Medication Management
  • Maternity Services
  • Patient Care and Treatment
  • Patient and Family Experience
  • Staff

For each performance metric considered:

  • rationales for selection are identified and generally explained
  • methodology for performance measurement in terms of numerator / denominator, frequency of data collection and data sources are articulated
  • target performance values to be achieved are stated
  • actual performance for each hospital site and overall performance for the RCSI HG are identified
  • national performance values (where available) are provided for comparative purposes
  • in certain instances due to either variance of services across the hospitals or because of particularly small incidence values, necessary caution in comparative analysis is identified
  • an interpretive trend commentary is provided

 

Dimension Performance Metrics
Access + Patient Flow 3.1 ED Patient wait volume for admission
3.2 ED Patient Experience Time (PET)
3.3 OPD Waiting Time for New appointments
3.4 Inpatient / Day Care Waiting Times
3.5 Access to Symptomatic Breast Cancer Services
3.6 Access to Rapid Access Clinic – Lung
3.7 Access to Rapid Access Clinic – Prostate
3.8 Urgent Colonoscopy Waiting Times
3.9 Endoscopy Waiting Times
3.10 Clients offered colonoscopy appointment date that occurs within 20 working days from when a client was deemed clinically suitable following pre-assessment/positive FIT
3.11 Access to National Neurosurgical Unit
3.12 Diagnostic Imaging waiting times
3.13 % ‘Did not Attend’ of new OPD bookings
3.14 Polyp Detection Rate
3.15 Caecal Intubation Rate
3.16 24 Day Case Procedures
3.17 Scheduled Care Entry Recording
Infection Control and Management 4.1 S Aureus notification rate per 10,000 bed days used
4.2 Rate of new cases of Hospital acquired Clostridium difficile infection
4.3 Number of patients confirmed with newly detected CPE
4.4 % compliance of Hospital staff with WHO’s 5 moments of hand hygiene using national audit tool
4.5 % Staff uptake of ‘Flu’ Vaccination
4.6 Sepsis Training
Medication Management 5.1 Rate of Medication Management Error
Maternity Services 6.1 Clinical Activities
6.2 Major Obstetric Events
6.3 Delivery Metrics
6.4 Competency Training
6.5 Fetal Anomaly Scanning
Patient Care and Treatment 7.1 % of emergency Hip fractures surgeries undertaken within 48 hours of admission
7.2 Serious Falls
7.3 Development of Grade 3 or greater pressure sore (decubitus ulcer) in Hospital
7.4 % of patients readmitted as an emergency within 28 days of discharge
7.5 Number of patients identified as requiring Home Care Packages / access to Long term Care or Rehabilitation inappropriately remaining in acute beds
7.6 Hospital Mortality for:
– Acute Myocardial Infarction
– Heart failure
– Ischaemic Stroke
– Haemorrhagic Stroke
– Chronic obstructive pulmonary disease and bronchiectasis
7.7 Thrombolysis in patients with confirmed acute ischaemic stroke
Patient and Family Experience 8.1 Patient satisfaction studies
8.2 % of complaints responded to within 30 days
8.3 Parliamentary Questions (PQs)
Staff 9.1 % Staff absenteeism
9.2 % Staff Garda Vetting

Note1 – these statistics reflect the most recent activity within RCSI Hospital Group. Data presented is subject to revision. Caution should be used in making comparisons between hospitals due to different sizes and services provided.