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 14 hours for reporting month 2022
  • average time spent in ED for non-admitted patients is 8 hours for reporting month 2022

Cavan General Hospital

  • average time spent in ED for admitted patients is 13 hours for reporting month 2022
  • average time spent in ED for non-admitted patients is 6 hours for reporting month 2022

Connolly Hospital

  • average time spent in ED for admitted patients is 11 hours for reporting month 2022
  • average time spent in ED for non-admitted patients is 5 hours for reporting month 2022

Drogheda Hospital

  • average time spent in ED for admitted patients is 11 hours for reporting month 2022
  • average time spent in ED for non-admitted patients is 7 hours for reporting month 2022

Target

  • 85% patients admitted or discharged or non-admitted from ED within 9 hours of registration (NSP 2022)

Performance

Beaumont Hospital

  • March 2022 64.5% compliance with 9 hour non-admitted PET / 24.8% compliance with admitted PET

Cavan General Hospital

  • March 2022 82.4% compliance with 9 hour non admitted PET / 39.1% compliance with admitted PET

Connolly Hospital

  • March 2022 87.3% compliance with 9 hour non admitted PET / 35.4% compliance with admitted PET

Drogheda Hospital

  • March 2022 76.4% compliance with 9 hour non admitted PET / 48.4% compliance with admitted PET

RCSI Hospital Group

  • March 2022 76.5% compliance with 9 hour non admitted PET / 37.5% compliance with admitted PET

National Performance Comparator

  • March 2022 79.6% compliance with 9 hour non admitted PET / 46.5% compliance with admitted PET

Target:    

  • 97% of patients wait less than 24 hours in Emergency Department for ward bed accommodation (NSP 2022)

Performance



  • Beaumont Hospital – Mar 2022 4.2% >24hours (0.1% Mar 2021) performance deterioration demonstrated
  • Cavan Hospital – Mar 2022 3.1% >24hours (0.3% Mar 2021) performance deterioration demonstrated
  • Connolly Hospital – Mar 2022 0% >24 hours (0% Mar 2021) performance maintenance demonstrated
  • Drogheda Hospital – Mar 2022 2.8% >24hours (0.4% Mar 2021) performance deterioration demonstrated

  • CSI HG – March 2022 2.5% > 24hours (0.2% March 2021)
  • National – March 2022 4.7% > 24hours (1.6% March 2021)

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
  • Our Lady of Lourdes Hospital: 12
  • RCSI Hospital Group: 40
  • National: 228

Performance

Beaumont Hospital

  • increase from n=0 to n=4 in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase from n=0 Jan-Mar 2021 to n=167 Jan-Mar 2022)
    • performance improvement commenced in July 2016 generally maintained during 2020 reporting period
    • an average daily count value of 4 demonstrated for March 2022 (Target <12 achieved)

Cavan General Hospital

  • increase from n=2 to n=4 in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase 81% (n=132) from n=162 Jan-Mar 2021 to n=294 Jan-Mar 2022)
  • an average daily count of 4 demonstrated for March 2022 (Target <8 achieved)

Connolly Hospital

  • increase of <1 in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase from n=0 Jan-Mar 2021 to n=26 Jan-Mar 2022)
  • an average daily count of <1 demonstrated for March 2022 (Target <8 achieved)

Drogheda Hospital

  • increase from n=0 to n=5 in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase 278% (n=336) from n=121 Jan-Mar 2021 to n=457 Jan-Mar 2022)
  • an average daily count of 5 demonstrated for March 2022 (Target <12 achieved)

RCSI Hospital Group

  • increase from n=2 to n=14 in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase 234% (n=661) from n=283 Jan-Mar 2021 to n=944 Jan-Mar 2022)
  • an average daily count of 14 demonstrated for March 2022 (Target <40 achieved)

National Performance Comparator

  • 193% increase in average number of patients awaiting ward bed accommodation in ED 2022 / 2021 for March (total count increase 167% (n=17,163) from n=10,250 Jan-Mar 2021 to n=27,413 Jan-Mar 2022)
  • an average daily count of 337 demonstrated for March 2022 (Target <228 not achieved)
  • May and June 2021 national performance not available via TrolleyGAR 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 waiting time target. Periodic local data extracts submitted to NTPF extrapolated for analysis and publication.

Target

  • 100% patients waiting <12 months for new outpatient appointment (RCSI Hospital Group target)
  • 98% patients waiting <18 months for new outpatient appointment (NSP 2022)

Performance <12 months

Beaumont Hospital

  • 98% of patients waiting <12 months on OPD wait list (2022)

Cavan General Hospital

  • 92% of patients waiting <12 months on OPD wait list (2022)

Connolly Hospital

  • 99% of patients waiting <12 months on OPD wait list (2022)

Drogheda Hospital

  • 86% of patients waiting <12 months on OPD wait list (2022)

Louth County Hospital

  • 81% of patients waiting <12 months on OPD wait list (2022)

Rotunda Hospital

  • 99% of patients waiting <12 months on OPD wait list (2022)

RCSI Hospital Group – % of OPD Patients <12 months – as at March 2022 

  • overall 94% of patients waiting <12 months on OPD wait list (2022) in RCSI Hospital Group

RCSI Hospital Group – % of OPD Patients <18 months – as at March 2022 

  • overall 98.3% of patients waiting <18 months on OPD wait list (2022) in RCSI Hospital Group

National Hospital Groups – % of OPD Patients <12 months – as at March 2022 

  • nationally 65% of patients waiting <12 months on OPD wait list (2022) 

National Hospital Groups – % of OPD Patients <18 months – as at March 2022 

  • nationally 76.4% of patients waiting <18 months on OPD wait list (2022)

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

  • 100% patients waiting <9 months for elective IP/DC (RCSI Hospital Group target)
  • 98% patients waiting <12 months for elective IP/DC (NSP 2022)

Performance

Beaumont Hospital

  • 87% of patients waiting <9 months for elective IP/DC (2022)

Cavan General Hospital

  • 100% of patients waiting <9 months for elective IP/DC (2022)

Connolly Hospital

  • 97% of patients waiting <9 months for elective IP/DC (2022)

Drogheda Hospital

  • 82% of patients waiting <9 months for elective IP/DC (2022)

Louth County Hospital

  • 94% of patients waiting <9 months for elective IP/DC (2022). Ophthalmology excluded which comprises 9.8% DC activity and is under the control of IEHG

RCSI Hospital Group

  • 89% of patients waiting <9 months for elective IP/DC (2022)

National Hospital Groups – % of IPDC Patients <9 months – as at March 2022

  • nationally 73% of patients waiting <9 months for elective IP/DC (2022)

National Hospital Groups – % of IPDC Patients <12 months – as at March 2022 

  • nationally 79% of patients waiting <12 months for elective IP/DC (2022)

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 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 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 2022 reporting period (100% achieved against a target of 95%). National performance for March 2022 (60.2%) did not achieve target.

  • 85.9% compliant Q4 2021
  • national performance not published

  • 75.0% compliant Q4 2021
  • national performance not published

  • 86.2% compliant Q3 2021. Q4-21 data not available at time of report publication
  • national performance not published

  • 63.1% compliant Q3 2021. Q4-21 data not available at time of report publication
  • 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 2022 reporting period (100% against a target of 95%). National performance for March 2022 (83.8%) 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 
  • 95% 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 2022 reporting period (100% achieved against a target of 95%). National Performance for March 2022 (78.2%) 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

  • 99.9% compliance within the RCSI Hospital Group for March 2022 monthly reporting period. Non-compliance of n=2 patients in Beaumont.

National Performance

  • 95.2% compliance nationally for March 2022 monthly reporting period. n=2087 total patient volume nationally requiring urgent colonoscopy at end of Mar-22 (performance maintenance vs same period in 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 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 not achieving this target for monthly reporting period (64.2% compliance)

Cavan General Hospital

  • Cavan General Hospital is currently achieving this target for monthly reporting period (92.3% compliance)

Connolly Hospital

  • Connolly Hospital is currently not achieving this target for monthly reporting period (62.6% compliance)

Drogheda Hospital

  • Drogheda Hospital is currently achieving this target for monthly reporting period (74.9% compliance)

Louth County Hospital

  • Louth County Hospital is currently achieving this target for monthly reporting period (73.1% compliance)

RCSI Hospital Group

  • RCSI Hospital Group is currently achieving this target for monthly reporting period (70.9% compliance)

National Performance Comparator

  • nationally this target is not being met for monthly reporting period (45.1% compliance)

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 Mar-22

  • LCH achieved target of 100% compliance Mar-22

  • national performance for March 2022 92.5%

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 

  • LCH exceeded target for Q4 2021 (100% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral
  • Rotunda did not achieve target for Q4 2021 (58% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral
  • to note, performance impacted in Q2-21 and Q3-21 by HSE cyber attack

  • LCH exceeded target for Q4 2021 (100% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral
  • Rotunda did not achieve target for Q4 2021 (79% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral
  • to note, performance impacted in Q2-21 and Q3-21 by HSE cyber attack

  • LCH exceeded target for Q4 2021 (100% achieved against a target of 90%) for low grade referrals seen within 8 weeks of referral
  • Rotunda did not achieve target for Q4 2021 (66% achieved against a target of 90%) for low grade referrals seen within 8 weeks of referral
  • to note, performance impacted in Q2-21 and Q3-21 by HSE cyber attack

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

  • 96% compliant Q1 2022

  • 92% compliant Q1 2022

  • 76% compliant Q1 2022

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 88% waiting < 3 months – Beaumont did not achieve target
  • MRI 97% waiting < 6 months – Beaumont did not achieve target
  • CT 85% waiting < 6 months – Beaumont did not achieve target

Connolly Hospital

  • US 95% 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 94% 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 69% waiting < 3 months – Drogheda/LCH did not achieve target
  • MRI 100% waiting < 6 months – Drogheda achieved target
  • CT 87% waiting < 6 months – Drogheda did not achieve target (Drogheda CT includes out-patients scanned in LCH)

RCSI Hospital Group

  • US 79% waiting < 3 months – Group did not achieve target
  • MRI 99% waiting < 6 months – Group did not achieve target
  • CT 89% waiting < 6 months – Group did not achieve target

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

  • US 45% 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 2022 reporting period 14.8% (n=6,340) of total new bookings did not attend (DNA) scheduled appointments / 2021 9.9% DNA (n=3,633)
    • Beaumont 2022 20.9% DNA / 2021 13.3% DNA
    • Monaghan 2022 10.4% DNA / 2021 6.9% DNA
    • Cavan 2022 8.5% DNA / 2021 3.9% DNA
    • Drogheda 2022 9.2% DNA / 2021 6.7% DNA
    • Connolly 2022 15.4% DNA / 2021 11.5% DNA
    • Rotunda 2022 11.7% DNA / 2021 8.7% DNA
    • Louth 2022 12.3% DNA / 2021 6.6% DNA

National Performance Comparator

  • during February 2022 monthly reporting period 14.7% of total new bookings (n=12,114) did not attend scheduled appointment. National performance for March 2022 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 national Polyp Detection rate target in 2020

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 national Caecal Intubation rate target in 2020

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. 

  • Beaumont improved overall compliance rate of 79% in Mar-22 from 76% in Jan-22 and Feb-22
  • Cavan improved overall compliance rate of 84% in Mar-22 from 78% in Jan-22 and 83% in Feb-22
  • Connolly improved overall compliance rate of 85% in Mar-22 from 79% in Jan-22 and 85% in Feb-22
  • Drogheda performance deteriorated overall compliance rate of 76% in Mar-22 from 83% in Jan-22 and 80% in Feb-22
  • overall RCSI Hospital Group improvement of overall compliance rate of 81% in Mar-22 from 79% in Jan-22 and 81% in Feb-22
  • 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 March 2022 overall sample group demonstrated 100% 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 March 2022 overall sample group demonstrated 82% 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 March 2022 overall sample group demonstrated 76% 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 March 2022 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 March 2022 overall sample group demonstrated 95% 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 and Q4 2022 data for DNA/CNA not available at time of report publication
  • national performance not produced