Quality & Patient Safety Audit Service

Transcription

1 Quality & Patient Safety Audit Service End of Year Report 2014 Easy Access Public Confidence Staff Pride

2 I. Introduction In 2014 Quality and Patient Safety Audit (QPSA) continued to build its profile and reputation to provide independent internal assurance for health and social care services in the HSE. In this QPSA have a key role in providing reasonable assurance as part of the HSE s overall assurance framework This is achieved by conducting evidence based audits that test the compliance of services with agreed standards for quality and patient safety, to provide robust, evidenced based information to aid decision making, and quality improvements in the best interest of the patient and service users. Significantly, the national and site specific recommendations made on foot of every audit inform national and local quality improvement plans. Acknowledging that it is the responsibility of the senior most accountable person to ensure that recommendations are acted upon in the service area concerned, QPSA monitors progress on the implementation of the key recommendations on a periodic basis. This information as a component of the overall performance reports on the safety and quality of services provides pertinent reporting to the HSE Leadership team and the Risk Committee. II. Audits Completed and In Progress Audits Completed (12) Code Audit Title Date Completed QPSA012/2013 Audit of the compliance of the notification and investigation of incidents of sudden, unexplained death of persons in community mental health services with legislative 15-Jan-14 requirements and HSE policy and procedures QPSA002/2013 Irish National Audit of Dementia Care in Acute Hospitals 31-Jan-14 QPSA008/2013 Audit of the National Ambulance Service against the Theme 5 of the National Standards 24-Feb-14 QPSA010/2013 Audit of HSE Incident Management Processes 28-Mar-14 QPSA013/2013 Audit of compliance with safeguarding measures to ensure the protection of service users in Intellectual Disability (ID) Services, from abuse 31-Mar-14 QPSA016/2013 Audit of characteristics, work practices and referral patterns to AMAU/AMU in selected acute hospitals as per the National Acute Medicine Programme report 30-May-14 QPSA002/2014 QPSA006/2014 QPSA001/2014 QPSA004/2014 QPSA003/2014 QPSA005/2014 Audit of compliance with Standard 3 of HSE Standards and Recommended Practices for Healthcare Records Management (HCRs) V3.0 (repeat audit in different sites) Assurance Project on the Implementation of Recommendations from Audits/Reviews carried out in Áras Attracta from November 2013 to May 2014 Audit of Compliance with selected European Network of Smoke Free Health Services Standards/Criteria and the HSE Tobacco Free Campus Policy of the Tobacco Control Framework, 2013 Review of clinical leadership and supervision in respect of CNM2/CMM2s in acute hospitals, with focus on the regularisation of acting up arrangements Audit of nursing staff compliance with documentation criteria, standards, guidelines and local policy pertaining to MDA Schedule 2 Drugs Management Audit of compliance with the Irish Maternity Early Warning Score (I-MEWS) Clinical Practice Guideline (2013) in selected maternity hospitals/units 23-Jul Aug Oct Oct Nov Dec-14 Audits in Progress (7) Code QPSA007/2014 QPSA008/2014 QPSA009/2014 Audit Title Audit of compliance of community Registered Nurse Prescribers (RNP) with selected criteria from the HSE National Policy for Nurse and Midwife Medicinal Product Prescribing (2012) Audit of accountability arrangements for quality and patient safety in acute hospitals (compliance with four standards from Theme 5, National Standards) Audit of quality and safety committees across 4 Pillars Social Care, Acute Hospitals, Mental Health and Primary Care Proposed completion Jan-14 Mar-15 Mar-15 2

3 QPSA010/2014 Audit of patient pregnancy protocols and diagnostic reference levels to support the safe and optimal use of medical ionising radiation as outlined in sections 4 and 7 of the Medical Exposure Radiation Unit s (MERU) Patient Radiation Apr-15 Protection Manual. QPSA011/2014 Audit of compliance with safeguarding measures to ensure the protection of service users in Intellectual Disability (ID Services) from abuse Mar-15 QPSA 012/2014 Patient and Public Participation Initiatives within the Acute Hospital Service On hold QPSA013/2014 Evaluation of the Quality and Standard of Care Provided to Service Users in Áras Attracta Feb-15 III Report Recommendations 2014 Final Audit Report Recommendations, by Division Audit recommendations are issued as part of each final audit report with the objective of improving HSE services and increasing quality and patient safety. In the 12 final audit reports issued in 2014, 78 recommendations were made. Below, recommendations are grouped according to the service division which has governance for implementation Final Audit Report Recommendations, by Theme The 78 recommendations were coded to identify common themes. For example, a recommendation to revise a policy was coded as policies, procedures, protocols and guidelines whilst a recommendation that a service must clarify accountability structures in leadership teams was coded as governance. The number and percentage of recommendations pertaining to each theme are outlined below: Theme Documentation & Records Management Governance / Accountability Training / Supervision Sample Recommendation AMAUs must record all experience times and all entries legibly in the HCR in order to comply with the HSE Standards and Recommended Practices for Healthcare Records (HCRs) Management V3.0 (2011) and to ensure that indicator data collected for the AMP programme is accurate. The Mental Health Services should ensure that the Clinical Director of the service is formally notified of incidents of sudden, unexplained death of persons in community mental health services. While a significant amount of training has been completed by frontline staff on safeguarding vulnerable adults, this training needs to be completed by all staff as a matter of urgency Recommendations No. % 19 24% 14 18% 12 15% Policies, Procedures, AMAUs must develop, implement and evaluate a policy, procedure, protocol 11 14% 3

4 Theme Protocols & Guidelines (PPPGs) Communication Data Quality and Audit Staffing / Human Resources Performance Monitoring Risk Management and Controls Sample Recommendation or guideline on admission avoidance in the AMAU, where one does not exist. The National Ambulance Service must ensure that feedback from service users and staff at all levels is sought to identify areas to improve, promote and strengthen a culture of quality and safety throughout the service, and that this is clearly documented. A ward based self-assessment audit programme for I-MEWS must be introduced in all hospitals with results and findings made available to nursing/midwifery staff. Workforce planning initiatives commenced by the DOH, ONMSD and NMPDU should be progressed and further expanded in order to determine the most effective and appropriate utilisation of existing and future nursing and support staff resources, reflecting a consistent approach. Where CNM2/CMM2s are working full-time in a non-clinical capacity, this should be reviewed. The National Ambulance Service should continue to utilise the Quality Assessment and Improvement Tool (June 2013) to facilitate their self assessment against the National Standards. Senior management must ensure that all adverse incidents and "near misses" are reported on the NAEMS system Recommendations No. % 9 12% 4 5% 3 4% 3 4% 3 4% Total % 2013 vs Recommendation Theme Comparison In a comparison between recommendations made in 2013 vs. recommendations made in 2014, four categories were in the top 5 both years. These include: documentation and records management; governance and accountability; PPPGs; and communication. It is clear that these areas continue to have ongoing concerns which need to be addressed across the system. Theme Documentation & Records Management 2013 Recommendations 2014 Recommendations No. % No. % 11 17% 19 24% Governance and Accountability 11 17% 14 18% Training / Supervision % PPPGs 15 23% 11 14% Communication 11 17% 9 12% Human Resources / Staffing 10 15% Implementation of Recommendations and Quality Improvements Feedback on the implementation of the recommendations is ongoing and forms part of the QPSA work programme. Progress on the implementation is periodically reported to QPSA, and can be subject to validation. In December 2014, a review commenced of audits completed June 2013 June 2014 to ascertain the status of implementation of final report recommendations. The following National Directors / service managers were requested to advise on recommendation implementation and evidence of service improvements: Acute services Clinical Programmes Health and Wellbeing Mental Health National Ambulance Service 4

5 Quality Improvement (formerly Quality and Patient Safety) Social Care The review examined the implementation of recommendations across a number of strata, for example: recommendations made to a specific service (i.e. Mental Health), or recommendations pertaining to a particular theme (i.e. PPPGs). Learning from reviews such as this provides valuable information which will contribute to health intelligence, including quality health profiles, performance analysis, trending, and measuring quality improvements. A total of 81 recommendations were reviewed. 22 (27%) recommendations have been implemented, 23 (28%) are in progress and 25 (30%) have not yet progressed the process of implementation. No feedback on the implementation of recommendations was received from the Social Care division who were responsible for the implementation of 12 (15%) recommendations. The 81 recommendations were coded to identify common themes. For example, a recommendation to revise a policy was coded as policies, procedures, protocols and guidelines whilst a recommendation that a service must clarify accountability structures in leadership teams was coded as governance. The number and percentage of recommendations pertaining to each theme are outlined below: Final Report Recommendations issued - June 2013 to June 2014 by Theme: Theme Sample Recommendations Recommendations Governance Documentation & Records Management Policies, Procedures, Protocols & Guidelines (PPPGs) Communication Performance Monitoring Human Resources Risk Management / Controls Training & Supervision IT & Equipment Quality improvement plans must be developed by local management for each reported incident/group of incidents to prevent future harm arising from the causes of the incident identified by investigation HSE to review and standardise incident report forms to ensure consistency within individual services. In particular, ensure that there is a discreet section dedicated to actions planned and/or taken to prevent recurrence of incidents. No % 19 23% 16 20% In consultation with the National Director of Acute Services, QPSD must explore the development of a Quality Guideline in respect of acute service management committee TORs. The policy will state that TORs should clarify accountability, responsibility and authority for quality and patient safety in each hospital. It will also recommend governance and monitoring arrangements are put in place for the TOR, including TOR authorisation; date of approval and next revision; document location; and responsibility for revision % QPSD should recommend to the ND Acute Services the demonstrated need for 12 15% hospitals to ensure that quality and patient safety features as a standing agenda item at hospital management team meetings. All issues relating to cost containment measures must consider the impact of quality and patient safety, and that this is clearly documented. Bi-annual auditing of HCR practice must occur at each acute hospital site. 7 9% NAS to work with HSE HR to ensure that job specifications for NAS senior management are available and that they clearly document that the post holder is accountable, responsible and has authority for delivering a quality service and ensuring patient safety. QPSD should ensure the timely revision of documents pertaining to the risk register process and archive those which are no longer relevant. HSE to review and standardise incident report forms to ensure consistency within individual services. In particular, ensure that there is a discreet section dedicated to actions planned and/or taken to prevent recurrence of incidents. Progress an ICT-based live risk register to allow the opportunity for a more proactive approach to Divisional level risk issues. 4 5% 4 5% 4 5% 1 1% The 81 recommendations were also coded by risk category and to the division that has responsibility for the implementation of recommendations. 5

6 The following table illustrates the number of recommendations that have been completed (22-27%) are in progress (23 28%) or have not yet commenced the process of implementation (25 30%). 1 No feedback on the implementation of the recommendations was received from the Social Care division (12 15%). Final Report Recommendations issued - June 2013 to June 2014 by Division: Risk Category Governance / Accountability Documentation / Records Management No. of Recommendations PPPG s 14 * Communication 12 Performance Monitoring Human Resources 4 Risk Management / Controls 7 4 Division Number of Recommendations Not Commenced / In Progress / Complete NAS 4 4 Not Commenced Mental Health Complete Health & Wellbeing In Progress 4 - Complete QPSD Not Commenced Acute 1 1- In Progress Mental Health 3 1 In Progress 2 Complete QPSD 5 2 Not Commenced 3 In Progress Clinical Programmes 2 2 In Progress Acute Not Commenced 2 In Progress Social Care 2 No Returns Received Mental Health 2 2 Complete Health & Wellbeing 4 4 Complete QPSD 1 1 Not Commenced Acute 1 1 In Progress Social Care 2 No Returns Received Clinical Programmes 4 1 In Progress 3 Complete NAS 1 1 Not Commenced Mental Health 2 1 In Progress 1 Complete QPSD 5 4 Not Commenced 1 In Progress Acute 3 2 In Progress 1 Complete Social Care 2 No Returns Received NAS 1 1 Not Commenced Health & Wellbeing 1 1 In Progress Clinical Programmes 1 1 Complete Acute 4 1 Not Commenced 3 In Progress NAS 1 1 Not Commenced Acute 1 1 In Progress Social Care 2 No Returns Received NAS 1 1 Not Commenced QPSD 3 2 Not Commenced 1 In Progress Training & Social Care 4 No Returns Received 4 Supervision IT & Equipment 1 QPSD 1 1 Not Commenced Total 81 *82 * Figures under communication do not add up as one recommendation was sent to two divisions; Mental Health & QPSD. 1 s issued to the National Director of the Social Care Division on January 5 th, 16 th, 29 th and February 5 th

7 Conclusion Directors Summary In 2014 the Quality and Patient Safety Audit (QPSA) service as a key constituent of the HSE Quality and Patient Safety Division, continued to provide internal independent assurance for clinical and social services. QPS Audit, as a small audit service, play an important role as part of the HSE assurance framework not only in providing assurance but also in driving quality improvement and strengthening accountability for quality and patient safety. Whilst QPSA completed a smaller number of audits in 2014, the audits completed were longer and more complex. Two auditors were also engaged in the National Audit of Dementia Care in Acute Hospitals. This was a significant audit and the auditor s role in validating the data was valued and acknowledged. Auditing in an organisation in transition brings additional challenges, particularly the lack of clarity in the area of governance as it concerns changing roles, accountabilities and responsibilities. QPSA s key objective is to improve quality and safety. To this end, we monitor the implementation of recommendations periodically and this forms part of the QPSA work programme. As this is a self reporting process, it is subject to validation including re-audit, In December 2014, a review commenced of audits completed June 2013 June 2014 to ascertain the status of implementation of final report recommendations (p.5). A total of 81 recommendations were reviewed. 22 (27%) recommendations have been implemented, 23 (28%) are in progress and 25 (30%) have not yet progressed the process of implementation. This self reported low implementation rate is of concern as it appears to be a recurring theme across services and suggests an urgent need to scrutinise why this continues to be an issue. To this end, QPSA will also evaluate the quantity and quality of recommendations made to ensure that recommendations are SMART. Whilst providing recommendations, the audit function is conscious that these recommendations need to provide information to services to inform quality improvements and to ensure that the PDSA cycle is completed (Appendix 1includes a summary of the findings from the audits and recommendations Additionally, It is important to note that in comparing recommendations made in 2013 vs. recommendations made in 2014, four categories were in the top 5 both years. These include: documentation and records management; governance and accountability; PPPGs; and communication. It is clear from QPSA audits that these areas continue to be ongoing concerns which need to be addressed across the system. In 2015, we will continue to monitor and report on the progress of the implementation 2 of QPSA recommendations including as resources allow, possible random re-audit to validate the implementation. QPSA, as part of its commitment to quality improvement, evaluated its own performance in 2014 and amend and reorganised to reflect this. In 2015 QPSA will present individual site reports as separate audits as is the practice in Internal Audit. To date, OPSA audit numbers only reflected the audit subject not the number of sites audited. Finally, I would like to acknowledge the performance and dedication of the QPSA auditors who as a small assurance service continue to make a positive difference to the quality and safety of patient care in the HSE and the services that welcomed and facilitated the audit teams. Dr. Edwina Dunne Director Quality and Patient Safety Audit 2 The implementation of audit recommendations is the responsibility of the senior most accountable person in the area concerned. 7

8 APPENDIX: 2014 Audit Findings / Learning QPSA008/2013 Audit of the National Ambulance Service against the Theme 5 of the National Standards 24-Feb-14 The National Ambulance Service (NAS) requested an audit to examine the NAS s level of compliance with the healthcare standards under Theme 5 Leadership, Governance and Management at a national level. A significant quantity of evidence was submitted to the audit team to demonstrate that the NAS is progressing toward full compliance with Theme 5 of the National Standards. Shortfalls identified included a lack of evidence to suggest service user engagement and adequate monitoring of strategies, plans and processes. Recommendations made in this report identify actions that the NAS must implement in order to demonstrate compliance with Theme 5 of the National Standards. Findings from this audit will assist the NAS in preparing for the forthcoming HIQA monitoring programme of the National Standards. QPSA010/2013 Audit of HSE Incident Management Processes 28-Mar-14 From the evidence reviewed, from the 20 sites (Midland Regional Hospital Mullingar; Midland Regional Hospital Portlaoise; St. Columcilles Hospital; Cavan General Hospital; Cavan Primary Care; Connolly Hospital; Our Lady of Lourdes hospital Drogheda; Our Lady s Hospital Navan; Bantry Hospital; Cork University Maternity Hospital; South Tipperary Hospital; St. Luke s Hospital; Waterford Regional Hospital; Donegal PCCC; St. Camillus Hospital; University Hospital Galway; Croom Orthopaedic; University Hospital Limerick; Ennis Hospital; University Maternity Hospital Limerick) the audit team can conclude that there is full compliance with both the Identification and Immediate Management phases of the HSE Incident Management Policy and Procedure. While there was a high level of compliance with the Reporting phase, shortfalls were identified in relation to both the Investigation and Closing the Loop phases. One standard incident report form should be in use within each HSE service. In particular, there should be a clearly defined section within this form for developing actions taken or planned to prevent future harm arising from the causes of the incident identified by investigation. Such a section would improve compliance with the critical Investigation and Closing the Loop phases of the Incident Management Policy and Procedure. The audit team conclude that using risk assessment processes to determine whether an investigation into reported incidents is undertaken is not appropriate, rather an assessment should be used to determine the type of investigation required as stated in the HSE Incident Management Policy and Procedure document. QIPs should be developed for each incident reported to prevent future harm arising from the causes of the incident identified by investigation. These QIPs should reflect the complexity of the incident reported, in other words a very simple QIP will suffice for a straightforward incident. Recommendations made in this report identify actions that local HSE management must implement in order to achieve full compliance with the HSE Incident Management Policy and Procedure nationally. Findings from this audit will assist the Programme Manager for Quality and Patient Safety in preparing a revision of the current policy and procedure document and with future re-audits of this in the future. QPSA012/2013 Audit of the compliance of the notification and investigation of incidents of sudden, unexplained death of persons in community mental health services with legislative requirements and HSE policy and procedures 15-Jan-14 The Mental Health Commission / National Office for Mental Health provided the audit team with a list of incidents of sudden, unexplained death by community service area for the period From this list, the audit team selected a sample for review. 8

9 Based on the information submitted, the audit team cannot provide assurance that incidents of sudden, unexplained death of persons in community mental health service are notified in accordance with HSE policy and procedures. Nor can it provide assurance that incidents of this nature are investigated using the systems analysis methodology. Almost half of the incidents included in the audit were not investigated and where they were investigated, reports tended to be brief with little evidence of systematic examination of events or a structured process of reflection. Although deficits have been identified, the audit team recognises the work of the small number of services who examined areas for improvement and made recommendations that may mitigate the likelihood of a similar incident occurring. QPSA013/2013 Audit of compliance with safeguarding measures to ensure the protection of service users in Intellectual Disability (ID) Services, from abuse 31-Mar-14 Eight organisations were audited (Western Care Association, Castlebar; Malta Services, Drogheda; St Catherine Association, Newcastle; Cheeverstown, Dublin; Brothers of Charity Waterford; Brothers of Charity Galway; Co-Action, West Cork; St Michaels House, Dublin). The findings represent reasonable assurance to Disability Services that the safeguarding policies and procedures of six organisations included in the audit are operational. However, limited assurance can only be provided in relation to the other two organisations. Implementation of the recommendations arising from this audit will help strengthen the approach of organisations with responsibility for the care of vulnerable adults and children. In addition, HSE Disability Services need to re-engage with all organisations at a local level regarding the implementation of the action plans/recommendations as a result of Phase One, CPA. Finally consideration should be given to disseminating the good practice identified by the audit team to all ID service providers. QPSA016/2013 Audit of characteristics, work practices and referral patterns to AMAU/AMU in selected acute hospitals as per the National Acute Medicine Programme report 30-May-14 A sample of six acute hospitals was selected for audit: three Model 3 hospitals (St Luke's Hospital, Kilkenny; Our Lady of Lourdes Hospital, Drogheda; and Mayo General Hospital) and three Model 4 hospitals (The Adelaide and Meath Hospital incorporating the National Children s Hospital, Tallaght; Waterford Regional Hospital, and University Hospital Limerick). Based on the information submitted, the site visits and the HCRs reviewed at each of the six sites, the key characteristics, work practices and referral patterns as identified in the AMP report 2010 are being implemented and continue to be a work in progress. Work practices, as identified in the AMP report, are not fully developed due to the fact that all Model 4 AMAUs are not operating on a 24 hour seven day a week basis and further development and implementation of work practices is ongoing. Areas needing improvement include: clear performance monitoring: recording of all experience times (PETs), communication with GPs, common definitions, IT supports and the development and implementation of an admission avoidance policy, procedure and/or guideline. Particular areas of good practice were noted as follows: expanded nursing roles, triaging of patients, rapid access to diagnostics, development of the role of the case manager, patient streaming (where available) and multidisciplinary team work. The audit team conclude that the implementation process is ongoing and that organisational structures to implement the AMP are in place. 9

10 QPSA001/2014 Audit of Compliance with selected European Network of Smoke Free Health Services Standards/Criteria and the HSE Tobacco Free Campus Policy of the Tobacco Control Framework, Oct-14 Eight sites were selected for audit: Beaumont Hospital, St James s Hospital, Dr. Steeven s Hospital, University Hospital Limerick, University Hospital Waterford, Cork University Hospital, Mayo General Hospital and Virginia Primary Care Centre. All eight sites demonstrated a reasonable level of good practice in relation to tobacco control; however, deficits were also noted that require action in order to increase compliance with ENSH - Global Standards. The level of compliance ranged from compliant to non-compliant with the ENSH - Global Standards. A significant quantity of evidence was submitted to the audit team in relation to the communication, training and managerial strategies used in the development of the TFC. There is a high level of variation in the documentation, terminology and signage used, and this needs to be addressed nationally in order to create an effective TFC brand. The audit team noted that the sites audited were at various stages with regard to the implementation of the TFC. There was evidence that the majority of sites had made significant progress in their work to-date towards a completely tobacco free environment. In the sites where progress was less obvious, in general, there were justifiable reasons that resulted in the work being done at a slower pace. Recommendations made in this report identify actions that must be implemented at national level in order to improve compliance with Standard 1, 3, 4 and 5 of the ENSH -Global Standards. QPSA002/2014 Audit of compliance with Standard 3 of HSE Standards and Recommended Practices for Healthcare Records Management (HCRs) V3.0 (repeat audit in different sites) 23-Jul-14 Four hospitals were selected for audit based on geographical spread and function and included one paediatric hospital and one maternity hospital as follows: Cavan General Hospital; Our Lady s Children s Hospital, Crumlin; St. Vincent s University Hospital; and University Maternity Hospital Limerick. The review of the HCRs demonstrated that all four sites maintained a high level of compliance with most of the selected criteria from Standard 3 of the HSE HCRs Standard V3.0. A lower level of compliance was noted in the need for a consistent approach to documenting allergies and alerts in the designated section of the HCR, the inappropriate use of unapproved abbreviations and in the requirement for the name of the primary clinician to be clearly identifiable in the HCR at all times. There was reasonable evidence provided by three of the four hospitals to demonstrate that formalised HCRs governance arrangements are in place. There was a lack of HCRs training, education and induction in three of the four hospitals. HCRs internal audit was of a high standard in all four hospitals. Recommendations made in this report identify actions that must be implemented at national level in order to improve compliance with Standard 3 of the HSE HCRs Standards. Findings from this audit, in particular feedback from the four hospitals and the innovative practices observed, will support the development of future versions of the Standards. QPSA003/2014 Audit of nursing staff compliance with documentation criteria, standards, guidelines and local policy pertaining to MDA Schedule 2 Drugs Management 13-Nov-14 A random sample of four acute hospitals was included in the audit: University Hospital Waterford, Sligo Regional Hospital, Temple Street Children s University Hospital, and Naas General Hospital. This audit found varying levels of compliance with documentation standards pertaining to MDA schedule 2 controlled drugs in the hospitals audited. Recommendations made in this report identify actions that these hospitals must implement in order to progress towards compliance in this area. 10

11 Vigilance with regards to documentation of controlled drugs must be maintained to ensure the safety of patients. There was evidence of some good practices at each hospital, as follows: the structure and format of the documentation in place for monitoring and checking the count for controlled drugs at shift changeover; and the documentation in the MPAR s examined. There was also evidence of a commitment of regular audit of MDA Schedule 2 controlled drugs. Some broader findings which came up during the course of this audit require clarification nationally. Local medication management policy must then be updated to reflect the guidance issued. QPSA004/2014 Review of clinical leadership and supervision in respect of CNM2/CMM2s in acute hospitals, with focus on the regularisation of acting up arrangements 28-Oct-14 The emphasis of this review was on clinical leadership and supervision in respect of CNM2/CMM2s in acute hospitals, with a focus on the regularisation of acting-up arrangements. From the evidence provided, the audit team concludes that acute hospitals and the HR department do not have a consistent and comparable perspective as to the number of CNM2/CMM2s in acting posts. Data is gathered from different sources and coded differently. Workforce management and the regularisation of posts require more oversight from a national perspective, as well as greater interdepartmental collaboration. Joined-up systems should then apply through the various strata of governance, from national level to hospital trust level to local nursing management and HR departments in individual hospitals. Recommendations made in this report identify actions that Acute Hospitals, HR, ONMSD, and the DOH must implement in order to improve oversight of the regularisation of CNM2/CMM2 posts and to enhance CNM2/CMM2s sense of empowerment and clarity in respect of their responsibility, authority, and accountability for safe and effective nursing/midwifery care of patients. QPSA005/2014 Audit of compliance with the Irish Maternity Early Warning Score (I-MEWS) Clinical Practice Guideline (2013) in selected maternity hospitals/units 02-Dec-14 Seven hospital sites were audited, including: The Coombe Women and Infants University Hospital; The Rotunda Hospital; University Hospital Galway; Cork University Maternity Hospital; Cavan General Hospital; South Tipperary General Hospital; and Midlands Regional Hospital Mullingar. Evidence for this audit was gathered from a retrospective examination of the observation charts and associated nursing and/or clinical notes in the sample of pre and post natal HCRs The audit team can give reasonable assurance that vital signs (TPR and BP) are appropriately recorded on the I-MEWS observation chart (excluding the Rotunda Hospital) by nursing/midwifery staff. Observations reviewed were found to be consistently numerically recorded and dated. The main deficits in compliance identified by the audit team were in relation to initialling and scoring of observations. In the case of the Rotunda Hospital there was clear evidence that the vital signs are appropriately recorded (i.e., numerically initialled and dated) using the local EWS guideline. The audit team observed that some hospitals recorded a small number of I-MEWS scores with a corresponding entry in the nursing notes in the format of I-MEWS = 2 Y etc. The audit team is of the view that this demonstrates good practice and should be incorporated into the national guideline and used consistently in all hospitals. Deficits were found in all hospitals (excluding the Rotunda) in relation to the completion of repeat observations within the recommended timeframes following a trigger. However, the majority of hospitals demonstrated a high level of compliance in relation to escalating the necessary clinical care in cases of red and multiple yellow triggers. The audit team acknowledge that the number of cases of DMS found was small and thus may not provide an accurate picture of the extent to which I-MEWS triggered an escalation of care. However, the team found reasonable evidence that the use of I-MEWS triggered the escalation of care in the cases of DMS reviewed. The use of midwifery metrics in all maternity hospitals will promote improvements in the delivery of safe, effective and person centred care. 11

12 QPSA006/2014 Assurance Project on the Implementation of Recommendations from Audits/Reviews carried out in Áras Attracta from November 2013 to May Aug-14 A significant amount of evidence was gathered in respect of this assurance project to demonstrate that identified risks have been or are being addressed at Áras Attracta. Strategies, plans and processes have been developed and Áras Attracta is progressing toward compliance with the regulations of the Health Act (2007) and the National Standards for Residential Services for Children and Adults with Disabilities (2013). The project team observed that Áras Attracta has made numerous improvements to its service since the five audits/reviews were issued, and can only provide reasonable assurance in the evidence that was viewed at this point that: Governance issues and risks identified in the five audits/reviews are in the process of being resolved; The standard of care observed by the project team was of high quality at the time of the audit; Áras Attracta is compliant with the HSE Risk Management Policy; and A number of monitoring processes are in place at local level to provide ongoing oversight and assurance in relation to implementing required action plans to address deficits in care. Implementation of the recommendations (there is still much to be done) from this assurance project will assist Áras Attracta in addressing the identified risks and in preparing for the forthcoming HIQA monitoring of the National Standards. The serious issues presented by the RTE programme were not evidenced to the project team at the time of the audit. QPSA008/2014 Audit of accountability arrangements for quality and patient safety in acute hospitals 07-April-15 Five hospitals were selected for audit, based on geographical spread and function. However, only three sites were visited due to audit service reconfiguration. Temple Street Children s University Hospital (TSCUH) - audit completed Cappagh National Orthopaedic Hospital (CNOH) audit completed Portiuncula Hospital, Ballinasloe (PHB) outstanding (to be completed in 2015) University Maternity Hospital, Limerick (UMHL) audit completed Our Lady of Lourdes Hospital, Drogheda (OLOLD). outstanding(to be completed in 2015) The objectives of the audit were to assess the level of compliance with the requirements of four selected standards from Theme 5 of the NSSBH (HIQA, 2012) and to determine the processes in place to inform the CEO and executive management team in respect of the key areas of quality and safety. TSCUH TSCUH provided sufficient evidence to demonstrate compliance with the selected standards from Theme 5 of the NSSBH. Clear accountability arrangements were in place with formalised governance arrangements for achieving the delivery of high quality, safe and reliable healthcare. A Statement of Purpose was being ratified by TSCUH at the time of the audit with a plan to publish once signed off. Formal agreements such as SLAs existed to monitor the quality and safety of services provided on behalf of TSCUH. Although a standing item on the agenda of most meetings, it was recommended that quality and patient safety becomes the first agenda item for all relevant committee meetings. The audit team agreed with the TSCUH self assessment of Theme 5 and recommended that TSCUH develop a documented process for clinical handover and that the Risk Assessment Strategy, the Escalation Pathway and the TOR for the Risk Register Review Group be finalised. UMHL UMHL demonstrated partial compliance with the selected standards of Theme 5 of the NSSBH and it was evident that a number of processes existed to inform the CEO and management team in 12

13 respect of effective quality and safety. However, although accountability arrangements were in place, some were not clear in terms of committee reporting / effectiveness. The Statement of Purpose lacked clarity in regards the location of UMHL and UL Hospitals Emergency / Paediatric Departments being situated on separate locations. Formalised agreements such as SLAs existed to monitor the quality and safety of services provided on behalf of UMHL. The Clinical Director had formally requested the Acting CEO recruit a Quality and Patient Safety Lead for the group. The audit team recommended that quality and patient safety be made the first agenda item for all relevant committee meetings; the Statement of Purpose should be made publicly available by the end of Q1; all documentation should be standardised; relevant KPI s for quality and safety need to be established; and that the HIQA Galway report recommendations must be implemented. CNOH CNOH demonstrated medium compliance with the selected standards from Theme 5 of the NSSBH and a number of processes existed to inform the CEO and management team in respect of effective quality and safety. The Statement of Purpose is being updated and once finalised, will be published. The Clinical Governance Strategy needs to be ratified and the Quality and Risk Committee TOR require updating, as do a number of PPPGs. Accountability arrangements had formal governance structures to support them and the quality and safety of services provided on behalf of CNOH were monitored through agreements such as SLAs. However, the HSE 2014 SLA was not received by CNOH until October 2014.The audit team recommended that quality and patient safety be made the first agenda item for all relevant committee meetings; the frequency of Clinical Governance Committee meetings change from bi-annual to quarterly; and develop a whole hospital quality improvement programme to integrate all QIPs from internal and external report recommendations. An Open Disclosure Policy was being developed and a QIP was in place for Theme 5 of the NSSBH. 13