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 – May 5.75% (38,000 lost hours = 232WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • due to the cyber attack no national data available

Cavan General Hospital

  • Cavan Hospital reported absence rates higher than national target – April 4.8% (7,484 lost hours = 45WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

Monaghan Hospital

  • Monaghan Hospital reported absence rates higher than national target – April 5.25% (921 lost hours = 6WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

Drogheda Hospital

  • Drogheda reported absence rates higher than national target – April 5.5% (18,121 lost hours = 116WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

Louth County Hospital

  • Louth Hospital reported absence rates higher than national target – April 10.0% (4,370 lost hours = 28WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

Connolly Hospital

  • Connolly Hospital reported absence rates higher than national target – April 4.17% (9,767 lost hours = 57WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

Rotunda Hospital

  • Rotunda Hospital reported absence rates lower than national target – April 3.21%(4,658 lost hours = 29WTE)
  • Increase in absenteeism can be attributed due to Covid-19 related absences
    • May data not available at time of report publication due to cyber attack

National Comparator – Hospital Groups – only available for January 2021

  • due to the cyber attack no national data available for April and May
  • RCSI Hospital Group reported absence rates of 5.20% for March 2021 and 5.31% for April 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 available

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

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

* Rotunda utilise NeoEWS tool

  • 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 submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed 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% of relevant staff are up to date with the national E-Learning Module on “An Introduction to Children First”

Performance

Note:

  1. Drogheda includes Louth County Hospital, separation of data unavailable at the time of report production due to system unavailability.
  2. National dataset for comparison not published.
  3. Due to the cyber attack no May data currently available.

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 submitted end of each month 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 of all staff

Performance

Note:

  1. Drogheda includes Louth County Hospital, separation of data unavailable at the time of report production due to system unavailability.
  2. National dataset for comparison not published.
  3. Due to the cyber attack no May data currently available.

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

The HSE operate a 100% compliance policy for Manual & Patient Handling.

Performance

Note:

  1. Drogheda includes Louth County Hospital, separation of data unavailable at the time of report production due to system unavailability.
  2. COVID-19 has impacted compliance due to the requirement for face-to-face practical training.
  3. National dataset for comparison not published.
  4. Due to the cyber attack no May data currently available.

FIRE SAFETY AWARENESS TRAINING COMPLIANCE

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 submitted monthly and extrapolated for analysis and publication.

Numerator

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

Denominator

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

Target

The HSE operate a 100% compliance policy for Fire Safety Awareness Training.

Performance

Note:

  1. Drogheda includes Louth County Hospital, separation of data unavailable at the time of report production due to system unavailability.
  2. No data available from Cavan / Monaghan at the time of publication.
  3. COVID-19 has impacted compliance due to the requirement for face-to-face practical training.
  4. National dataset for comparison not published.
  5. Due to the cyber attack no May data currently available.