Ms. Eileen Tormey, Quality and Patient Safety Auditor

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1 QUALITY AND PATIENT SAFETY AUDIT EXECUTIVE SUMMARY Title Number Audit of Accountability Arrangements for Quality and Patient Safety in Acute Hospitals QPSA008/2014 Timeframe October 2014 February 2015 QPSA Team Members Ms. Patricia Gibbons, Quality and Patient Safety Auditor (Lead) Ms. Eileen Tormey, Quality and Patient Safety Auditor Approved by Audit Liaison Dr. Edwina Dunne, Director, Quality and Patient Safety Audit Ms. Maureen Flynn, National Lead, Quality and Safety Governance Development Source of Evidence Type Request for Evidence Date Evidence returned between November 2014 and December 2014 Site Visits: TSCUH CNOH UMHL Issue Date 08 April November /10 December December BACKGROUND / RATIONALE The Health Service Executive (HSE) defines clinical governance as: the system through which healthcare teams are accountable for the quality, safety and experience of patients in the care they have delivered (HSE, 2014). For healthcare staff it means specifying the clinical standards a service will deliver and showing the measurements a service has made to demonstrate that the service has done what it set out to do (HSE, 2014, p. 1). A number of reports and guidance documents for clinical governance have been developed by the HSE to assist and support services in the provision and delivery of high quality, safe, responsive services, such as: (i) Quality and Patient Safety Clinical Governance Information Leaflet, (HSE, 2012) (ii) Quality and Patient Safety Clinical Governance Development Assurance Check for Health Service Providers (HSE, 2012) and (iii) Quality and Safety Committee(s) Guidance and Sample Terms of Reference (HSE, 2013b). In addition, the requirement for governance structures with clear accountability arrangements is specifically outlined within Theme 5 of the National Standards for Safer Better Healthcare (HIQA, 2012). The HSE published the Report of the Quality and Safety Clinical Governance Development Initiative Sharing our Learning on the 6 May 2014, (HSE, 2014). That report shows the role that clear managerial leadership plays in making quality and safety the number one priority and is built 1

2 on the model of the Chief Executive Officer (CEO)/General Manager (GM) or equivalent, working in partnership with clinical directors, directors of nursing/midwifery (DONM) and service/professional leads in all matters related to the quality and safety of services provided. There are different interpretations of what falls within the realm of clinical governance, but most would agree that it consists of the following elements: education, clinical audit, clinical effectiveness, risk management, research and development and openness. Clear accountability is one of the ten guiding principles for clinical governance. Accountability arrangements support the development of governance for quality and safety and ensure the delivery of safe, high quality services. Though there is often ambiguity in its application, accountability is considered the lynchpin of clinical governance. 2. AIM AND OBJECTIVES The aim of this audit was to provide assurance in relation to the accountability arrangements in place for quality and patient safety in a sample of acute hospitals. The objectives of the audit were to: 1. Assess the level of compliance with the requirements of four selected standards from Theme 5 of the NSSBH (HIQA, 2012), including: Standard 5.1: Service providers have clear accountability arrangements to achieve the delivery of high quality, safe and reliable healthcare. Standard 5.2: Service providers have formalised governance arrangements for assuring the delivery of high quality, safe and reliable healthcare. Standard 5.3: Service providers maintain a publicly available statement of purpose that accurately describes the services provided, including how and where they are provided. Standard 5.9: The quality and safety of services provided on behalf of healthcare service providers are monitored through formalised agreements. 2. Determine the processes and systems in place to support and inform the Chief Executive Officer (CEO) and senior/executive management team in respect of the key areas of quality and safety in the acute hospital. 3. FINDINGS The findings were determined as a result of a review of evidence, documentation, interviews with senior management, and questionnaires completed by senior managers. 3.1 Accountability arrangements in place for quality and patient safety There was reasonable evidence provided by all three hospitals to demonstrate that accountability arrangements are in place to support quality and patient safety. In one hospital, however, specific areas require attention to ensure that the documented accountability arrangements are fully communicated and embedded from a directorate level to a hospital group level. Management team structures across hospital sites varied. The audit team considers that national guidance would be beneficial in order to inform and direct a common approach to specific hospital committee structures, including information flow to and from relevant committees and names of committees. A number of documents provided from two of the three hospitals were not dated, and many terms of reference (TORs) did not reflect a standardised approach to document control which is necessary to ensure that all documentation is reviewed and updated systematically. The audit team observed that the senior manager job descriptions did refer to the individual s accountability for quality and patient safety in the hospital. The three hospitals involved in this audit must update and make the Statement of Purpose publicly available as soon as it is finalised. 2

3 3.2 Governance arrangements for monitoring the delivery of high quality and safe care There was reasonable evidence provided by all three hospitals to demonstrate that the hospitals have documented arrangements in place for monitoring quality and patient safety and ensuring that the CEO/GM and senior management team are kept fully informed of all key areas of quality and patient safety in the hospital. In two of the three hospitals, however, the monitoring arrangements must be further strengthened and improved. There was limited evidence of discussion of quality and patient safety at senior management team meetings. Topics relating to quality and patient safety were discussed when the need arose, but were not a standing item on agendas. In the majority of management team and clinical governance committee minutes of meetings reviewed for two of the three hospitals, it was not always clear what agreements were reached, decisions taken, responsible persons and follow-up actions agreed. 3.3 Evidence that quality and patient safety is a priority for the CEO and senior management There was reasonable evidence provided by all three hospitals demonstrating that quality and patient safety is a priority for the CEO/GM and senior management. The CEO/GM s accountability for clinical outcomes / monitoring needs to be developed and embedded through quality and safety / clinical governance committees. 4. CONCLUSION Based on the evidence, the audit team can conclude that TSCUH is compliant with the selected standards from Theme 5 of the NSSBH, Cappagh National Orthopaedic Hospital (CNOH) is in partial compliance with the selected standards from Theme 5 of the NSSBH and University Maternity Hospital, Limerick (UMHL) was in partial compliance with the selected standards of Theme 5. In two of the hospitals, a number of accountability arrangements were in place but some of them were not clear in terms of committee reporting / effectiveness. Standardisation of documents must be ensured, as document control is an important part of governance. UMHL is in the process of embedding directorate structures within a hospital group with a newly appointed chief executive officer (November 2014). At the time of audit, a number of QIPs / action plans were in place. The audit team was advised by the management team in one of the hospitals, that the progression of these action plans has been challenging. The Clinical Director had written to the acting CEO regarding the need to appoint a lead person for Patient Safety and Quality for the Directorate. The risk associated with the lack of a risk advisor in Paediatrics and a lead person for quality and patient safety for the Maternal Child Health Directorate has been escalated via the risk assessment process / risk register. Governance for quality and patient safety is in place in each of the three hospitals and the reporting relationships are becoming embedded as the hospital group structures evolve. The three hospitals must ensure that quality and safety is the first agenda item of meetings, including the Board of Directors and that committee meeting agendas and minutes are aligned with the NSSBH standards, as outlined in Health Service Executive (HSE) (2013b), Quality and Safety Committee(s), Guidance and Sample Terms of Reference. Each hospital must identify quality indicators and outcome measures to be monitored and reviewed by the quality and safety governance committee in the organisation. CNOH and UMHL should complete the self assessment of Theme 5 National Standards for Safer Better Healthcare (NSSBH), Quality Assessment + Improvement (QA + I) tool. 3

4 A whole hospital quality improvement programme to integrate all Action Plans / QIPs from internal and external report recommendations (NSSBH, HIQA, risk management, audit, incidents /complaints, patient experience, etc.) would be beneficial to put in place, where one does not exist, and the recommendations progressed as a matter of urgency. In terms of accountability arrangements relating to quality and patient safety between hospitals and from hospitals to/from the community, the senior managers in the three hospitals were of the opinion that the new hospital groups and community healthcare organisations (CHO s) will provide appropriate structures for quality and patient safety accountability. Hospital management team structures and names varied significantly across the three hospitals. The audit team considers that it would be beneficial to have national guidance to inform and direct hospital management team structures and names. The current accountability arrangements for quality and patient safety established in the hospitals are evolving and expanding with the development of the clinical directorates and new hospital groups. Reasonable evidence was provided to the audit team to demonstrate that the CEO/GM and senior management team in each hospital are fully informed of key areas of quality and patient safety in their hospital hospitals have documented arrangements in place for monitoring quality and patient safety and a number of processes and systems are in place to ensure that quality and patient safety is a priority for senior managers.. Recommendations made in the site reports identify actions that the hospitals must implement in order to demonstrate full compliance with the selected theme of the national standards. The following recommendations are inclusive of the three acute hospital sites. 5. RECOMMENDATIONS 1. The acute hospitals audited must ensure that quality and patient safety is the first agenda item for all relevant committee meetings, including the Board of Directors. 2. The three hospitals involved in this audit must update and make the Statement of Purpose publicly available as soon as it is finalised. 3. Two of the three hospitals must ensure the consistent use of an identifiable brand on all documents, including committee meeting agendas and minutes, for the purpose of document control. 4. Two of the three hospitals should align committee meeting agendas and minutes to the NSSBH standards in accordance with guidance in the Quality and Safety Committee (s): Guidance and Sample Terms of Reference (HSE 2013b) and the National Standards (HIQA 2012). 5. The three hospitals should identify quality indicators and outcome measures to be monitored and reviewed in the organisation. 6. The Quality and Safety Committees should monitor the clinical programmes against relevant outcome indicators. 7. Two of the three hospitals should complete the self assessment of Theme 5 National Standards for Safer Better Healthcare (NSSBH), Quality Assessment + Improvement (QA + I) tool. 4

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