Annual Report: Quality and Patient Safety

Ms Susan Moloney
Group Quality & Patient Safety Manager
Professor Siobhan Gormally
Group Clinical Director for Quality & Patient Safety

During 2018, the QPS Directorate was continuously mindful of the need to strike a balance between the proactive innovative aspects of its work in driving change and the need to have an effective and robust reactive risk management operational model to respond quickly to safety events.

Key areas of focus in 2018 included:

Learning from Mistakes

Learning from mistakes has been a key priority for QPS Directorate in 2018.  Significant progress was made in sharing and dissemination of all Review findings.

Leadership for Quality

2018 saw the embedding of the SIMF (Senior Incident Management Forum) model across all sub specialties with Medicine being added in Q2 2018.

Considerable work continued on Complaint Management with positive outcomes as defined by compliance with national and RCSI HG targets and a dramatic decrease in level 3 complaints for the Group.  The Hospital Group complaints audit process was commended by the Ombudsman.


Among the RCSI QPSD innovations developed in 2018 were:-

  • establishment and embedding of a Quality and Safety subcommittee of the RCSI Hospital Group Board.
  • the introduction of a RCSI HG bespoke After Action Review programme in partnership with the Institute of Leadership, RCSI.
  • QPS Utilisation of the MERP Taxonomy for medication error reporting and analysis.
  • the preparatory work for procurement of a Quality Management System (QMS) began in conjunction with Sheila McGuiness COO. 
Staff Engagement

Significant work was completed on support of staff involved in Incident and Complaints.  This included:

  • QPSD statement document/algorithm designed to help GM/Risk Managers and Senior Clinicians support staff during incidents,
  • rollout of RCSI After Action Review (AAR) Training.
Quality and Safety Subcommittee of the RCSI Hospital Group Board
  • this subcommittee of the RCSI Hospital Group Board was established in July 2018. The committee meets quarterly and convened twice in 2018.
  • terms of Reference were developed for the subcommittee.
  • a standardised agenda is in place to reflect the business of the committee.
  • the RCSI HG Risk Register and a defined suite of Quality and Safety Metrics is also analysed by the committee.
RCSI Hospital Group Quality and Patient Safety Committee

The RCSI Hospital Group Quality and Patient Safety Committee is the high level steering group for Quality and Safety in the HG and is chaired by Prof Gormally, Clinical Director QPS.   Meetings of the Quality and Patient Safety Committee took place quarterly in 2018.

RCSI Hospital Group Quality and Patient Safety Managers Forum

This Forum includes Quality and Safety and Complaints Managers from each Hospital. This Forum has served as an important avenue for shared learning while also facilitating the Quality and Patient Safety Directorate to provide coaching, support, and guidance to consolidate necessary changes based on best practice. The forum met 7 times in 2018.

RCSI Hospital Group Senior Incident Management Fora:

When the RCSI Quality and Patient Safety Directorate (QPSD) was established in October 2015, a key priority was to maximise transparency and to standardise management of Serious Reportable Events (SRE’s) and Serious Incidents (SI’s) while at the same time ensuring that learning from the adverse incidents had occurred across the Group.  We have identified 3 key divisions:

  • Women’s and Children
  • Perioperative
  • Medicine
Women & Children (WAC) Group Senior Incident Management Forum

The Women’s and Children’s Senior Incident Management Forum (WAC SIMF) was established in 2016 and in 2018, the Chair of the Forum was taken over by Dr Mary Holohan, Consultant Obstetrician.    Meetings are held on a monthly basis. There have been 12 meetings in 2018 at which 70 cases were discussed.  In 14% (n=10) of cases the local hospital decision regarding the type of reviewed required, was overturned by the SIMF group.

One of the key priorities for the W&C SIMF in 2018 was to theme recommendations from Reviews.  In 2018, the recurrent recommendation themes in Women’s and Children’s Reviews included (1) Documentation (2) Guidelines and (3) Communication.  These themes have formed the basis for the teaching schedule for a monthly multidisciplinary interactive Maternity/Gynaecology Teaching Programme which was facilitated by Dr Mary Holohan, in Our Lady of Lourdes Hospital, Drogheda and Cavan General Hospital during 2018.

RCSI Hospitals Group Peri-operative Senior Incident Management Forum

In 2017, a similar Senior Incident Management Forum model was established for Perioperative SRE and SIs under the Chairmanship of Prof Paddy Broe.   Six meetings were held in 2018.  Forty-nine cases were discussed.  There was a significant increase in perioperative cases presented compared to 2017 (8 vs 3.5 SRE/SIs per meeting)

The recommendations from Peri-Operative Reviews presented at SIMF in 2018 have been reviewed. The key themes include (1) Policy/Protocols (2) Education and (3) Communication. Further interrogation of the themes is planned before methods to support dissemination of the learning within and across all sites in the RCSI Hospital Group is considered.

RCSI Hospitals Group Medical Senior Incident Management Forum

In August 2018, the final phase for the Senior Incident Management Forum concept was introduced with the inaugural meeting of the Medicine SIMF.  This Forum is chaired by Prof Paddy Broe, Clinical Director of the RCSI HG.   The Medicine SIMF replicates the purposes, structures and governance of the W&C SIMF and Perioperative SIMF with a focus on patients who access Medical and ED services in the 4 acute hospitals in the RCSI Hospital Group.  During 2018 a standardised SRE/SI and clinical review descriptor list was commenced to support hospitals to identify clinical incidents for presentation and discussion at the Forum. Two meetings were held in 2018.  A total of 25 cases were discussed. In one case the local decision re: type of review was overturned.

Group Model for Adverse Clinical Incident Review

The Quality and Patient Safety Directorate developed an algorithm titled RCSI Hospital Group Adverse Clinical Incident Review Model to standardise and streamline the review process across the Hospital Group. This algorithm was developed in line with Incident Management Framework (2018), HSE and the National Standards for the Conduct of Reviews of Patient Safety Incidents (2017), HIQA.

The RCSI Hospital Group has revised incident management training to ensure that staff are familiar with the best practice in conducting Systems Analysis Reviews. This training was facilitated by La Touche and 42 Staff were trained across the HG in 2018.

Model for Staff Support

The QPSD developed a statement document/algorithm designed to help GM/Risk Managers and Senior Clinicians and Line Managers support staff during incidents.

Hospital Incident Reviews

Within the QPSD all open Incident reviews per Hospital are now logged and monitored. During 2018 the time to completion status of all reviews was documented and presented at SIMF meetings, local Hospital Performance Meetings and the RCSI Group Executive Council and Board. This allowed a high level oversight of the review process.

Complaint Management

Standardisation of management of complaints across the Group continued to be a priority in 2018

In 2017, the QPSD completed a comprehensive audit of current practices in complaints management across the Group. The results of this audit were used to customise RCSI Complaints Management Training in 2018 and 83 staff were trained across the Hospital Group.

The national target for complaints resolution within 30 days is 75% for which the Hospital Group is compliant. This data is published monthly at

Unresolved patient complaints (Level 3) forwarded to the RCSI Hospital Group reduced to n= 5 in 2018 compared to n=12 in 2017 and n= 17 in 2016.

Quantification of Risk Document

The RCSI Hospital Group Risk Register quantifies risks through the lens of capacity, capability and culture. The Quantification of Risk Document was published on the Website for maximal transparency and is updated bi monthly.

Implementation of a Quality Management System

In 2018 preparatory work for procurement of a Quality Management System (QMS) was finalised in and Our Lady of Lourdes Hospital is the pilot site for the introduction of Q Pulse.

After Action Review

An After Action Review (AAR) is a means of framing a structured facilitated discussion following an event or incident. The outcome of this discussion enables the individuals involved in the event to understand what went well and why and what didn’t go well and why. This allows them to agree on what they would do differently in the future and what can be learnt to improve services. The purpose of implementing AAR is to enable a culture which uses experience to improve performance by preventing recurrent errors and reproducing successes.

In partnership with our colleagues in the Institute of Leadership, RCSI we have been able to provide customized AAR training for the RCSI Hospital Group. Training on AAR commenced in December 2017 and 42 staff are trained.

Sharing of Learning from Reviews and Complaints

During 2018 recommendations from completed reviews have been anonymised and shared across the Hospital Group via the relevant Senior Incident Management Forum. Recommendations from completed complaints are also anonymised and discussed in the RCSI Hospital Group Quality and Patient Safety Managers Forum.

Medical Alerts

A bespoke medical alert notification and process has been developed in 2018. The aim of this process is to share key learning and alerts from incidents across the RCSI HG. The requirement for a medical alert notification is determined at the appropriate SIMF and is disseminated by the QPSD across the HG.

Health Service Excellence Awards:

RCSI HG QPSD was shortlisted in two categories in the Health Service Excellence Awards,

  • The Women’s’ and Children’s Senior Incident Management Forum a New Model for Governance.
  • Effective Use of Data to Improve the Management of Complaints
International Forum, on Quality and Safety in Healthcare, Glasgow 2019:

Posters accepted for presentation

  • Using Data to Improve the Management of Patient Complaints, RCSI Hospital Group, Ireland.
  • The RCSI Hospital Group (Ireland) Senior Incident Management Forum: A New Model for Hospital Group Governance and Risk.

Presentation to the Minister for Health Bahrain in RCSI on the work of the RCSI Hospital Group, Quality  and Safety Directorate.

 RCSI Hospital Group Metrics

In the context of an  RCSI Hospital Group philosophy of maximal transparency in relation to performance measurement and in order to enable patients, relatives and the general public to see and understand current performance, publication of key metrics continues on a cumulative basis on the RCSI Hospital Group website

Standardisation of QPS Local Hospital Performance (Aide Memoire)

In order to strengthen the ability of Hospital Teams to analyse their Quality and Safety metrics a standardised aide memoire document was developed and implemented in 2017.  Two significant revisions are the use of the MERP Taxonomy for medication incidents and monitoring of sepsis training rates.


A new component of the aide memoire in 2018 is the utilisation of the Medication Error Reporting and Prevention Taxonomy Index (MERP) for Medication Errors.

The MERP Taxonomy is utilised during monthly Hospital Performance meetings with the Group and also at Hospital level. This has resulted in an additional focus on medication incident reporting. Medication Incident reporting for 2018 shows an increase year on year which we suggest demonstrates the advancement of an increased reporting culture in hospitals. 

Sepsis Training

Sepsis is a common and time-dependent medical emergency. International data suggests that optimal sepsis management, based on early recognition of sepsis with timely intervention within the first hour, results in a reduction in mortality from severe sepsis/septic shock in the order of 20-30%.

While acknowledging the fact that each hospital has local sepsis training programme, it is the policy of the RCSI Hospitals Group that all frontline clinical staff complete the online HSE Sepsis Training module (HSE land). Maternity sepsis training (PROMPT/RHOET) is mandatory for all Midwives and Medical staff working in Antenatal, Postnatal and Labour wards. Completion of these training modules is intended to standardise and to optimise the skills of staff in managing sepsis. Rates of Sepsis training across the Hospital Group are continuously monitored and published quarterly

National Patient Experience Survey (NPES) (FIGURE 14)

Participation in the National Patient Experience Survey (NPES) is one of the methods used by the group to collect this data on patients and families’ experiences of care. 1,931 patients from hospitals across the Group took part. Overall the RCSI Hospital Group has demonstrated performance improvement in relation to patient experience (2018 v 2017).