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 14.43 hours for reporting month 2023
• average time spent in ED for non-admitted patients is 7.50 hours for reporting month 2023

Cavan General Hospital

• average time spent in ED for admitted patients is 9.09 hours for reporting month 2023
• average time spent in ED for non-admitted patients is 5.10 hours for reporting month 2023

Connolly Hospital

• average time spent in ED for admitted patients is 12.40 hours for reporting month 2023
• average time spent in ED for non-admitted patients is 5.58 hours for reporting month 2023

Drogheda Hospital

• average time spent in ED for admitted patients is 12.03 hours for reporting month 2023
• average time spent in ED for non-admitted patients is 7.11 hours for reporting month 2023

Target

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

Performance

Beaumont Hospital

• March 2023 68.6% compliance with 9 hour non-admitted PET / 21.8% compliance with admitted PET

Cavan General Hospital

• March 2023 91.8% compliance with 9 hour non admitted PET / 60.1% compliance with admitted PET

Connolly Hospital

• March 2023 79.9% compliance with 9 hour non admitted PET / 28.4% compliance with admitted PET

Drogheda Hospital

• March 2023 77.2% compliance with 9 hour non admitted PET / 50.0% compliance with admitted PET

RCSI Hospital Group

• March 2023 78.5% compliance with 9 hour non admitted PET / 40.1% compliance with admitted PET

National Performance Comparator

• March 2023 78.3% compliance with 9 hour non admitted PET / 45.6% 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 2023 5.0% >24hours (4.2% Mar 2022) performance deterioration demonstrated
• Cavan Hospital – Mar 2023 0.1% >24hours (3.1% Mar 2022) performance improvement demonstrated
• Connolly Hospital – Mar 2023 0% >24 hours (0% Mar 2022) performance maintenance demonstrated
• Drogheda Hospital – Mar 2023 10.0% >24hours (2.8% Mar 2022) performance deterioration demonstrated

• RCSI HG – Mar 2023 3.8% > 24hours (2.7% Mar 2022)
• National – Mar 2023 5.3% > 24hours (4.7% Mar 2022)

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

• decrease from n=4 to n=2 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 193% (n=323) from n=167 Jan-Mar 2022 to n=490 Jan-Mar 2023)
  • performance improvement commenced in July 2016 generally maintained during subsequent reporting period
  • an average daily count value of 2 demonstrated for March 2023 (Target <12 achieved)

Cavan General Hospital

• increase from n=4 to n=5 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 73% (n=214) from n=294 Jan-Mar 2022 to n=508 Jan-Mar 2023)
• an average daily count of 5 demonstrated for March 2023 (Target <8 achieved)

Connolly Hospital

• increase from n=0 to n=1 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 350% (n=91) from n=26 Jan-Mar 2022 to n=117 Jan-Mar 2023)
• an average daily count of 1 demonstrated for March 2023 (Target <8 achieved)

Drogheda Hospital

• increase from n=5 to n=8 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 64% (n=292) from n=457 Jan-Mar 2022 to n=749 Jan-Mar 2023)
• an average daily count of 8 demonstrated for March 2023 (Target <12 achieved)

RCSI Hospital Group

• increase from n=14 to n=16 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 97% (n=920) from n=944 Jan-Mar 2022 to n=1,864 Jan-Mar 2023)
• an average daily count of 16 demonstrated for March 2023 (Target <40 achieved)

National Performance Comparator

• increase from n=337 to n=359 in average number of patients awaiting ward bed accommodation in ED 2023 / 2022 for March (total count increase 10% (n=2,757) from n=27,413 Jan-Mar 2022 to n=30,170 Jan-Mar 2023)
• an average daily count of 359 demonstrated for March 2023 (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)
• 98% patients waiting <18 months for new outpatient appointment (NSP 2022)

Performance <12 months

Beaumont Hospital

• 89.3% of patients waiting <9 months on OPD wait list (2023)

Cavan General Hospital

• 77.7% of patients waiting <9 months on OPD wait list (2023)

Connolly Hospital

• 96.9% of patients waiting <9 months on OPD wait list (2023)

Drogheda Hospital

• 76.3% of patients waiting <9 months on OPD wait list (2023)

Louth County Hospital

• 79.2% of patients waiting <9 months on OPD wait list (2023)

Rotunda Hospital

• 99.2% of patients waiting <9 months on OPD wait list (2023)

RCSI Hospital Group – % of OPD Patients <9 months

• overall 85.1% of patients waiting <9 months on OPD wait list (2023) in RCSI Hospital Group

National Hospital Groups – % of OPD Patients <9 months

• nationally 65.3% of patients waiting <9 months on OPD wait list (2023)

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)
• 98% patients waiting <12 months for elective IP/DC (NSP 2022)

Performance

Beaumont Hospital

• 78.3% of patients waiting <9 months for elective IP/DC (2023)

Cavan General Hospital

• 99.8% of patients waiting <9 months for elective IP/DC (2023)

Connolly Hospital

• 95.1% of patients waiting <9 months for elective IP/DC (2023)

Drogheda Hospital

• 94.4% of patients waiting <9 months for elective IP/DC (2023)

Louth County Hospital

• 98.8% of patients waiting <9 months for elective IP/DC (2023). Ophthalmology excluded which comprises 9% DC activity and is under the control of IEHG

RCSI Hospital Group

• 83.3% of patients waiting <9 months for elective IP/DC (2023)

National Hospital Groups – % of IPDC Patients <9 months

• nationally 75.2% of patients waiting <9 months for elective IP/DC (2023)

National Hospital Groups – % of IPDC Patients <12 months

• nationally 83.2% of patients waiting <12 months for elective IP/DC (2023)

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 2023 reporting period (100% achieved against a target of 95%). National performance for March 2023 (85.3%) did not achieve target. It should be noted that national performance does not include Letterkenny Hospital as this was unavailable at time of report publication.

• 92.3% compliant Q3 2022
• national performance not published

• 76.3% compliant Q3 2022
• national performance not published

• 81.0% compliant Q3 2022
• national performance not published

• 66.7% compliant Q3 2022
• 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 achieved National Target set for 2023 reporting period (100% against a target of 95%). National performance for March 2023 (80.4%) did not achieve target. It should be noted that national performance does not include Cork University Hospital as this was unavailable at time of report publication.

• 47.0% compliant Q4 2022
• national performance not published

• 40% compliant Q4 2022
• 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 2023 reporting period (100% achieved against a target of 95%). National Performance for March 2023 (84.7%) did not achieve target. It should be noted that national performance does not include St James’s Hospital as this was unavailable at time of report publication.

• 64.7% compliant Q4 2022
• national performance not published
• note¹ – therapeutic intervention includes radiotherapy, surgery and active surveillance and excludes hormone treatment

• 91.7% compliant Q4 2022
• 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

Performance

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

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

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 February 2023 monthly reporting period.

National Performance

• 99.83% compliance nationally for March 2023 monthly reporting period. n=2,602 total patient volume nationally requiring urgent colonoscopy at end of Mar-23 (25% increase vs same period in 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 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 2022)

Performance

Beaumont Hospital

• Beaumont Hospital is currently achieving this target for monthly reporting period (75.5% compliance)

Cavan General Hospital

• Cavan General Hospital is currently achieving this target for monthly reporting period (83.6% compliance)

Connolly Hospital

• Connolly Hospital is currently achieving this target for monthly reporting period (86.7% compliance)

Drogheda Hospital

• Drogheda Hospital is currently achieving this target for monthly reporting period (68.4% compliance)

Louth County Hospital

• Louth County Hospital is currently achieving this target for monthly reporting period (72.7% compliance)

RCSI Hospital Group

• RCSI Hospital Group is currently achieving this target for monthly reporting period (77.6% compliance)

National Performance Comparator

• nationally this target is not being met for monthly reporting period (60.5% 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-23

• LCH achieved 100% compliance Mar-23

• national performance for Mar-23 85.9% 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

• national data not produced in a manner that enables comparison

• LCH exceeded target for Q1 2023 (100% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral
• Rotunda did not achieve target for Q1 2023 (66% achieved against a target of 90%) for urgent referrals seen within 2 weeks of referral

• LCH exceeded target for Q1 2023 (98% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral
• Rotunda did not achieve target for Q1 2023 (66% achieved against a target of 90%) for high grade referrals seen within 4 weeks of referral

• LCH exceeded target for Q1 2023 (99.7% achieved against a target of 90%) for low grade referrals seen within 8 weeks of referral
• Rotunda did not achieve target for Q1 2023 (22% 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

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

Performance

• Connolly Hospital achieved the target of 100% for KPI 1 in February 2023
• Beaumont, Rotunda, Cavan and Drogheda Hospitals did not achieve the target of 100% for KPI 1 in February 2023

• Rotunda and Drogheda Hospitals achieved the target of 100% for KPI 2 in Q4 2022
• Beaumont, Cavan and Connolly Hospitals did not achieve the target of 100% for KPI 2 in Q4 2022

• Beaumont, Cavan and Connolly Hospitals did not achieve the target of 100% for KPI 3 in Q4 2022
• *note all Rotunda and Drogheda 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 Group

• 100% (42 out of 42 patients) were admitted within the specified time for Q1 2023. KPI achieved.

• 100% (39 out of 39 patients) were admitted within the specified time for Q1 2023. KPI achieved.

• 91% (104 out of 114 patients) were admitted within the specified time for Q1 2023. KPI achieved.

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 89.8% waiting < 3 months – Beaumont did not achieve target
• MRI 95.0% waiting < 6 months – Beaumont did not achieve target
• CT 100% waiting < 6 months – Beaumont achieved target

Connolly Hospital

• 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 Hospital

• US 100% waiting < 3 months – Cavan achieved target
• MRI 100% waiting < 6 months – Cavan achieved target
• CT 83.8% waiting < 6 months – Cavan did not achieve target

Drogheda Hospital

• US 89.6% waiting < 3 months – Drogheda/LCH did not achieve target
• MRI 98.9% waiting < 6 months – Drogheda did not achieve target
• CT 92.0% waiting < 6 months – Drogheda did not achieve target (Drogheda CT includes out-patients scanned in LCH)

RCSI Hospital Group

• US 91.8% waiting < 3 months – Group did not achieve target
• MRI 97.3% waiting < 6 months – Group did not achieve target
• CT 92.4% waiting < 6 months – Group did not achieve target

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

• US 37% 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 2023 reporting period 15.2% (n=7,185) of total new bookings did not attend (DNA) scheduled appointments / 2022 15.1% DNA (n=6,517)
  • Beaumont 2023 20.0% DNA / 2022 21.6% DNA
  • Cavan 2023 13.8% DNA / 2022 8.5% DNA
  • Connolly 2023 14.8% DNA / 2022 15.5% DNA
  • Louth 2023 12.0% DNA / 2022 12.9% DNA
  • Monaghan 2023 11.3% DNA / 2022 10.4% DNA
  • Drogheda 2023 9.9% DNA / 2022 9.2% DNA
  • Rotunda 2023 13.5% DNA / 2022 11.7% DNA

National Performance Comparator

• during February 2023 monthly reporting period 13.0% of total new bookings (n=12,022) did not attend scheduled appointment. National performance for Mar-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

• 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 via Local hospital Endoscopy Units

Target

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

Performance

• all hospitals in RCSI Hospital Group achieved target Q4 2022
• Q2-21 data unavailable due to cyber attack

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 via Local hospital Endoscopy Units

Target

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

Performance

• all hospitals in RCSI Hospital Group achieved target Q4 2022
• Q2-21 data unavailable due to cyber attack

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

% of discharged inpatients whose GP was issued a Discharge Letter within 2 weeks (iPMS data only and one month in arrears)

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 overall compliance rate maintained at 76% in Mar-23 and Feb-23
• Cavan overall compliance rate improved to 97% in Mar-23 from 96% in Feb-23, with 100% compliance in Patients Details, Primary Healthcare Details and Admission and Discharge Details
• Connolly overall compliance rate improved to 96% in Mar-23 from 95% in Feb-23 with 100% compliance in Admission and Discharge Details
• Drogheda overall compliance rate decreased to 77% in Mar-23 from 78% in Feb-23
• RCSI Hospital Group overall compliance rate improved to 87% in Mar-23 from 86% in Feb-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 recording of patient details onto scheduled care waiting list record ≤ 3 days

• note overall sample size n=100 patients (20 per hospital)
• during March 2023 overall sample group demonstrated 97% 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 2023 overall sample group demonstrated 97% 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 2023 overall sample group demonstrated 97% 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 2023 overall sample group demonstrated 100% compliance with requirement to send acknowledgement letter

% compliance of patient specific minimum data set completeness on WL Record

• note: overall sample size n=420 data points
• during March 2023 overall sample group demonstrated 92% 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 (DNA n=54; CNA n=39)
• note: insufficient cancellations/ dnas to comply with 100 records being checked
• during Q1 2023 overall sample group demonstrated 100% compliance with DNA policy
• during Q1 2023 overall sample group demonstrated 84% compliance with CNA policy
• data produced on quarterly basis
• national performance not produced