Dimension: Access and Patient Flow (A+PF)

Rationale for measurement

Patients arrive to ED via self-referral, GP referral or via ambulance with all patients being triaged to ascertain clinical priority. When a patient arrives via ambulance the ambulance staff then handover the patient to ED staff but must remain with the patient until the clinical handover in the ED is complete. If there are pressures in ED and/or other patients have been triaged and identified as a higher clinical priority then this can lead to longer waits for the ambulance staff before they can leave for the next call. Longer waits can ultimately lead to ambulances not being able to attend other calls and patients being delayed with possible adverse outcomes.

Measurement methodology and data sources

Ambulance turnaround times calculate the time interval between the arrival of an ambulance to ED to when the ambulance crew declares the readiness of the ambulance to accept another call (‘clear and available’).

Local hospital data collated, extrapolated and published by HSE-BIU with national data (National Ambulance Service (NAS)). The NAS acknowledges that Ambulance Turnaround data combines the time intervals from ambulance arrival time (through clinical handover in the ED of specialist units) to when the ambulance crew declares the readiness of the ambulance to accept another call

Target

90% ≤60 minutes (RCSI HG target)

Performance – % Compliance – 2023 ≤60 minutes
img-397

  • Rotunda Hospital achieving 90% target for Dec-23
  • Beaumont, Cavan, Connolly and Drogheda Hospitals not achieving 90% target for Dec-23

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

  • 97% of patients admitted / discharged from ED within 24 hours

Performance

Beaumont Hospital
img-999

  • average time spent in ED for admitted patients is 17.42 hours for reporting month 2024
  • average time spent in ED for non-admitted patients is 7.39 hours for reporting month 2024

Cavan General Hospitalimg-888

  • average time spent in ED for admitted patients is 11.38 hours for reporting month 2024
  • average time spent in ED for non-admitted patients is 6.25 hours for reporting month 2024

Connolly Hospitalimg-702

  • average time spent in ED for admitted patients is 13.85 hours for reporting month 2024
  • average time spent in ED for non-admitted patients is 6.06 hours for reporting month 2024

Drogheda Hospitalimg-649

  • average time spent in ED for admitted patients is 12.54 hours for reporting month 2024
  • average time spent in ED for non-admitted patients is 7.24 hours for reporting month 2024

Target

  • 85% patients admitted or discharged or non-admitted from ED within 9 hours of registration (NSP 2024)

Performance

Beaumont Hospital img-75

  •  January 2024 71.8% compliance with 9 hour non-admitted PET / 14.4% compliance with admitted PET

Cavan General Hospitalimg-251

  • January 2024 84.6% compliance with 9 hour non admitted PET / 51.8% compliance with admitted PET

Connolly Hospitalimg-34

  • January 2024 83.0% compliance with 9 hour non admitted PET / 20.0% compliance with admitted PET

Drogheda Hospitalimg-341

  • January 2024 74.0% compliance with 9 hour non admitted PET / 46.0% compliance with admitted PET

RCSI Hospital Groupimg-808

  • January 2024 77.6% compliance with 9 hour non admitted PET / 34.2% compliance with admitted PET

National Performance Comparatorimg-108

  •  January 2024 82.2% compliance with 9 hour non admitted PET / 44.5% compliance with admitted PET

Target:

  • 97% of patients wait less than 24 hours in Emergency Department for ward bed accommodation (NSP 2024)

Performanceimg-878img-923img-279img-671

  • Beaumont Hospital – Jan 2024 8.4% >24hours (8.6% Jan 2023) performance compliance not demonstrated
  • Cavan Hospital – Jan 2024 4.5% >24hours (3.9% Jan 2023) performance compliance not demonstrated
  • Connolly Hospital – Jan 2024 1.0% >24hours (2.0% Jan 2023) performance compliance demonstrated
  • Drogheda Hospital – Jan 2024 8.0% >24hours (5.7% Jan 2023) performance compliance not demonstrated

img-15

  •  RCSI HG – Jan 2024 6.0% > 24hours (5.3% Jan 2023). Performance compliance not demonstrated
  • National – Jan 2024 4.3% > 24hours (5.1% Jan 2023). Performance compliance not demonstrated

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 Hospitalimg-921

  • performance maintenance of n=9 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count decrease 1% (n=2) from n=267 YTD 2023 to n=265 YTD 2024)
    • performance improvement commenced in July 2016 generally maintained during subsequent reporting period
    • an average daily count value of 9 demonstrated for January 2024 (Target <12 achieved)

Connolly Hospitalimg-575

  • performance maintenance of n=3 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count decrease 4% (n=3) from n=84 YTD 2023 to n=81 YTD 2024)
  • an average daily count of 3 demonstrated for January 2024 (Target <8 achieved)

Cavan General Hospitalimg-417

  • performance maintenance of n=7 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count decrease 8% (n=18) from n=226 YTD 2023 to n=208 YTD 2024)
  • an average daily count of 7 demonstrated for January 2024 (Target <8 achieved)

Drogheda Hospitalimg-312

  • increase from n=9 to n=11 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count increase 14% (n=40) from n=289 YTD 2023 to n=329 YTD 2024)
  • an average daily count of 11 demonstrated for January 2024 (Target <12 achieved)

RCSI Hospital Groupimg-716

  • performance maintenance of n=28 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count increase 2% (n=17) from n=866 YTD 2023 to n=883 YTD 2024)
  • an average daily count of 28 demonstrated for January 2024 (Target <40 achieved)

National Performance Comparatorimg-601

  • increase from n=337 to n=341 in average number of patients awaiting ward bed accommodation in ED 2024 / 2023 for January (total count increase 1% (n=134) from n=10,444 YTD 2023 to n=10,578 YTD 2024)
  • an average daily count of 341 demonstrated for January 2024 (Target <228 not achieved)

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 < 9 months for new outpatient appointment (RCSI Hospital Group target)
  • 90% patients waiting <15 months for new outpatient appointment (NSP 2024)

Performance

Beaumont Hospitalimg-271

  • 88.4% of patients waiting <9 months on OPD wait list (2024)

Cavan General Hospitalimg-225

  • 95.8% of patients waiting <9 months on OPD wait list (2024)

Connolly Hospitalimg-704

  • 100% of patients waiting <9 months on OPD wait list (2024)

Drogheda Hospitalimg-465

  • 90.8% of patients waiting <9 months on OPD wait list (2024)

Louth County Hospitalimg-328

  • 98.8% of patients waiting <9 months on OPD wait list (2024)

Rotunda Hospitalimg-911

  • 98.3% of patients waiting <9 months on OPD wait list (2024)

RCSI Hospital Group – % of OPD Patients <9 monthsimg-489

  • overall 91.5% of patients waiting <9 months on OPD wait list (2024) in RCSI Hospital Group

National Hospital Groups – % of OPD Patients <9 months img-272

  • nationally 72.4% of patients waiting <9 months on OPD wait list (2024)

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 elective inpatient admission/day case. 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)
  • 90% patients waiting <9 months for elective IP/DC (NSP 2024)

Performance

Beaumont Hospitalimg-701

  • 81.1% of patients waiting <9 months for elective IP/DC (2024)

Cavan General Hospitalimg-813

  • 98.9% of patients waiting <9 months for elective IP/DC (2024)

Connolly Hospital img-582

  • 99.7% of patients waiting <9 months for elective IP/DC (2024)

Drogheda Hospitalimg-357

  • 99.9% of patients waiting <9 months for elective IP/DC (2024)

Louth County Hospital img-621

  • 99.8% of patients waiting <9 months for elective IP/DC (2024)

RCSI Hospital Groupimg-11

  • 86.4% of patients waiting <9 months for elective IP/DC (2024)

National Hospital Groups – % of IPDC Patients <9 months1 img-398

  • nationally 78.8% of patients waiting <9 months for elective IP/DC (2024)
  • note1 – RCSI Hospital Group noting achieved through inscourcing rather than outsourcing to private sector

National Hospital Groups – % of IPDC Patients <12 monthsimg-832

  • nationally 85.8% of patients waiting <12 months for elective IP/DC (2024)

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 Hospitalimg-528

  • Beaumont Hospital exceeded National Target set for 2024 reporting period (100% achieved against a target of 95%). National performance for January 2024 (82.3%) did not achieve target.

img-711

  • 90.0% compliant Q3 2023. Target of 90% achieved.
  • national performance not published

img-625

  • 79.0% compliant Q3 2023. Target of 90% not achieved.
  • national performance not published

img-495

  • 22.0% compliant Q3 2023. Target of 90% not achieved.
  • national performance not published

img-415

  • 8.3% compliant Q3 2023. Target of 80% not achieved.
  • 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 Hospitalimg-946

  • Beaumont Hospital exceeded National Target set for 2024 reporting period (97.4% against a target of 95%). National performance for January 2024 (86.4%) did not achieve target.

img-312

  • 21.0% compliant Q3 2023. Target of 90% not achieved.
  • national performance not published

img-906

  • 19.0% compliant Q3 2023. Target of 90% not achieved.
  • 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 img-247

  • Beaumont Hospital exceeded National Target set for 2024 reporting period (100% against a target of 95%). National Performance for January 2024 (76.3%) did not achieve target.

img-478

  • 83.1% compliant Q3 2023. Target of 95% not achieved.
  • national performance not published
  • note1 – therapeutic intervention includes radiotherapy, surgery and active surveillance and excludes hormone treatment

img-801

  • 75.3% compliant Q3 2023. Target of 80% not achieved.
  • national performance not published

Introduction

Melanoma also known as malignant melanoma is one of the most common skin cancers. Melanoma is a disease in which malignant (cancer) cells form in melanocytes (cells that colour the skin). The number of people diagnosed with melanoma is increasing rapidly each year in Ireland and around the world1. There are four centres providing melanoma services in the RCSI Hospital Group, Beaumont, Cavan, Connolly and Drogheda Hospitals.

Rationale for measurement

Significant delays in accessing hospital services and delays in diagnosis have the potential for less than optimal patient outcomes. The Key Performance Indicators (KPIs) outlined beneath measure access to treatment, multidisciplinary discussion and pathology reporting.

Measurement methodology and data source

  • Periodic local data extracts, extrapolated for analysis and publication 
  • The metrics beneath apply to a subset of patients with melanoma or primary invasive cutaneous malignant melanoma in situ, who have undergone excisional biopsy only (i.e. excludes punch biopsy, incisional biopsy or any other type of melanoma biopsy) 

Target

  • 95% of patients referred for excision of melanoma in situ or primary invasive cutaneous malignant melanoma are seen within 6 weeks of referral
  • 95% of patients with a diagnosis of melanoma in situ or primary invasive cutaneous malignant melanoma should be discussed at MDM within 4 weeks of diagnosis
  • 90% of patient histopathology reports of melanoma in situ or primary invasive cutaneous malignant melanoma which have primary excision should be issued within 10 working days of biopsy

Performanceimg-105

  • Beaumont Hospital provide MDM for all RCSI hospitals and some external hospitals
  • Patients from Connolly Hospital are included in Beaumont Hospital data
  • Beaumont and Drogheda Hospitals provide shared melanoma services

Reference: 1 https://www.mariekeating.ie/cancer-information/skincancer/melanoma

img-957

  • target of 95% not achieved

img-62

  • Beaumont Hospital 90% compliant Q3 2023. Target of 95% not achieved
  • Drogheda Hospital 100% compliant Q3 2023. Target of 95% achieved

img-992

  • Beaumont Hospital 62% compliant Q3 2023. Target of 90% not achieved
  • Drogheda Hospital 76% compliant Q3 2023. Target of 90% not achieved
  • Cavan Hospital 100% compliant Q3 2023. Target of 90% achieved

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 img-6

  • 98.08% compliance within the RCSI Hospital Group for January 2024 monthly reporting period

National Performance img-651

  • 92.84% compliance nationally for January 2024 monthly reporting period

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 (NSP 2024)

Performance

Beaumont Hospitalimg-8

  • Beaumont Hospital is currently achieving this target for monthly reporting period (88.2% compliance)

Cavan General Hospitalimg-377

  • Cavan General Hospital is currently not achieving this target for monthly reporting period (62.9% compliance)

Connolly Hospitalimg-977

  • Connolly Hospital is currently achieving this target for monthly reporting period (98.7% compliance)

Drogheda Hospitalimg-495

  • Drogheda Hospital is currently achieving this target for monthly reporting period (75.2% compliance)

Louth County Hospitalimg-746

  • Louth County Hospital is currently achieving this target for monthly reporting period (86.1% compliance)

RCSI Hospital Groupimg-902

  • RCSI Hospital Group is currently achieving this target for monthly reporting period (83.5% compliance)

National Performance Comparatorimg-989

  • nationally this target is not being met for monthly reporting period (61.1% 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 img-939

  • Connolly had no patients for whom an appointment was scheduled in January 2024

img-232

  • LCH achieved 100% compliance for January 2024

img-703

  • national performance for January 2024 77.4% did not achieve compliance target

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

img-90

  • national data not produced in a manner that enables comparison

img-785

  • LCH exceeded target for Q4 2023 (100% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral
  • Rotunda did not achieve target for Q4 2023 (60% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral

img-88

  • LCH exceeded target for Q4 2023 (100% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral
  • Rotunda did not achieve target for Q4 2023 (89% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral

img-916

  • LCH exceeded target for Q4 2023 (100% achieved against a target of 90%) for low grade referrals seen within 8 weeks of referral
  • Rotunda did not achieve target for Q4 2023 (88% achieved against a target of 90%) for low grade referrals seen within 8 weeks of referral

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

5%-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 weeks2. National KPIs developed by NWIHP measure the numbers of patients who receive histological confirmation within 8 or 12 weeks.

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)
  • KPI 1 – Number of patients referred to the Gynaecology Service with PMB seen within 4 weeks (also expressed as percent). This KPI is collated monthly.
  • KPI 2 – Number of patients referred to the Gynaecology Service with PMB who required biopsy and had histological confirmation within 8 weeks of referral from GP (also expressed as percent). This KPI is collated quarterly.
  • KPI 3 – 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). This KPI is collated quarterly.

Local hospital data extrapolated for analysis and publication

Target

  • 95% of patients seen within 4 weeks of referral
  • 95% of patients have histological confirmation within 12 weeks of referral

Performance

img-138

  • Beaumont, Cavan, Drogheda and Connolly Hospitals achieved target of 95% for KPI 1 in December 2023
  • Rotunda Hospital did not achieve target of 95% for KPI 1 in December 2023

img-803

  • Beaumont Hospital achieved target of 95% for KPI 3 in Q3 2023
  • Cavan Hospital did not achieve target of 95% for KPI 3 in Q3 2023
  • note1 all Rotunda, Drogheda and Connolly patients with PMB who required a biopsy received histological confirmation within 8 weeks

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 a Traumatic Brain Injury (TBI) admitted to Unit within 12 hours of acceptance.
  2. 90% of patients triaged as Grade I / II aneurysmal Subarachnoid Haemorrhage (aSAH) admitted to Unit within 24 hours of acceptance.
  3. 90% of patients triaged as having a Space Occupying Lesion (SOL) are transferred to Unit within 5 working days / 7 calendar days of acceptance.

Performance

RCSI Hospital Groupimg-790

  • 100% of patients were admitted within the specified time for Q4 2023. KPI achieved.

img-533

  • 100% of patients were admitted within the specified time for Q4 2023. KPI achieved.

img-984

  • 88% of patients were admitted within the specified time for Q4 2023. KPI not achieved.

Introduction

Bladder cancer occurs when abnormal cells appear in the lining of the bladder or in the bladder wall. The method of treatment for bladder cancer depends on the progression of the cancer into the layers of the bladder and the grade of the cancer. Bladder cancer affects about 490 people in Ireland each year and is more common in men than in women and it is currently the 14th most common cancer in Ireland (not counting non melanoma skin cancer)1.

Beaumont Hospital provides a specialist service in the Urology Department for patients diagnosed with bladder cancer.

Rationale for measurement

When detected early, bladder cancer is very treatable. One of the treatments is a cystectomy which is the full or partial removal of the bladder. Cystectomies may be recommended to treat cancer that begins in or spreads to the bladder.

Measurement methodology and data sources

  • local data extracts of volume of cystectomies performed, extrapolated for analysis and publication

Target

  • no target for volume of cystectomies performed
  • no national target available

Performanceimg-97

References:
1 Marie Keating Foundation (2023), Bladder Cancer – What you should know

Introduction

Penile cancer is a rare cancer and approximately 50 patients are diagnosed with it annually in Ireland1. It most commonly affects those over the age of 50 but can affect younger patients. Beaumont Hospital provides a specialist service in the Urology Department for patients diagnosed with penile cancer.

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 local data extracts of volume of patients extrapolated for analysis and publication
  • quarterly local data extracts of % of patients surgically treated with extrapolated for analysis and publication

Target

  • no target for volume of patients waiting for and treated by the Penile Cancer Service
  • 100% of patients with penile cancer surgically treated within 20 working days of decision to treat (local target)
  • no national target available

Performance
img-432

  • target of 100% achieved during Q3 2023

References:
1 Irish Cancer Society (2020), Cancer Information and Support – Penile Cancer

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 img-126img-755img-972

  • US 95.7% waiting < 3 months – Beaumont did not achieve target
  • MRI 77.9% waiting < 6 months – Beaumont did not achieve target
  • CT 98.8% waiting < 6 months – Beaumont did not achieve target

Connolly Hospital img-435img-652img-248

  • US 100% waiting < 3 months – Connolly achieved target
  • MRI 100% waiting < 6 months – Connolly achieved target
  • CT 100% waiting < 6 months – Connolly achieved target

Cavan Hospitalimg-649img-20img-315

  • US 100% waiting < 3 months – Cavan achieved target
  • MRI 87.6% waiting < 6 months – Cavan did not achieve target
  • CT 61.3% waiting < 6 months – Cavan did not achieve target

Drogheda Hospitalimg-646img-69img-889

  • US 88.9% waiting < 3 months – Drogheda/LCH did not achieve target
  • MRI 97.6% waiting < 6 months – Drogheda did not achieve target
  • CT 94.0% waiting < 6 months – Drogheda did not achieve target (Drogheda CT includes out-patients scanned in LCH)

RCSI Hospital Groupimg-933img-977img-960

  • US 92.5% waiting < 3 months – Group did not achieve target
  • MRI 83.5% waiting < 6 months – Group did not achieve target
  • CT 86.4% waiting < 6 months – Group did not achieve target

Rotunda Hospital (not included in Group total – only Gynae scans)img-166

  • US 86.0% waiting < 3 months – Rotunda did not achieve target
  • Rotunda data for November, December 2023 and January 2024 unavailable at time of report publication

Note – actual national performance currently published for diagnostics is not produced in a format that enables performance to be discernible or comparable

Introduction

The data presented below outlines the turnaround time (TAT) of chest and abdominal plain film radiology investigations requested by ED (Emergency Department) staff, from the time of imaging to radiology reporting, in each of the acute hospitals of the RCSI Hospital Group.

Rationale for measurement

Unreported radiology films have the potential for significant mortality and morbidity.

Measurement methodology and data sources

Data for this report was sourced from NIMIS Metrics 2 and generated on 13.10.2023.

The time frame represented is 01/07/2023 2023 to 30/09/2023. The data set initially extracted from NIMIS included cancelled and unreported investigations. The cancelled investigations were subsequently excluded from the data.

Unreported investigations are included in the volume totals, however they are excluded when calculating the median TAT. The following diagnostics are included: X-ray abdomen, X-ray KUB, X-ray chest, X-ray chest isolation, X-ray chest lateral, X-ray chest portable, and X-ray chest portable isolation.

Target

All X-rays taken in the Emergency Department have a target time of 48 hours for report completion1

1National Radiology Quality Improvement Programme (NRQIP) 2021

Performance

Volume of Reported & Unreported investigations per Hospital for January 2024
img-959
Note: XR reporting timeframe 48 hours
CT reporting timeframe 12 hours
MRI reporting timeframe 12 hours

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 img-300

  • cumulative for 2024 reporting period 14.0% (n=2,397) of total new bookings did not attend (DNA) scheduled appointments / 2023 14.7% DNA (n=2,258)
  • Beaumont 2024 18.7% DNA / 2023 19.9% DNA
  • Monaghan 2024 9.2% DNA / 2023 11.0% DNA
  • Cavan 2024 9.1% DNA / 2023 15.2% DNA
  • Drogheda 2024 8.9% DNA / 2023 11.4% DNA
  • Connolly 2024 13.4% DNA / 2023 16.3% DNA
  • Rotunda 2024 12.7% DNA / 2023 10.5% DNA
  • Louth 2024 15.6% DNA / 2023 11.3% DNA

National Performance Comparatorimg-874

  • during August 2023 monthly reporting period 13.0% of total new bookings (n=12,951) nationally did not attend scheduled appointment. National performance for Sep-23, Oct-23, Nov-23, Dec-23 and Jan-23 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 img-33

  • 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

Data is recorded in local hospital Endoscopy Units and uploaded to the National Quality Assurance Intelligence System (NQAIS). NQAIS functions as a central repository for quality improvement data and was developed by the Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons and HSE Health Intelligence Ireland.

Results are reported as colonoscopies with polyp detected expressed as a % of total colonoscopies per endoscopist.

Data Sources:

  • NQAIS

Target

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

Performance img-385

  • all hospitals in RCSI Hospital Group achieved target Q3 2023

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

Data is recorded in local hospital Endoscopy Units and uploaded to the National Quality Assurance Intelligence System (NQAIS). NQAIS functions as a central repository for quality improvement data and was developed by the Conjoint Board in Ireland of the Royal College of Physicians and Royal College of Surgeons and HSE Health Intelligence Ireland.

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:

  • NQAIS

Target

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

Performance img-727

  • all hospitals in RCSI Hospital Group achieved target Q3 2023

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

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
img-680

img-953

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.

img-513

  • Beaumont overall compliance rate decreased to 77% in Jan-24 from 78% in Dec-23
  • Cavan overall compliance rate decreased to 95% in Jan-24 from 96% in Dec-23
  • Connolly overall compliance rate maintained at 98% in Jan-24 and Dec-23
  • Drogheda overall compliance rate decreased to 82% in Jan-24 from 87% in Dec-23
  • RCSI Hospital Group overall compliance rate decreased to 88% in Jan-24 from 90% in Dec-23
  • comparative national data not available

Rationale for measurement

Four key reasons that 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 3.5)

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 of recording of patient details onto scheduled care waiting list record ≤ 3 days1

img-989

  • note1 overall sample size n=100 patients (20 per hospital)
  • during January 2024 overall sample group demonstrated 98% compliance with data entry requirements

% compliance of recording of patient details onto scheduled care waiting list record (Start date = DTA)1img-1000

  • note1 overall sample size n=100 patients (20 per hospital)
  • during January 2024 overall sample group demonstrated 98% compliance with data entry requirements

% compliance with booking form returned to scheduling office < one working day and date stamped1 img-342

  • note1 overall sample size n=100 patients (20 per hospital)
  • during January 2024 overall sample group demonstrated 97% compliance with booking form returned within 1 working day and date stamped

% compliance of sending acknowledgement letter (Out Patients)1 img-265

  • note1 overall sample size n=100 patients (20 per hospital)
  • during January 2024 overall sample group demonstrated 100% compliance with requirement to send acknowledgement letter

% compliance of patient specific minimum data set completeness on WL Record1 img-26

  • note1 overall sample size n=100 data points
  • during January 2024 overall sample group demonstrated 89% compliance with completion of patient specific minimum data set

% compliance of DNA / CNA Policy compliance1234 img-659img-638

  • note1: DNA policy: DNA patients are removed from waiting list
  • note2: if patient cannot attend (CNA) their wait time clock restarts
  • note3: report sample size (DNA n=60; CNA n=40)
  • note4: insufficient cancellations/ dnas to comply with 100 records being checked
  • during Q4 2023 overall sample group demonstrated 100% compliance with DNA policy
  • during Q4 2023 overall sample group demonstrated 100% compliance with CNA policy
  • data produced on quarterly basis
  • national performance not produced