FREEDOM OF INFORMATION GUIDE FREEDOM OF INFORMATION GUIDE

FREEDOM OF INFORMATION GUIDE FREEDOM OF INFORMATION GUIDE MERCY UNIVERSITY HOSPITAL MERCY UNIVERSITY HOSPITAL FREEDOM OF INFORMATION FREEDOM OF INFORMATION Guide to the Function and Records of the Hospital Guide to the Function and Records of the Hospital Freedom of Information Act, 1997 & 2003 Freedom of Information Act, 1997 & 2003 Section 16 Reference Book Section 16 Reference Book

FOREWARD As providers of a public health service, the Mercy University Hospital welcomes the introduction of Freedom of Information Legislation. Implementation of the act is part of greater openness with regard to decision-making by public bodies and access by the public to personal and general information held by them. This reference manual has been published in accordance with Section 16 of the Freedom of Information Act 1997 & 2003 as amended. The purpose of this manual is to facilitate access to information held by the Mercy University Hospital, and to assist members of the public in making a request under the Freedom of Information Act 1997 & 2003. This manual will be updated on an ongoing basis and is being provided to all who require it free of charge. Comments on this manual will be welcome to the Freedom of Information Office, Mercy University Hospital, Cork. Tel: (021) 4935389 Mr. Pat Madden, Chief Executive Officer

PREFACE How to use this Reference Book This Reference Book supersedes the April, 2006 Edition and has been prepared and published in accordance with the requirements of Section 16 of the Freedom of Information Act, 1997. Section 16 of the FOI Act provides for a publication containing a guide to the administration of services. To achieve the maximum benefit from this Reference Book, it is worthwhile spending some time looking through the contents pages, the different chapters, the glossary and the general index to get an idea of the book s scope. If any assistance is required in using this reference book, or on any aspect of the Freedom of Information Act, please contact the FOI Office at 021-4935389

CONTENTS 1. Introduction 2 Legislative Background to the MUH 3. Policies 4. Eligibility Criteria 5. Patient/Visitor Information 6. Appeals/Complaints 7. How to obtain information

1. Introduction Freedom Of Information Act - Summary The Freedom of Information Act 1997 & 2003 as amended is designed to facilitate public access to information held by public bodies which is not routinely available through other sources. The Freedom of information Act 1997 & 2003came into effect for Government Departments on 21 st April 1998, for Health Boards on 21 st October 1998 and Voluntary Hospitals on 21 st October 1999. The Freedom of Information Act 1997 establishes three statutory rights: A legal right for each person to access information held by public bodies. A legal right for each person to have official information in relation to him/herself amended where it is incomplete, incorrect or misleading. A legal right to obtain reasons for decisions affecting oneself. Access to information under the Act is subject to certain exemptions and involves specific procedures and time limits. The Act asserts the right of members of the public to obtain official, information from public bodies, to the greatest extent possible consistent with public interest and the right to privacy of individuals. Information routinely available The Mercy University Hospital currently makes information available to the public about its functions and services. Information leaflets, guidelines, application forms and other general information will still be available without the need to use the Freedom of Information Act. General Overview of Section 15 Section 15 of the Freedom of Information Act requires the Mercy University Hospital to produce a reference book setting out its structures and organisation, its functions, powers and duties, the services it provides and the procedures by which these services may be availed of by the public. General overview of Section 16 Section 16 of the Freedom of Information Act requires the Mercy University Hospital to produce a reference book setting out rules, guidelines or practices used in the administration of services. In accordance with this section, the Mercy University Hospital has prepared a manual containing details of: Introduction Legislative background including regulations MUH Policies Eligibility criteria Patient and Visitor Information Appeals procedure

Adoptive Leave Act 1995 Anti Discrimination Pay Act 1974 2. Legislative Background Births & Deaths Registration Act 1863-1972 Child Care Act 1991 Civil Liability and Courts Act 2004 Civil Registration Act 2004 Clinical Trials Regulations 1995 Clinical Trials on Medicinal Products for Human Use Regulations 20 Companies Act 1963-2003 Competition Acts, 1991-1996 Contractual Obligations (Applicable Law) Act, 1981 Control and Supply of Drugs Regulations 1995, 2003 Coroners Act 1962 Coroners (Amendment) Act 2005 Data Protection Act 1988 Data Protection (Access Modification) Health Regulations 1989 Health Data Social Work Data Data Protection Directive 95/46/EC Department of Health Circulars Disability Act 2005 Equal Status Act 2000 EU Directive on Establishment of European Works Councils E U Procurement Directives E U Regulations (where applicable) European Communities (Clinical trials on Medicinal Products for Human Use) Regulations 2004 Employment Equality Act 1977, 1998 and 2004 Finance Acts Fire Service Act, 1981 Freedom of Information Act 1997 & 2003 Food and Hygiene Regulations 1950-1989 Health Act 1970 Health (Amendment) Act 1986-1994 - Road Traffic Accidents Health (Amendment) Act 1996 Health (Amendment) Act 2005 Health Amendment Regulations (In-Patient charges) 1997 Health Amendment Regulations (Out-Patient charges) 1997 Health and Social Care (Amendment) Act 2005 Health Services (In-Patient and Out-Patient) Regulations 1991 Health and Social Care Professionals Act 2005

Industrial Relations Act 1946-1990 Industrial Relations and Trade Union Acts, 1913-1976 Infectious Diseases Regulations 1981-1988 Irish Medicines Board Act 1995 Jury Service Act 1976 Maternity Protection Act 1994 Maternity Protection (Amendment) Act 2004 Maternity Protection of Employees Act 1981 Medical Practitioners Act 1978-1993 Medical Devices Directives 1994 Medicinal Products (Prescription and Control of Supply) Regulations 2003 Mental Treatment Act 1945-1961 Mental Health Act 2001 Minimum Notice & Terms of Employment Acts 1973-1997 Misuse of Drugs Act 1977/1984- as amended 1993 Misuse of Drug Regulations 1998 National Minimum Wage Act 2000 Non-Fatal Offences Against the Persons Act 1997- Section 23 Nurses Act 1985 Ombudsman Act Organisation of Working Time Act 1997 Parental Leave Act 1998 Payment of Wages Act 1991 Pharmacy Act 1875 as amended 1991 Poisons Act 1961 & Regulations 1991 Protection of Employment Act, 1977 Protection of Young Persons (Employment) Act, 1996 Pregnant Employees Regulations 1994 Prompt Payment of Accounts Act 1997 Radiological Protection Act 1991- The Radiology Department works under licence issued to them by the Radiological Institute of Ireland. Redundancy Payment Act, 1967-1991 Safety, Health and Welfare (General Applications) Regulations 2007 Safety Health and Welfare at Work Act 2005 Sale of Goods and Supply of Services Act 1980 Statute of Limitations Acts 1957 and 1991 Statute of Limitations (Amendment) Act 2000 Terms of Employment (Information) Act 1994 Transnational Information and Consultation of Employees Act, 1996 Unfair Dismissals Act 1977 as amended 1993

Voluntary Hospitals Superannuation Scheme 1969 as amended 1977 & 1995 Waste Management Acts 1996 and 2001 Worker Participation (Enterprise) Acts, 1977 and 1988 Worker Protection Regular Part-Time Employee s Act 1991

3. Policies Hospital Wide Policies Audit Policy Hygiene Standards Casemix Policy Communications Policy Complaints Policy Completion of Death Notification for Registration Corporate Code of Ethics and Business Conduct (this policy is in addition to previous Donations Policy) Daily Image Management (PACS / RIS) Decontamination Policy Guidelines for Completion of Death Certificates for Cremation Guidelines for Merging Patient Details on the Information Technology (IT) Systems Medical Records Department Image Copying (PACS / RIS) Implementation of the Estimated Date of Discharge Tracker Form Implementation of the Medical Documentation and Communication of an Estimated Length of Stay / Estimated Date of Discharge for Elective Admissions and Direct Admission to MUH Importing of Images onto PACS PACS / RIS Username and Password Policy PACS General Usage Policy PACS System Downtime Password Policy Permit to Work Policy and Procedure Prevention of Nosocomial Aspergillosis and other Airborne Fungal Infections during Construction / Renovation Activities Processes For Creation, Review And Amendment Of Policies Release of Patients Charts from MUH Serious Adverse Event Policy Telephone Policy and Procedure Use of USB Devices Visiting Policy for Sales Representatives detailing Pharmaceutical and Medical Products in MUH (and associated free samples)

4. Eligibility Criteria Persons ordinarily resident in Ireland and using public hospital services may choose to be public or private patients: Private patients are liable for Consultant and accommodation charges Public patients (excluding medical card holders and other specific exemption categories) are liable for daily charges for accommodation. Short-term visitors are entitled for services as follows: Visitors from the UK and other EU countries are entitled to urgent medical treatment, without charge, in public hospitals. Patients must provide a European Health Insurance Card (EHIC) or proof of UK residence. Non EU patients charge of 1000 & 75 per night ( 75 charged to a max of 10 nights) and are liable for other charges e.g. x-rays, bloods etc. Long-stay extended care: Patients admitted to the long-stay units are liable for maintenance charges Respite services: Patients admitted for respite care are liable for a daily/weekly charge. Category One Eligibility applies to persons who have medical cards which are issued to eligible patients who satisfy a means test based on personal income. Person in Category One are entitled to: In-patient hospital services (including Consultant services) in public wards Out-patient public hospital services (including Consultant services) Attendance at the Emergency Department Category Two Eligibility applies to persons who do not qualify for a medical card. Persons in Category Two are entitled to: All in-patient public hospital services in public wards (including Consultant services) subject to the in-patient levy, which stands currently at 75 per day subject to a maximum of 750 in any consecutive 12 month period. Details of public hospital charges are available from any Hospital Administration or Accounts Department. All out-patient public hospital services (including Consultant services). Free attendance at the Emergency Department provided the patient has a referral letter from his/her doctor. Otherwise there is a charge of 100 levied Choice of Public or Private Care A person using hospital services may choose to be a public or private patient. The implications of this choice with regard to in-patient and out-patient services are as follows: In-patient services If a person chooses to be a public in-patient He or she must use a public bed

He or she is not the private patient of any Consultant and does not pay Consultant s fees. If there is a waiting list, he or she will be placed on this list for a public bed If a person chooses to be a private in-patient He or she must use a private or semi-private bed He or she is the private patient of his or her own Consultant and any other Consultants involved in his or her care, (e.g. Radiologist, Pathologists, Anaesthetists) and is liable for Consultant fees either personally or through their Health Insurance Scheme If there is a waiting list, he or she will be placed on this list for a private or semiprivate bed In a medical emergency, a patient will be accommodated in whatever bed is available at the time. In such a case, a private patient may be admitted to a public bed until private or semi-private accommodation becomes available. Patients admitted from Consultants private rooms are treated as private inpatients, unless written authorisation stating otherwise is received from the Consultant. Will remain private patient for future admission for same complaint Out-Patient Services If a person chooses to be a public out-patient He or she attends a public out-patient clinic. He or she is not liable for Consultant s fees. If a person chooses to be a private out-patient He or she attends the Consultant privately in the Consultants rooms or private clinic. He or she is the private patient of any other Consultants he or she may be referred. He or she is liable for Consultant s fees. Exemptions from Public Hospital Charges: Women receiving maternity services Children up to six weeks of age Children receiving treatment for mental handicap, mental illness, phenylketonuria, cystic fibrosis, spina bifida, hydrocephalus, haemophilia or cerebral palsy Medical Examination patients Children referred from Child Health Clinics and School Health Examinations Patients in state custody Persons receiving services in respect of prescribed infectious diseases Patients with Army/Navy cover Long-stay patients who are already being charged under the Health (charges for in-patients services) Regulations

Hepatitis C patients Short-term visitors from European Union (EU) or European Economic Area (EEA) Member States receiving Urgent Medical Treatment are not liable for these charges (must have EHIC). EHIC holders, including UK citizens Hospitals have discretion to waive public hospital charges in cases of hardship. Applications should be made to the hospital. Charges for Private and Semi-Private accommodation in public hospitals: Charges for private and semi-private accommodation in public hospitals are outlined below. These charges are additional to the daily public hospital accommodation charge (which is 75 per day at present). Hospital Category Private Semi-Private Day-Care Health Board Regional Hospitals, Voluntary & Joint Board Teaching Hospitals. 985 788 730 Health Board County Hospitals, Voluntary Non- Teaching Hospitals 607 488 434 Health Board District Hospitals 260 222 193 Road Traffic Accidents Where treatment is required as a result of a road traffic accident and the patient may be entitled to receive compensation from a third party arising from the accident, a public hospital may charge the cost of providing treatment. The patient/solicitor will be notified of charges when the treatment has been provided. The account is payable when compensation is received. The Health Board or Hospital which provides treatment may waive some or all of the charges in certain specified circumstances. Hardship Cases The Mercy University Hospital has the discretion to waive public hospital charges in cases of hardship. Appeals/Queries in relation to Charges These are addressed by the Supervisor in the Patients Accounts Department when they arise.

5. Patient and Visitor Information Visiting Times General Areas: 2pm 4pm and 6.30pm 8.30pm We welcome visitors to our Hospital and realise the importance of these visits to the well-being of our patients. However, people in hospital do require peace, quiet and rest to recover. Therefore, no more than two visitors should be at the bedside at any one time. Please co-operate with staff if you are asked to leave the Ward for a time to maintain this number. Children under 12 years other than the patient s own children should not be brought to visit. Children must be under the supervision of an adult at all times while in the hospital. Children s ward: 8.30am 9.00pm {Parents/guardians only} General ward visiting policy applies to children s wards. Parents/Guardians may visit from 8.30am 9.00pm daily. One parent/guardian may stay overnight with the child. The Unit Manager may give permission to alter these arrangements in some very specific cases. Car Parking We regret that there are no car parking facilities available at the Hospital. The parking area around the Hospital is a disc-parking zone; and the nearest multi-storey car parks are at Dunnes Stores Shopping Centre at North Main Street and St. Finbarr s Car Park in the newly developed area near Jury s Hotel on the Western Road. Taxis There are a number of free-phones located in the main reception of the hospital and in the Emergency Department. Bus Bus Eireann provides a service to the hospital environs as follows: Bus Stop on Washington St. and the Mardyke area (no 5 & 8) Bus stop located on Sheare St to service city centre and northside of City (5 &8). Shop Opening Hours: 8am - 9pm The Hospital shop is located opposite the main lift, on the second floor. Essential items are available here, including telephone cards, parking discs, toiletries, newspapers, cards and gifts. A trolley service operates daily throughout the Hospital, during the hours of 9-11am. This service provides newspapers, minerals, toiletries, etc.

Telephones Public card and coin phones are available throughout the Hospital. Telephone call cards can be purchased at the Hospital shop. It would be appreciated if calls from relatives and friends to the staff were kept to a minimum. THE USE OF MOBILE PHONES IS STRICTLY PROHIBITED within the Hospital as they interfere with vital medical equipment. Telephone Enquiries Our staff are committed to the protection of patients privacy; thus you will appreciate that the delivery of the patients progress must be carefully controlled. It would be appreciated if calls from relatives and friends to the staff were kept to a minimum. Please remember, while our staff are prepared to help with enquiries at all times, their primary role is the delivery of care to the patient. Unnecessary enquiries should be avoided. Necessary enquiries should be conducted by an appointed spokesperson for the family/patient where possible. You may telephone the Hospital +353 (21) 4271971 and ask for the relevant ward. Public Toilets/Wheelchair Access Toilets The visitors toilet is on the ground floor and reached through the double doors to the Emergency Department. Chaplaincy and Pastoral Care Mass Monday Thursday 12 noon; First Friday of Month 7.15pm; Saturday Evening 7.15 p.m. (For Sunday) Sunday 11am (Note- Sunday mass is also available on Mercy TV). Communion delivered everyday throughout ward from 7.20 am onwards and on Sundays from 11.50 am onwards The Sacrament of Healing Confession is available at any time in the ward by request through the ward manager or any of the chaplaincy team. Other Denominations and Faiths A Church of Ireland chaplain is available in the hospital. There is also a prayer room available for those of Muslm faith. Patients may request through the ward manager a minister or representative of their faith. Special Needs Our staff are conscious of and highly committed to addressing the special needs of our patients. It may be that you have a mobility, communication, visual, hearing or language

difficulty. If you have a special need, please make it known to the Ward Nurse Manager on your admission or at any point throughout your stay

6. Appeals/Complaints The procedures to be followed are set out below: Appeals Procedure The Freedom of Information Act 1997 & 2003 sets out a series of exemptions to protect sensitive information, where its disclosure may damage key interests of the State or third parties. Where the Mercy University Hospital invokes these provisions to withhold information, the decision may be appealed. Decisions in relation to deferral of access, charges, forms of access, etc. may also be appealed. Appeals mechanisms are outlined as follows: Internal Review You may seek Internal Review of the initial decision, which will be carried out by an official at a higher level if: You are dissatisfied with the initial response received e.g. refusal of access, form of access, charges etc. You have not received a reply within four weeks of your initial application. This is deemed to be a refusal of your request and allows you to proceed to Internal Review. Requests for Internal Review should be submitted in writing within four weeks of the initial decision. The Mercy University Hospital must complete the review within three weeks. An Internal Review must normally be completed before an appeal can be made to the Information Commissioner. Requests for Internal Review should be sent to: Internal Review, The Freedom of Information Department, Mercy University Hospital Grenville Place Cork. Review by the Information Commissioner If following completion of the Internal Review, your request has still been refused in part or in full, you may seek independent review of the decision by the Information Commissioner. If you have not received a reply to your application for internal review within three weeks, this is to be deemed a refusal and you may appeal to the Information Commissioner. Appeals may be made to: The Information Commissioner 18 Lower Leeson Street, Dublin 2. Tel: (01) 6785222 Fax: (01) 6610570 Email: foi@ombudsman.irlgov.ie

Appeal to the High Court A party to a review by the Information Commissioner or any other person affected by the decision of the Information Commissioner following such a review may appeal to the High Court of Law only. Appeals outside Freedom of Information Act Any appeals in relation to our services e.g. access to services should be addressed to the relevant Head of Service or Medical Professional concerned. Complaints Procedure All patients have the right to complain about any aspect of hospital service, to have the complaint investigated and to be informed of the outcome. All complaints must be forwarded in writing and addressed to: Complaints Co-ordinator, Mercy University Hospital Grenville Place Cork. The complaint will be investigated in accordance with our complaints procedure. Internal Review You may seek Internal Review if you are unhappy with the results of the investigation carried out you can request an internal review by referring back to the Complaints Coordinator who will organise the internal review. Review by the Officer of the Ombudsman If following completion of the Internal Review you are still unhappy with the outcome you can refer your compliant to the Office of the Ombudsman, 18 Lower Leeson Street, Dublin 2.

7. How to Obtain Information Refer to Section 7 and 8 of Section 15 manual. Contact Names Requests under Freedom of Information 1997 & 2003 It is important to ensure all requests for information are dealt with efficiently and correctly and in accordance with the appropriate policies/procedures. For information purposes the hospital also requires the number and nature of requests to be monitored and recorded for statistical purposes. It is also necessary to ensure adherence to time scales for processing requests. Accordingly there is one central co-ordinator for all information requests and this office will be responsible for forwarding the request to the appropriate internal department head for processing. Contact for further information/requests for information; Freedom of Information Office, Mercy University Hospital Grenville Place Cork. Tel: 021 4271971 Requests for further information in relation to a service provided, access to services etc. Contact in writing or by calling to the appropriate head of the service concerned or relevant Consultant in relation to Consultant led services.