Annual Report: Quality and Patient Safety

Ms Susan Moloney
Group Quality & Patient Safety Manager
Professor Siobhan Gormally
Group Clinical Director for Quality & Patient Safety
In 2016, the Quality and Patient Safety Directorate focused on establishing a baseline for existing QPS structures in the RCSI Hospital Group, prioritising areas for development, standardising best practice across QPS areas, which included formalising measurement for improvement, providing a robust and transparent oversight model for maternity and paediatric governance, engaging with and optimising communication pathways with specific sites to facilitate change based on best practice.
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

The RCSI Hospital Group Quality and Patient Safety Committee met 7 times in 2016. 2017.

RCSI Hospital Group Quality and Patient Safety Managers Forum

This Forum was established in September 2016. This Forum has served as an important avenue for listening to the challenges and concerns of local sites, whilst also facilitating the Quality and Patient Safety Directorate to provide coaching, support, and guidance to consolidate necessary changes based on best practice, within local hospitals.

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.
Pathways for Adverse incidents (SI/SRE)

In Q1 2016 work was completed by the Quality and Patient Safety Directorate on standardising Pathways for Adverse Incidents / Serious Adverse Events (SAE) across all sites. An algorithm was developed to simplify the process and agreement on a Hospital Group wide approach was achieved.

Group Model for Review of SRE/SI

Quality and Patient Safety Directorate developed an RCSI Hospital Group Incident Management Model to standardise and streamline necessary review process across the Group. While this remained true to the philosophy of HSE Guidelines for the Systems Analysis Investigation of Incidents (2016), necessary emphasis was placed on time frame (timely completion), efficient use of time, simple language and SMART recommendations that can be delivered. The RCSI Hospital Group commissioned training to deliver this model and by end 2016 55 staff had been trained including 23 Senior Managers and 27 Consultant/Nursing staff.

Hospital Incident Reviews

Open Incident reviews per Hospital are now logged and monitored. During 2016 the time to completion status of all reviews was documented and utilised at local Site Performance Meetings, the RCSI Group Executive Council and Hospital Group Board. This allowed a high level oversight of the review process and an opportunity to empower local sites to actively manage any outliers.

Quantification of Risk Document

An extensive revision of the RCSI Hospital Group Risk Register was undertaken quantifying risks through the lens of capacity, capability, control and culture. The resulting Quantification of Risk Document is published on the RCSI Hospital Group Website for maximal transparency and updated bi monthly.

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.

In Q4 2016, the QPS Directorate in conjunction with the Hospital Group CEO developed a suite of QPS Metrics and KPIs for use at hospital level, to actively use in measuring, tracking and generally guiding performance in various dimensions of care across all clinical services. In consultation with site General Managers / CEOs and Risk Managers an Excel Metrics template was finalised for use at local hospital level. This contains clear definitions of the parameters being used together with numerators and denominators for each metric. By Q4 2016, this template was being piloted by Risk Managers for Performance meetings in each Hospital.

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.

The performance metrics, first published in October 2016, are available:

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.

The national target of 75% of complaints resolved within 30 days was achieved within the Group in November 2016. In Q4 2016, the Quality and Patient Safety Directorate commenced a QI in complaints management, beginning with a comprehensive audit of current practices across the Group. Results will be available in Q3 2017.

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

In 2016, the Quality and Patient Safety Directorate made site visits to Our Lady of Lourdes Hospital, Cavan General, Connolly, Beaumont and Rotunda Hospitals. GM/CEO, DON, DOM, Clinical Directors and other members of the local Senior Management Team attended. The purpose of these visits was to both engage with key staff and to outline the vision of the OPSD.

Local Hospital Site Performance Meetings

A member of the Quality and Patient Safety Directorate attended all local hospital performance meetings in 2016.

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

Quality and Patient Safety

8th March, 2018