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

Beaumont Hospital

  • – Beaumont Hospital absence rates higher than national target – January 11.03% (59,329 lost hours = 411WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Cavan General Hospital

  • Cavan Hospital reported absence rates higher than national target – January 15.00% (22,542 lost hours = 131WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Monaghan Hospital

  • Monaghan Hospital reported absence rates higher than national target – January 28.0% (5,213 lost hours = 30WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Our Lady of Lourdes Hospital, Drogheda

  • OLOL reported absence rates higher than national target – January 11.0% (37,928 lost hours = 243WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Louth County Hospital

  • Louth Hospital reported absence rates higher than national target – January 26.0% (11,705 lost hours = 75WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Connolly Hospital

  • Connolly Hospital reported absence rates higher than national target – January 9.64% (22,628 lost hours = 70WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

Rotunda Hospital

  • Rotunda Hospital reported absence rates higher than national target – January 3.87%(5,608 lost hours = 36WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • national performance pertaining to January not available at time of report publication

National Comparator – Hospital Groups – only available for January-November 2020

  • national performance pertaining to December and January not available at time of report publication
  • RCSI Hospital Group reported absence rates of 6.08% for December 2020 and 14.93% for January 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

CHILDREN FIRST TRAINING 

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 E-Learning Module on “An Introduction to Children First”.

Measurement methodology and data source

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

Numerator

Number of staff trained (expressed as %)

Denominator

Number of staff eligible for training (expressed as %)

Target

100% of relevant staff are up to date with the national E-Learning Module on “An Introduction to Children First”

Performance

  • National data not available

 

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.

* Rotunda utilise NeoEWS tool

  • OLOL NEWS training compliance decreased due to revised programme
  • national data currently not published

 

STANDARD PRECAUTIONS AND HAND HYGIENE TRAINING

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. Monitoring of standard precaution training including hand hygiene commenced on July 2020.

Measurement methodology and data source

Local data extracts submitted end of each month and extrapolated for analysis and publication.

Numerator

Number of staff trained (expressed as %)

Denominator

Number of staff eligible for training (expressed as %)

Target

100% compliance of all staff

Performance

  • national dataset 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

  • national dataset not published