Annual Report: Quality and Patient Safety
Group Quality & Patient Safety Manager
Group Clinical Director for Quality & Patient Safety
Commissioned Review Of Present QPS / Risk Structures Across The RCSI Hospital Group
To ensure the RCSI Hospital Group’s Quality and Patient Safety management structures and system were maximised, a review of existing quality and safety functions was undertaken in 2016. The review examined the structures and processes to support Quality and Safety across the RCSI Hospital Group and made recommendations designed to best support the Group’s governance structure and to ensure all sites operated effectively with regard to quality and safety management.
RCSI Hospital Group Quality and Patient Safety Committee
RCSI Hospital Group Quality and Patient Safety Managers Forum
RCSI Hospital Group Women and Children’s Senior Incident Management Forum (W&C SIMF)
The RCSI Hospital Group W&C SIMF was established on July 2016. The primary purpose of this forum was to provide oversight of Incident Reviews in the Women’s (Maternity & Gynaecology) and Children’s Directorate. The establishment of the W&C SIMF represents major organisational change, enabling the three maternity units within RCSI Hospital Group to function together, with senior clinical leadership provided by the Rotunda Hospital, chaired by Dr Peter McKenna, Group Associate Clinical Director for Women & Childrens Health.
Priority actions Group for 2016 included:
- Standardisation and transparency of reviews processes following SI/SRE
- Document on standardisation for definitions for SI / SRE and trigger list
- Maternity Metrics
- Sharing and Learning from reviews – ‘Recommendations into action’
- A structured onsite interactive Maternity/Gynaecology Teaching Programme for Midwives, Doctors and Allied Health Professionals commenced in Cavan General Hospital in October 2016 and in Our Lady of Lourdes Hospital in November 2016. This programme was facilitated by Dr McKenna, in his role as Clinical Director, the Rotunda Hospital.
Standardisation Of Processes
Pathways for Adverse incidents (SI/SRE)
Group Model for Review of SRE/SI
Hospital Incident Reviews
Quantification of Risk Document
Measuring For Change
Measurement of quality to drive improvement is one of the hallmarks of a high performing healthcare system. The RCSI Quality and Patient Safety Directorate recognises the importance of a common relevant set of metrics and key performance indicators, 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.
RCSI Hospital Group Website project
In the context of an RCSI Hospital Group philosophy for maximal transparency in relation to performance measurement and in order to enable patients, relatives and the general public to see and understand current performance, a Website Project commenced in Q3 and Q4 2016. The remit of this project was to facilitate the publishing of key metrics on a cumulative basis on an RCSI Hospital Group web site. These performance metrics were organised within 7 core dimensions: – (1) Access and Patient Flow, (2) Infection Control and Management, (3) Medication Management, (4) Maternity Services, (5) Patient Care and Treatment, (6) Patient and Family Experience, (7) Staff.
Incidents – Trend Analysis
All Serious Incidents and Serious Reportable Events which occur within the RCSI Hospital Group are reported to the Quality and Patient Safety Directorate. This data is discussed and analysed at Monthly Performance meetings with Group Executive Team and local Site Management Team. This has enabled the identification of trends and the implementation of QI initiatives where required to improve patient and staff safety.
During 2016 there was significant variation with number of incidents recognised and analysed. Both under reporting and over reporting of incidents contributed to variance in incident numbers together with differences in definitions being used in individual sites. Standardisation of both is a key priority for Q1 2017
Figure 13. RCSI Hospital Group 2016 Severity of Clinical Incidents
Figure 14. RCSI Hospital Group 2016 Clinical Incident Themes
The Rotunda Hospital “Clinical Procedures” Data incorporates “Other
Following establishment of the Quality and Patient Safety Directorate, internal complaint process was reviewed. While some sites managed complaints well, sub optimal management of complaints by other sites was recognized, as evidenced by (1) the number of level 3 complaints being sent to the Directorate, (2) timeliness of responses to complaints (3) lack of GM/CEO oversight of complaints (4) absence of quality improvement recommendations from complaint responses, (5) lack of evidence that learning from the complaint had been disseminated to relevant staff and that practices had changed. Therefore standardisation of the management of Complaints procedure across the Group became a priority. An RCSI Hospital Group Policy was developed. In order to effectively translate this policy to practice, a Quality and Patient Safety Directorate Complaints Managers Forum was established in October 2016 comprising of staff from each clinical site.
Collaboration with RSCI Health Research Board (HRB):
In conjunction with RCSI Academic partner, a combined RCSI / Quality and Patient Safety Directorate research application was submitted to the HRB in 2016. The aim of this application was to support and evaluate feasibility of healthcare practitioners across the RCSI hospital group to be trained and mentored by experienced RCSI staff in the design, implementation and evaluation of QI initiatives in several areas, including Complaint Management. The grant application also included a proposal to conduct a QI initiative aimed at optimising development of QI findings in a way that would facilitate the transferability of these findings into different contexts. This application is ongoing.
The National Open Disclosure Policy was launched in 2013. Engaging in open disclosure enables staff to engage in open, honest and transparent communication with patients/service users following adverse events which have or may have caused them harm. Driving and supporting the implementation of Open Disclosure by local sites has involved training of ‘on the ground’ staff in local sites and Train the Trainers seminars. Since its launch, 1113 staff have attended briefing/workshops on Open Disclosure.
Figure 15. Open Disclosure Training 2013 – to date
*to note a number of the trainers per hospital are Consultant Clinicians
Quality and Patient Safety Directorate ‘Meet & Greet’ Initiative
Local Hospital Site Performance Meetings
Top Ten Priorities for 2017
- commence formal meetings of expanded RCSI Hospital Group Quality and Patient Safety Committee
- ongoing RCSI Hospital Group Website publication of key performance metrics
- critical notification of incident by local sites – encouragement for increased reporting and tracking of themes
- standardisation of QPS Performance Report
- translation of recommendations from Women and Children Reviews into action
- audit and QI of top three themes from Women and Children Reviews
- RSCI Hospital Group Study day for Women and Children Governance as a platform for sharing of recommendations
- completion of Quality and Patient Safety Directorate Complaints Audit to be followed by QI to improve the management of complaints
- RSCI Hospital Group Early Warning Score Audit
- to assess compliance with National Guidelines
- identification of areas for improvement
- establishment of Surgical SIMF / Medical SIMF
- facilitating communication via shared IT i.e. shared drive, Intranet, HUB
- updating existing IT systems and developing new IT systems to capture and record information
- staff Resilience
- introduction of Schwartz Rounds
- introduction of inter-disciplinary targeted facilitation programme to achieve and sustain positive culture change