Dimension: Staff

Rationale for measurement

The presence of an adequate number of health care staff is essential for optimal patient care. High absenteeism rates can potentially affect quality of patient care and staff morale. The resultant ad hoc use of temporary staff from an external Agency to cover sick leave can also impact on continuity of care for the patient.

Measurement methodology and data sources

  • Local data set from monthly performance metrics

Target

  • 3.5%

Performance

Charts below exclude data related to Covid-19 (cocooning available to work) which averages between 1.5-2.5% per site

Beaumont Hospital

  • Beaumont Hospital absence rates – July 4.76% (26,001 lost hours = 173WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Cavan General Hospital

  • Cavan Hospital absence rates – August 5.58% (9,611 lost hours = 56WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Monaghan Hospital

  • Monaghan Hospital absence rates – August 3.20% (640 lost hours = 4WTE). (National target <3.5% achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Drogheda Hospital

  • Drogheda absence rates – August 7.0% (22,853 lost hours = 146WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Louth County Hospital

  • Louth Hospital absence rates – August 12.0% (5,539 lost hours = 36WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Connolly Hospital

  • Connolly Hospital absence rates – August 5.59% (12,577 lost hours = 74WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

Rotunda Hospital

  • Rotunda Hospital absence rates – Aug 5.13% (6,685 lost hours = 48WTE). (National target <3.5% not achieved) 
  • increase in absenteeism can be attributed due to Covid-19 related absences 
    • due to the cyber attack no national data available since March 

National Comparator – Hospital Groups – only available for January-March 2021 

  • due to the cyber attack no national data since March 
  • RCSI Hospital Group reported absence rates of 5.31% for April, 4.83% for May, 5.06% for June 2021, 5.70% for July 2021 

Rationale for measurement

The National Vetting Bureau (Children and Vulnerable Persons) Acts 2012-2016 came into effect on 29 April 2016. This legislation makes it mandatory for people who carry out relevant work or activities in respect of children or vulnerable adults to be vetted by the National Vetting Bureau (NVB) of the Garda Siochana. The Acts define relevant work or activities as ‘any work or activity which is carried out by a person, a necessary and regular part of which consists mainly of the person having access to, or contact with, children or vulnerable adults’.

Section 21 of the Act provides for the retrospective vetting of employees who are carrying out ‘relevant work or activities’ and who were not previously vetted. The Regulations (SI No. 223 of 2016) provide that applications for retrospective vetting disclosures shall be made not later than March 2018.

Measurement methodology and data sources

  • Local data set from monthly performance metrics

Target

  • 100% of employees engaged in ‘relevant work’

Performance

  • in line with legislation members of staff are not allowed to work until their Garda vetting is completed
  • national data not published

OPEN DISCLOSURE TRAINING

Introduction

Open Disclosure is an open and consistent approach to communicating with patients and their families when things go wrong in healthcare. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event. Open Disclosure is important for building patient and public trust in the health system. This is supported by relevant legislation,

  • The Civil Liability (Amendment) Act, 2017, provides the legal framework to support voluntary open disclosure.
  • Draft Patient Safety Legislation is awaited. This legislation which will provide a legal framework for mandatory open disclosure

The HSE Open Disclosure Policy, 2019 also provides a framework for open disclosure in the health service.

Rationale for measurement

It is government policy that open disclosure is in place and is supported across the health system in line with relevant legislation and HSE Policy. Training is provided in the form of

a) briefing sessions face to face or via online module on HSE land

b) skills workshops

c) bespoke MPS/RCSI HG Training

Measurement methodology and data source

Quarterly local data extracts, extrapolated for analysis and publication

Numerator: Number of relevant staff trained (Expressed as %)

Denominator:  Total number of relevant staff (Expressed as %)

Target

100% of relevant staff have completed either a briefing session or a skills workshop in Open Disclosure

Performance

  • RCSI HG hospitals are not achieving the target of 100% 
  • national dataset not published for comparative purposes 

 

EARLY WARNING SCORE

Rational for measurement

National Early Warning System (NEWS), Irish Maternity Early Warning System (IMEWS), Paediatric Early Warning System (PEWS).

Introduction

Acute physiological deterioration is a time-crucial medical emergency. Failure to detect and treat patient deterioration in a judicious manner poses a threat to patient safety. Early recognition of clinical deterioration by regular measurement and documentation of physiological parameters, followed by prompt and effective action, can minimise the occurrence of adverse events such as cardiac arrest.

Measurement methodology and data sources

The following guidelines guide clinical practice (NEWS, PEWS, IMEWS)

  • In September 2020 the Irish National Early Warning System Clinical Care Guideline was revised and updated to INEWS V2 (previously NEWS). This National Clinical Guideline is relevant to all healthcare professionals working in acute settings. This guideline applies to adult (≥ 16 years) non-pregnant patients in acute settings
  • Clinical Practice Guideline – Irish Maternity Early Warning System (IMEWS) should be used for women who are clinically pregnant or who were delivered within the previous 42 days
  • The Paediatric Early Warning System (PEWS) should be used for patients < 16 years of age

These guidelines endorse the concept that facilitates the timely assessment of, and response to, the deterioration of acutely ill patients by:

  • Classifying the severity of a patient’s illness
  • Providing prompts and structured communications tools to escalate care
  • Following a definitive escalation plan
  • Providing a clear, structured response model

The above tools utilised by trained staff lead to a reduction in instances of unanticipated admission and/or readmission to ICU and in instances of unanticipated cardiac arrest

Target

100% of Medical, Nursing & Midwifery professionals trained in the appropriate tool/tools depending on work speciality. Staff may require training on multiple tools depending on the patients they care. Training is a once off for each tool.

  • compliance measuring staff trained on INEWS since its introduction in Sept 2020. Staff would have previously been trained in NEWS 
  • RCSI HG hospitals are not achieving the target of 100%, with the exception of Nursing in Drogheda 

  • Drogheda and Cavan Hospitals are achieving target of 100% 
  • Rotunda Hospital is not achieving target of 100% 

* Rotunda utilise NeoEWS tool

  • Drogheda and Cavan Hospitals are achieving target of 100% 
  • national data currently not published 

 

CHILDREN FIRST TRAINING COMPLIANCE

Rationale for measurement

The Children First Act 2015 puts elements of the Children First: National Guidance for the Protection and Welfare of Children (2011,) on a statutory footing and places a wide range of responsibilities on HSE and its funded services. All staff are required to complete the E-Learning Module on “An Introduction to Children First”.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed online Children First Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance 

Performance

  • HSE cyber attack impacted on ability of sites to participate in online training

 

STANDARD PRECAUTIONS AND HAND HYGIENE TRAINING COMPLIANCE

Rationale for measurement

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect healthcare workers and prevent healthcare workers from spreading infections among patients.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed Standard Precautions and Hand Hygiene Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance 

Performance

  • HSE cyber attack impacted on ability of sites to participate in online training

 

MANUAL AND PATIENT HANDLING TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with manual handling and people handling activities. The Safety, Health and Welfare at Work, (General Applications) Regulations 2007 Act requires that training and instruction be provided to relevant staff. The theory component requires completion of the online training course.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed (practical & theory) Manual / Patient Handling Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance 

Performance

  • HSE cyber attack impacted on ability of sites to participate in online training
  • Covid-19 restrictions has resulted in challenges with classroom-based training for practical elements

 

FIRE SAFETY AWARENESS TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with Fire. The Health and Welfare at Work Act 2005 states that employers must ensure so far as is reasonably practicable, that sufficient information, training and supervision is provided to ensure the safety of employees.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed the online component of Fire Awareness Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance. This target comprises of an online and practical element to the training. Compliance figures below relate currently to the online element only. 

Performance

  • HSE cyber attack impacted on ability of sites to participate in online training

 

GDPR AWARENESS TRAINING COMPLIANCE

Rationale for measurement

The Data Protection Act 2018 states that all employees must comply with GDPR legislation including awareness training. All hospitals are legally required to comply with this legislation.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained.

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance 

Performance

  • HSE cyber attack impacted on ability of sites to participate in online training