Measurement of quality to drive improvement is one of the hallmarks of a high performing healthcare system.

The RCSI Hospital Group recognises the importance of a common relevant set of metrics and key performance indicators and their active usage in measuring, tracking and generally guiding performance in various dimensions of care across all clinical services. Their usage also helps identify where improvement is required and the impact of purposeful quality improvement initiatives when introduced.

The RCSI Hospital Group is committed to full transparency in relation to performance measurement and in order to enable patients, relatives and the general public to see and understand current performance these metrics are now published on a cumulative basis on this website. Therefore focus of this report is a statement of performance rather a description of actions to improve performance. All data presented is anonymous and necessary patient confidentiality is and will be maintained at all times.

Selection methodology

The performance metrics are organised within 7 core dimensions:

  • Access and Patient Flow
  • Infection Control and Management
  • Medication Management
  • Maternity Services
  • Patient Care and Treatment
  • Patient and Family Experience
  • Staff

For each performance metric considered:

  • rationale for selection is identified and generally explained
  • methodology for performance measurement in terms of numerator / denominator, frequency of data collection and data sources are defined
  • target performance values to be achieved are clearly stated
  • actual performance for each hospital site and overall performance for the RCSI HG is identified
  • national performance values (where available) are provided for comparative purposes
  • in certain instances due to either variance of services across the hospitals or because of particularly small incidence values, necessary caution in any comparative analysis is identified
  • an interpretive trend commentary is provided
Dimension Performance Metrics
Access + Patient Flow 3.1 Ambulance Turnaround Times
3.2 ED Patient Experience Time (PET)
– Average time spent in ED – non admitted / admitted
– PET 9 hour compliance admitted and non-admitted
– PET >24 hour breaches for all patients
3.3 ED Patient wait volume for admission
3.4 OPD Waiting Time for New appointments
3.5 Inpatient / Day Care Waiting Times
3.6 Access to Symptomatic Breast Cancer Services
3.7 Access to Rapid Access Clinic – Lung
3.8 Access to Rapid Access Clinic – Prostate
3.9 Melanoma – Access, MDM Discussion & Pathology
3.10 Urgent Colonoscopy Waiting Times
3.11 Endoscopy Waiting Times
3.12 Clients offered colonoscopy appointment date that occurs within 20 working days from when a client was deemed clinically suitable following pre-assessment/positive FIT
3.13 Colposcopy Services
3.14 Post menopausal Bleeding
3.15 Access to National Neurosurgical Unit
3.16 Bladder Cancer – Cystectomies
3.17 Penile Cancer
3.18 Diagnostic Imaging waiting times
3.19 Radiology Turnaound Times
3.20 ‘Did not Attend’ Rate of new OPD bookings
3.21 24 Day Case Procedures
3.22 Polyp Detection Rate
3.23 Caecal Intubation Rate
3.24 Clinical Discharge Summary
3.25 Compliance with mandatory HIQA Standards on Clinical Discharge Summary
3.26 Scheduled Care Entry Recording
Infection Control and Management 4.1 Rate of new cases of Hospital acquired Staphylococcus Aureus bloodstream infection
4.2 Rate of new cases of Hospital acquired Clostridium (C. difficile) infection
4.3 CPE Testing
4.4 % compliance of Hospital staff with WHO’s 5 moments of hand hygiene using national audit tool
4.5 % Staff uptake of ‘Flu’ Vaccination
4.6 Covid-19 Staff Vaccination
4.7 Covid-19 Cases Admitted on Sites
Medication Management

 5.1 Rate of Medication Incidents
5.2 Administration of Prescribed Medication
5.3 Medication Storage & Custody
Maternity Services 6.1 Clinical Activities
6.2 Major Obstetric Events
6.3 Delivery Metrics
6.4 Fetal Anomaly Scanning
Patient Care and Treatment 7.1 Irish Hip Fracture Standards
7.2 Hospital Falls
7.3 Falls Prevention and Injury Management
7.4 Development of Grade 1-4 pressure ulcer (decubitus ulcer) in Hospital
7.5 Pressure Ulcer Prevention and Management
7.6 Nutrition and Hydration
7.7 % of patients readmitted on an emergency basis within 30 days of discharge
7.8 COPD
7.9 Delayed Transfers of Care (DTOC)
7.10 Covid-19 Testing prior to Residential Care Transfer from Hospital
7.11 Hospital Mortality (NHQRS):
– Acute Myocardial Infarction
– Ischaemic Stroke
– Haemorrhagic Stroke
7.12 National Audit of Hospital Mortality (NAHM)
– Acute Myocardial Infarction
– Heart failure
– Ischaemic Stroke
– Haemorrhagic Stroke
– Chronic obstructive pulmonary disease
– Pneumonia
7.13 Unplanned Readmissions to ITU within 48 Hours
7.14 Stroke Services (Irish National Audit of Stroke / National Office of Clinical Audit)
7.15 Thrombolysis in patients with confirmed acute ischaemic stroke
7.16 Rate of Venous Thromboembolism (VTE) associated with hospitalisation
Patient and Family Experience 8.1 Satisfaction Surveys
8.2 Reporting Of SREs And SIs
8.3 Systems Analysis Review
8.4 Review Of Serious Falls And Grade 3&4 Pressure Injuries
8.5 % of complaints responded to within 35 days
8.6 Parliamentary Questions (PQs) and Representations (Reps)
Staff 9.1 Staff absenteeism
9.2 Garda Vetting
9.3 Staff Training
Integrated Care Framework




 10.1 Physical Assessment
10.2 Functional Assessment
10.3 Care Assessment
10.4 Infection Prevention and Control
10.5 Staff Training

Note1 – these statistics reflect the most recent activity within RCSI Hospital Group. Data presented is subject to revision. Caution
should be used in making comparisons between hospitals due to different sizes and services provided.
Note2 – updated Monthly on RCSI Hospital Group Website