Dimension: Access and Patient Flow (A+PF)

Rationale for measurement

International studies have demonstrated extended length of stay within overcrowded EDs leads to poorer clinical outcomes for patients.

Measurement methodology and data sources

  • data extract from hospital site patient administration system (PAS), extrapolated by HSE Business Intelligence Unit, measuring for all ED attendances the length of time spent in the Emergency Department.


Average time spent in ED – non admitted / admitted

Target

  • 100% of patients admitted / discharged from ED within 24 hours

Performance

Beaumont Hospital

  • average time spent in ED for admitted patients is 12 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 7 hours for reporting month 2021

Cavan General Hospital

  • average time spent in ED for admitted patients is 11 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 5 hours for reporting month 2021

Connolly Hospital

  • average time spent in ED for admitted patients is 11 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 5 hours for reporting month 2021

Drogheda Hospital

  • average time spent in ED for admitted patients is 9 hours for reporting month 2021
  • average time spent in ED for non-admitted patients is 6 hours for reporting month 2021

Target

  • 100% patients admitted or discharged or non-admitted from ED within 9 hours

Performance

Beaumont Hospital

  • December 2021 73.9% compliance with 9 hour non-admitted PET / 32.5% compliance with admitted PET

Cavan General Hospital

  • December 2021 88.4% compliance with 9 hour non admitted PET / 47.0% compliance with admitted PET

Connolly Hospital

  • December 2021 88.8% compliance with 9 hour non admitted PET / 37.7% compliance with admitted PET

Drogheda Hospital

  • December 2021 82.0% compliance with 9 hour non admitted PET / 57.4% compliance with admitted PET

RCSI Hospital Group

  • December 2021 82.4% compliance with 9 hour non admitted PET / 44.7% compliance with admitted PET

National Performance Comparator

  • December 2021 84.1% compliance with 9 hour non admitted PET / 53.9% compliance with admitted PET

Target:    

  • 100% of patients wait less than 24 hours in Emergency Department for ward bed accommodation

Performance



  • Beaumont Hospital – Dec 2021 1.1% >24hours (0.1% Dec 2020) performance deterioration demonstrated
  • Cavan Hospital – Dec 2021 2.5% >24hours (1.5% Dec 2020) performance deterioration demonstrated
  • Connolly Hospital – Dec 2021 0% >24 hours (0% Dec 2020) performance maintenance demonstrated
  • Drogheda Hospital – Dec 2021 2.2% >24hours (0.3% Dec 2020) performance deterioration demonstrated

  • RCSI HG – December 2021 1.5% > 24hours (0.3% December 2020)
  • National – December 2021 3.3% > 24hours (1.9% December 2020)

Rationale for measurement

Overcrowding within ED negatively impacts on both dignity and privacy for patients and the ability of staff to deliver fully effective care / treatment. Related international studies have also demonstrated extended length of stay within overcrowded EDs leads to poorer clinical outcomes for concerned patients.

Measurement methodology and data sources

  • data refers to the daily number of patients on trolleys in ED, at 8.00am daily, as recorded by the hospital
  • data set is provided by BIU – HSE

Target

The following daily targets were set by the HSE Acute Hospital Division:

  • Beaumont Hospital: 12
  • Cavan General Hospital: 8
  • Connolly Hospital: 8
  • Drogheda Hospital: 12
  • RCSI Hospital Group: 40
  • National: 228

Performance

Beaumont Hospital

  • performance maintenance in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count reduction 100% n=526 Jan-Dec)
    • performance improvement commenced in July 2016 generally maintained during 2020 reporting period
    • an average daily count value of 0 demonstrated for December 2021 (Target <12 achieved)

Cavan General Hospital

  • increase from n=1 to n=2 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count increase 28% n=201 Jan-Dec)
  • an average daily count of 2 demonstrated for December 2021 (Target <8 achieved)

Connolly Hospital

  • performance maintenance in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count reduction 100% n=401 Jan-Dec)
  • an average daily count of 0 demonstrated for December 2021 (Target <8 achieved)

Drogheda Hospital

  • increase from n=0 to n=3 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count increase 2% n=13 Jan-Dec)
  • an average daily count of 3 demonstrated for December 2021 (Target <12 achieved)

RCSI Hospital Group

  • increase from n=1 to n=5 in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count reduction 30% n=713 Jan-Dec)
  • an average daily count of 5 demonstrated for December 2021 (Target <40 achieved)

National Performance Comparator

  • 58% increase in average number of patients awaiting ward bed accommodation in ED 2021 / 2020 for December (total count increase 18% n=8,668 Jan-Dec) (due to unavailability of national data during cyber attack (May-Jun 2021) corresponding dates in 2020 have been removed to provide comparator equivalence)
  • an average daily count of 208 demonstrated for December 2021 (Target <228 achieved)
  • national performance not available via TrolleyGAR for May and June 2021 due to cyber attack.

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome for patients.

Measurement methodology and data source

  • Compliance % with <52 weeks waiting time. Periodic local data extracts submitted to NTPF extrapolated for analysis and publication.

Target

  • 100% patients waiting <52 weeks for new outpatient appointment (RCSI Hospital Group target)
  • 75% patients waiting <52 weeks for new outpatient appointment (National target)

Performance <52 months

Beaumont Hospital

  • 99% of patients waiting <52 weeks on OPD wait list (2021)

Cavan General Hospital

  • 87% of patients waiting <52 weeks on OPD wait list (2021)

Connolly Hospital

  • 98% of patients waiting <52 weeks on OPD wait list (2021)

Drogheda Hospital

  • 84% of patients waiting <52 weeks on OPD wait list (2021)

Louth County Hospital

  • 78% of patients waiting <52 weeks on OPD wait list (2021)

Rotunda Hospital

  • 100% of patients waiting <52 weeks on OPD wait list (2021)

RCSI Hospital Group – % of OPD Patients <52 weeks – as at December 2021 

National Hospital Groups – % of OPD Patients <52 weeks – as at December  2021 

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

Number of adult patients waiting for admission / attendance. Periodic local data submission to NTFP extrapolated for analysis and publications excluding patients with ‘to come in date‘ (tci) (NTPF – definition).

Target

  • 85% patients waiting <15 months for admission / attendance (National target)
  • 100% patients waiting <8 months for admission / attendance (RCSI HG target)

Performance

Beaumont Hospital

  • 94% of patients waiting <8 months for admission / attendance (2021)

Cavan General Hospital

  • 100% of patients waiting <8 months for admission / attendance (2021)

Connolly Hospital

  • 100% of patients waiting <8 months for admission / attendance (2021)

Drogheda Hospital

  • 88% of patients waiting <8 months for admission / attendance (2021)

Louth County Hospital

  • 95% of patients waiting <8 months for admission / attendance (2021). Ophthalmology excluded which comprises 9.8% DC activity and is under the control of IEHG

RCSI Hospital Group

  • 95% of patients waiting <8 months for admission / attendance (2021)

National Performance by Hospital Group Comparator

  • nationally 70% of patients waiting <8 months for admissions / attendance (2021)

Introduction 

Beaumont Hospital is one of 8 Breast Cancer Centres nationally. Each cancer centre provides data to the National Cancer Control Programme (NCCP) on performance against the targets outlined beneath.

Rationale for measurement

Significant delays in accessing hospital services and delays in commencing necessary treatment have the potential for less than optimal patient outcomes.

Measurement methodology and data source

  • periodic local data extracts submitted to the National Cancer Control Programme (NCCP), extrapolated for analysis and publication

Target

  • 95% of attendances whose referral was triaged as urgent by the cancer centre and attended or were offered an appointment within 2 weeks
  • 90% of breast cancer patients triaged as urgent are discussed at MDM within 10 working days of attendance at first OPD
  • 90% of patients with primary invasive or in situ breast tumours are offered surgery within 20 working days of MDM
  • 90% of primary breast cancer patients commenced radiation therapy within 84 days of their final therapeutic surgical procedure
  • 80% of primary breast cancer patients commenced radiation therapy within 28 days of completing chemotherapy

Performance

Beaumont Hospital

  • Beaumont Hospital exceeded National Target set for 2021 reporting period (100% achieved against a target of 95%). National Performance for December 2021 (58.9%) did not achieve target.

  • 85.9% compliant Q4 2021
  • national performance not published

  • 75.0% compliant Q4 2021
  • national performance not published

  • 85.7% compliant Q4 2021
  • national performance not published

  • 74.0% compliant Q4 2021
  • national performance not published

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

  • periodic local data extracts submitted to NCCP, extrapolated for analysis and publication

Target:

  • 95% of patients attending the rapid access clinic who attended or were offered an appointment within 10 working days of receipt of referral in the cancer centre
  • in 90% of patients receipt of referral to treatment MDM was ≤ 20 working days
  • in 90% of patients receipt of referral to surgery date offered was ≤ 45 working days

Performance

Beaumont Hospital

  • Beaumont Hospital exceeded National Target set for 2021 reporting period (96% against a target of 95%). National Performance for December 2021 (87%) did not achieve target.

  • 79.0% compliant Q4 2021
  • national performance not published

  • 25.0% compliant Q4 2021
  • national performance not published
  • surgery performed in St James’s Hospital

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data source

  • periodic local data extracts submitted to NCCP, extrapolated for analysis and publication

Target:

  • 95% of patients attending the rapid access clinic who attended or were offered an appointment within 20 working days of receipt of referral in the cancer centre
  • 95% of patients diagnosed with prostate cancer are discussed at the MDM prior to first intervention
  • 80% of histology reports following a first biopsy are available within 10 working days of the procedure

Performance

Beaumont Hospital

  • Beaumont Hospital exceeded National Target set for 2021 reporting period (100% achieved against a target of 95%). National Performance for December 2021 (82.1%) did not achieve target.

  • 95.9% compliant Q4 2021
  • national performance not published
  • note1 – therapeutic intervention includes radiotherapy, surgery and active surveillance and excludes hormone treatment

  • 89.4% compliant Q4 2021
  • national performance not published

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome for patients.

Measurement methodology and data source

  • Periodic local data extracts submitted to NTPF, extrapolated for analysis and publication

Target

  • 100% of patients identified a requiring urgent colonoscopy undertaken / offered appointment within 28 days

Performance

RCSI Hospital Group

  • 100% compliance within the RCSI Hospital Group for December 2021 monthly reporting period
  • May and June data not available at time of report publication due to cyber attack

National Performance

  • 88% compliance nationally for December 2021 monthly reporting period. n=2016 total patient volume nationally requiring urgent colonoscopy at end of Dec-21 (2% decrease vs same period in 2020)
  • May and June data not available at time of report publication due to cyber attack

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data sources

  • Periodic local data extracts submitted to NTPF, extrapolated for analysis and publication

Target

  • 65% of patients identified as requiring routine GI endoscopy undertaken or offered appointment within 13 weeks

Performance

Beaumont Hospital

  • Beaumont Hospital is currently achieving this target for monthly reporting period (100% compliance)

Cavan General Hospital

  • Cavan General Hospital is currently achieving this target for monthly reporting period (100% compliance)

Connolly Hospital

  • Connolly Hospital is currently achieving this target for monthly reporting period (99% compliance)

Drogheda Hospital

  • Drogheda Hospital is currently achieving this target for monthly reporting period (81% compliance)

Louth County Hospital

  • Louth County Hospital is currently achieving this target for monthly reporting period (81% compliance)

RCSI Hospital Group

  • RCSI Hospital Group is currently achieving this target for monthly reporting period (93% compliance)

National Performance Comparator

  • nationally this target is not being met for monthly reporting period (48% compliance)
  • national performance for June (due to the cyber attack) not available at time of report publication

Rationale for measurement

Significant delay in accessing hospital services delays diagnosis and any necessary treatment commencement with potential for less than optimal outcome.

Measurement methodology and data sources

  • Monthly data provided by BowelScreen programme

Target

  • Minimum standard target is ≥90% of clients offered a colonoscopy appointment that occurs within 20 working days from when a client was deemed clinically suitable following pre-assessment / notification of positive FIT

Performance

RCSI Hospital Group

  • Connolly achieved 100% compliance Dec-21
  • May data not produced by BowelScreen Programme due to cyber attack

  • Connolly achieved 100% compliance Dec-21
  • May data not produced by BowelScreen Programme due to cyber attack

  • national performance for December 80%. National performance for May not produced by BowelScreen Programme due to cyber attack.

Introduction

A cervical screening test (previously known as a smear test) looks to see if a woman might be at greater risk of developing cervical cancer in the future. Occasionally following smear test abnormal cells may be identified and a further test called a colposcopy may be required. A colposcopy is a simple examination that is carried out in the same way as a smear test. A doctor or nurse will look at the cervix (neck of the womb) using a type of microscope called a colposcope. During the examination, a liquid or dye may be applied to the cervix to help identify any changes to the cells and to decide if any treatment is needed.

Rationale for measurement

There are two centres providing colposcopy services in the RCSI Hospital Group, Louth County Hospital and the Rotunda Hospital.

Delays have the potential to result in less than optimal outcomes for patients.

Measurement methodology and data sources

  • % of patients referred to the Colposcopy Service who were offered an appointment
  • periodic local data extracts submitted to Cervical Screening Service, extrapolated for analysis and publication

Target

  • Urgent Referral – 90% seen within 2 weeks of referral
  • High Grade Referral – 90% seen within 4 weeks of referral
  • Low Grade Referral – 90% seen within 8 weeks of referral

Performance

  • national data not produced in a manner that enables comparison

Introduction 

Menopause is a natural biological process and is diagnosed after a woman has had 12 months without a menstrual period. Vaginal bleeding after menopause is abnormal and all postmenopausal vaginal bleeding should be investigated. The cause of postmenopausal bleeding (PMB) may be entirely harmless. However, 5- 10% of women who present with PMB will have endometrial cancer1.

Rationale for measurement 

Five-10% of women who present with PMB will have endometrial cancer1. Delays in diagnosis have the potential to result in less than optimal outcomes for patients.  In August 2020, the National Women and Infants Health Programme (NWIHP) recommended that all referrals of women with PMB from GPs should be assessed in a hospital Outpatient/Ambulatory Clinic within 4 weeks with histological confirmation within 12 weeks2.

Gynaecology Services in the RCSI Hospital Group are provided in Beaumont Hospital, Cavan Monaghan Hospitals, Connolly Hospital, Louth Hospitals, and the Rotunda Hospital.

Measurement methodology and data sources 

  • Number of patients referred to the Gynaecology Service with post-menopausal bleeding (PMB)
  • Number of patients referred to the Gynaecology Service with PMB seen within 4 weeks (also expressed as percent)
  • Number of patients referred to the Gynaecology Service with PMB who required biopsy and had histological confirmation within 12 weeks of referral from GP (also expressed as percent)

Local hospital data extrapolated quarterly for analysis and publication

Target 

  • 100% of patients seen within 4 weeks of referral from GP
  • 100% of patients have histological confirmation within 12 weeks of referral from GP

Performance 

  • Beaumont, Cavan, Connolly, Drogheda and the Rotunda Hospitals did not achieve the target of 100%
  • national data not produced

  • Beaumont, Cavan, Connolly, Drogheda and the Rotunda Hospitals did not achieve the target of 100%
  • national data not produced

References 

1. Gredmark T, Kvint S, Havel G, Mattson L. Histopathological findings in women with postmenopausal bleeding. BJOG 1995; 102:133-136. 

2. NWIHP corresponded August 2020: National Clinical Guidance on the appropriate timeframe for the investigation of Postmenopausal Bleeding 

Rationale for measurement

Beaumont Hospital is the National Referral Centre for Neurosurgery in Ireland. Neurosurgery concerns the operative and non-operative management of patients with disorders of the central and peripheral nervous systems. The specialty developed initially through the treatment of cranial trauma and intracranial mass lesions. Subsequent advances in microsurgical techniques, non-invasive imaging, neuro-anaesthesia, intensive care, image-guided surgery, and the introduction of sophisticated radio-oncological and interventional treatments have substantially enhanced and widened the scope of effective neurosurgical treatment. Delay in access to Unit can result in delay in treatment commencing with potential for less than optimal outcome for patients.

Measurement methodology and data sources

  • Beaumont is the National Neurosurgical Unit. Therefore data for Beaumont hospital only is represented.
  • Periodic local data extracts submitted quarterly and retrospectively extrapolated for analysis and publication.

 Targets

  1. 100% of patients triaged as Traumatic Brain Injury (TBI) admitted to Unit within 12 hours of acceptance.
  2. 90% of patients triaged as Grade I / II Sub-arachnoid Haemorrhage (SAH) admitted to Unit within 24 hours of acceptance.
  3. 90% of patients triaged as having a brain tumour are transferred to Unit within 5 working days / 7 calendar days of acceptance

Performance

RCSI Hospital Group

  • 100% compliant Q4 2021

  • 100% compliant Q4 2021

  • 81% compliant Q4 2021

Rationale for measurement

Significant delay in securing necessary diagnostic image report can delay primary diagnosis, treatment commencement or treatment review with potential for less than optimal outcome for patients.

Measurement methodology and data sources

  • waiting time from diagnostic order identification and diagnostic being undertaken (either GP or Consultant)
  • local site data sets extrapolated for analysis and publication, by definition excluding time staged diagnostic order requirements
  • national data set currently combines CT, MRI and US patient cohorts segregates into urgent, semi urgent, routine, excludes these patients not vetted using ‘new’ criteria or not vetted electronically – accordingly actual national performance for their specific diagnostics is not readily discernible or comparable

Target

  • Ultrasound – 100% compliance < 3 months (RCSI HG target)
  • MRI – 100% compliance < 6 months (RCSI HG target)
  • CT – 100% compliance < 6 months (RCSI HG target)

Performance

Beaumont Hospital

  • US 97% waiting < 3 months – Beaumont did not achieve target
  • MRI 96% waiting < 6 months – Beaumont did not achieve target
  • CT 95% waiting < 6 months – Beaumont did not achieve target

Connolly Hospital

  • US 91% waiting < 3 months – Connolly did not achieve target
  • MRI 100% waiting < 6 months – Connolly achieved target
  • CT 100% waiting < 6 months – Connolly achieved target

Cavan Hospital

  • US 87% waiting < 3 months – Cavan did not achieve target
  • MRI 100% waiting < 6 months – Cavan achieved target
  • CT 100% waiting < 6 months – Cavan achieved target

Drogheda Hospital

  • US 67% waiting < 3 months – Drogheda/LCH did not achieve target
  • MRI 98% waiting < 6 months – Drogheda did not achieve target
  • CT 90% waiting < 6 months – Drogheda did not achieve target (Drogheda CT includes out-patients scanned in LCH)

RCSI Hospital Group

  • US 80% waiting < 3 months – Group did not achieve target
  • MRI 98% waiting < 6 months – Group did not achieve target
  • CT 95% waiting < 6 months – Group did not achieve target

Rotunda Hospital (not included in Group total – only Gynae scans)

  • US 64% waiting < 3 months – Rotunda did not achieve target

NB – actual national performance for diagnostics is not readily discernible or comparable

Rationale for measurement

Non-attendance of new patients for OPD appointment negates the ability to diagnose and treat and generally wastes clinical time. This wasted clinical time significantly adds to wait times for other patients.

Measurement methodology and data sources

  • periodic local data extracted and extrapolated for analysis and publication by HSE BIU
  • source for national data provided by BIU OPD MDR

Target

  • <12% of new OPD bookings do not attend scheduled appointment

Performance

RCSI Hospital 

  • cumulative for 2021 reporting period 13.3% (n=22,670) of total new bookings did not attend (DNA) scheduled appointments / 2020 11.6% DNA (n=16,851) – represents 34.5% increase
    • Beaumont 2021 17.7% DNA / 2020 15.1% DNA
    • Cavan 2021 7.1% DNA / 2020 6.0% DNA
    • Connolly 2021 17.5% DNA / 2020 12.1% DNA
    • Louth 2021 8.8% DNA / 2020 8.6% DNA
    • Monaghan 2021 7.6% DNA / 2020 7.1% DNA
    • Drogheda 2021 9.4% DNA / 2020 7.4% DNA
    • Rotunda 2021 10.6% DNA / 2020 11.5% DNA

National Performance Comparator

  • during December 2021 monthly reporting period 14.0% of total new bookings (n = 9,583) did not attend scheduled appointment. It should be noted that OPD Data for the Coombe or Tullamore Hospitals was not available at time of report publication

Introduction

Elective day surgery is the admission of selected patients to hospital for a planned surgical procedure who return home on the same day. Elective day surgery benefits patients as they receive treatment that is suited to their needs and allows them to recover in their own home. In addition the risk of patients contracting a hospital acquired infection is reduced. Elective day case surgery releases inpatient beds for major cases, this improves throughput of patients and reduces waiting lists.

Rationale for measurement

75% of elective admissions on each of the 24 procedures identified can be carried out as day cases (National Elective Surgery Programme, Royal College of Surgeons in Ireland, Irish College of Anaesthetists and Health Service Executive).

(Orchidopexy, Circumcision, Inguinal Hernia Repair, Excision of Breast Lump, Anal Fissure Dilatation or Excision, Haemorrhoidectomy, Laparoscopic Cholecystectomy, Varicose Vein Stripping or Ligation, Transurethral Resection of Bladder Tumour (<2cm), Excision of Dupuytren’s Contracture, Carpal Tunnel Decompression, Excision of Ganglion, Arthroscopy, Bunion Operations, Removal of Metal-ware, Extraction of Cataract with/without Implant, Correction of Squint, Myringotomy, Tonsillectomy, Sub Mucous Resection, Reduction of Nasal Fracture, Operation for Bat Ears, Dilatation and Curettage/Hysteroscopy, Laparoscopy).

Measurement methodology and data sources

Local Hospital HIPE Data extrapolated for analysis and publication and published on a quarterly basis.

Target

75% of treatments in basket case are carried out as a day case.

Performance

  • 81% of procedure basket undertaken on a day case basis – overall target achieved
  • national dataset not available

Introduction:

A colonoscopy is an examination of the bowel using a small camera on the end of a thin flexible tube. The tube is inserted into the rectum and then into the large bowel.

During the examination a small sample of the lining of the bowel may be taken to look at more closely. This is called a biopsy. The test looks for any polyps or signs of disease in the lining of the bowel. Polyps are small growths that are not cancer but, if not removed, might turn into cancer over time. If polyps are found they are usually removed during the colonoscopy. This is to reduce the risk of cancer developing.

Rationale for measurement

Internationally accepted guidelines on performance indicators for colonoscopy recommend monitoring of the detection rates of suspicious lesions including polyps and adenomas.

Measurement methodology and data sources

The data is recorded at local hospital Endoscopy Units. It is subsequently reported into Conjoint Board in Ireland of the Royal College of Physicians and Royal College National Quality Improvement Programme in GI Endoscopy (NEQI Programme) in collaboration with the National Cancer Control Programme. Results are reported as colonoscopies with polyp detected expressed as a % of total colonoscopies per endoscopist.

Data Sources:

  1. https://www.rcpi.ie/quality-improvement-programmes/gastrointestinal-endoscopy
  2. National GI Endoscopy Quality Improvement Programme 2019 Data Report, Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons

Target

  • ≥ 20% of all colonoscopies should have a polyp(s) detected

Performance

  • Q2-21 data unavailable due to cyber attack
  • all hospitals in RCSI Hospital Group achieved target Q4 2021

  • all hospitals in RCSI Hospital Group achieved target

Introduction:

Caecal intubation is defined as the passage of the tip of the colonoscope to a point proximal to the ileocecal valve so that the entire cecum is visualised.

Rationale for measurement

Caecal intubation rates (CIR) are a key quality indicator of colonoscopy. Caecal intubation can be expected to be difficult in 5%–15% of colonoscopies, but skilled colonoscopists should be able to apply techniques to overcome the difficulties in most of these instances and reach the cecum in ≥90% of all cases.

Measurement methodology and data sources

The data is recorded at local hospital Endoscopy Units. It is subsequently reported into Conjoint Board in Ireland of the Royal College of Physicians and Royal College National Quality Improvement Programme in GI Endoscopy (NEQI Programme) in collaboration with the National Cancer Control Programme.

Results are reported as number of colonoscopies where the terminal ileum/caecum/anastomosis has been reached as a % of total colonoscopies per endoscopist.

Data Sources:

  1. https://www.rcpi.ie/quality-improvement-programmes/gastrointestinal-endoscopy
  2. National GI Endoscopy Quality Improvement Programme 2019 Data Report, Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons

Target

  • ≥ 90% of all colonoscopy cases should reach the terminal ileum/caecum/anastomosis

Performance

  • Q2-21 data unavailable due to cyber attack
  • all hospitals in RCSI Hospital Group achieved target Q4 2021

  • all hospitals in RCSI Hospital Group achieved target

Rationale for measurement 

The clinical discharge summary generated at the end of an inpatient stay provides the basis for communication between healthcare professionals in different healthcare settings. In order for the clinical discharge summary to be effective it must be a complete, accurate and relevant record of the inpatient stay and must be sent to the primary care healthcare professional ‘in a timely manner’ 

National Standard for a Clinical Summary (Patient Discharge) | HIQA 

Compliance with issuing GPs of discharged inpatients with a Discharge Letter within 1 week

Measurement methodology and data sources 

The discharge process requires the transfer of information which involves a clinical discharge summary document being sent from secondary or tertiary care to a patient’s primary healthcare provider. This clinical discharge summary document can be in the form of a letter or the completion of a clinical discharge summary form on paper, or electronically generated, i.e. iPMS or PIPE systems.

Data source local hospital data. 

Numerator
Total number of inpatients discharged/month whose primary healthcare provider is sent a clinical discharge summary 

Denominator
Total number of inpatient discharges/month 

Target 

100% of inpatients discharged will have clinical discharge summary issued to their primary healthcare provider within 1 week of discharge. 

Performance

Rationale 

Datasets contained within discharge correspondence in line with the National Standards for a Clinical Summary (Patient Discharge), HIQA 2013. 

Measurement methodology and data sources 

In keeping with the HIQA 2013 standard, Clinical Discharge Summaries are audited for completion of the mandatory data set in the following 7 sections: 

  1. Patients Details 
  2. Primary Healthcare Details 
  3. Admission and Discharge Details 
  4. Clinical Narrative 
  5. Medication Details 
  6. Future Management 
  7. Details of Persons completing the Discharge Summary 

This audit is of electronic patient discharges and data source local hospital data, extrapolated from electronic patient discharge systems: 

  • Beaumont PIPE data audit of discharge summaries
  • Cavan iPMS data audit of discharge summaries
  • Connolly iPMS data audit of discharge summaries
  • Drogheda iPMS data audit of discharge summaries 

Target 

100% of Clinical Discharge Summaries will be completed containing the mandatory data outlined in the 7 specified sections of the HIQA 2013 standard. 

Performance 

% compliance with mandatory HIQA standards on Clinical Discharge Summary. 

  • comparative national data not available

Rationale for measurement

Four key reasons may cause delay in patients receiving timely diagnosis and treatment and can also waste clinical treatment time:

  • tardy recording of patient details onto scheduled care waiting list record (OPD / IP / DC)
  • tardy receipt of booking form in scheduling office and compliance with date stamp received on booking form
  • incomplete patient specific minimum data set record
  • non-compliance with Hospital Group policies in regard to patients not being able to attend (CNA) scheduled OPD appointment / Day Care attendance / Inpatient admission date or patients who do not attend (DNA) scheduled OPD appointment / Day Care attendance / Inpatient admission (see 3.4)

Measurement methodology and data sources

  • periodic sampling (taken on a monthly basis) of Hospital Group ‘waiting list’ data sets to ascertain:
    • time period from receipt of GP referral letter / treatment requirement identification and waiting list record entry
    • advance patient notification in regard to intended scheduled care: OPD appointment / Day Care attendance / Inpatient admission date
    • time period of booking form received in scheduling office and compliance of date stamp received on booking form
    • completeness of patient specific minimum data set record: all hospital waiting list cards examined for inclusion of 25 items
    • for those patients identified as ‘could not attend’ (CNA) i.e. sickness, leave, family commitments review of subsequent practises in terms of record keeping including patient waiting time
    • for those patients identified as ‘did not attend’ (DNA) review of subsequent practices in terms of record keeping including patient waiting time

Target:

  • > 95% of New OPD / Day Care / Inpatient record entries. Two measurements of compliance
    • WL record is updated within 3 working days of receipt of WL booking form
    • start date on WL record = Decision to Admit date
  • 100% compliance with booking form received to scheduling office within one working day
  • 100% compliance with date stamp received on booking form
  • > 95% compliance with sending acknowledgement letter (outpatients)
  • > 85% compliance with completeness of patient specific minimum data set record
  • > 90% compliance with DNA / CNA RCSI HG policies

Performance

% compliance recording of patient details onto scheduled care waiting list record ≤ 3 days

  • note overall sample size n=100 patients (20 per hospital)
  • during Q4 2021 overall sample group demonstrated 90% compliance with data entry requirements

% compliance of recording of patient details onto scheduled care waiting list record (Start date = DTA)

  • note overall sample size n=100 patients (20 per hospital)
  • during Q4 2021 overall sample group demonstrated 98% compliance with data entry requirements

% compliance with booking form returned to scheduling office < one working day and date stamped 

  • note: overall sample size n=100 patients (20 per hospital)
  • during Q4 2021 overall sample group demonstrated 42% compliance with booking form returned within 1 working day and date stamped

% compliance of sending acknowledgement letter (Out Patients)

  • note: overall sample size n=100 patients (20 per hospital)
  • during Q4 2021 overall sample group demonstrated 100% compliance with requirement to send acknowledgement letter

compliance of patient specific minimum data set completeness on WL Record

  • note: sample size n=500 data points
  • during Q4 2021 overall sample group demonstrated 87% compliance with completion of patient specific minimum data set

compliance of DNA / CNA Policy compliance

  • note: DNA policy: DNA patients are removed from waiting list
  • note: if patient cannot attend (CNA) their wait time clock restarts
  • note: report sample size (n=100)
  • note: insufficient cancellations/ dnas to comply with 100 records being checked
  • during Q3 2021 overall sample group demonstrated 100% compliance with DNA and CNA policies
  • Q4 2021 data for DNA/CNA not available at time of report publication
  • national performance not produced