Dimension: Patient and Family Experience
Rationale for Measurement
The RCSI Hospital Group wishes to provide opportunities for patients and families to tell us about their experiences of care. This feedback can then be used to improve care for all patients. The Hospital Group uses various methods to capture the patient’s experience of our services. Participation in the yearly National in-Patient Experience Survey (NIES) is one of the methods used. The NIES Programme is a joint initiative by the Health Information and Quality Authority (HIQA), the Health Service Executive (HSE) and the Department of Health. A number of quality improvements have been developed as a result of analysing the feedback beneath and these are displayed on the RCSI HG website for maximal transparency.
Measurement Methodology and Data Sources
All adult patients, with a postal address in the Republic of Ireland, who spent 24 hours or more in one of the 40 participating hospitals were asked to complete the NIES survey. In total, 7222 patients of the HSE DNE Region were invited to participate in the survey and 2822 completed responses have been returned.
Ref: https://www.yourexperience.ie
The final datasets are listed below and have been broken into 6 themes:
- Admissions
- Care on the Ward
- Examination, Diagnosis and Treatment
- Discharge or Transfer
- Patient Safety
- Overall experience
National Performance
HSE DNE
- HSE DNE scored higher than the national average on the theme of Patient Safety. It scored the same as the national average on the theme of Overall Experience, Examinations, Diagnosis and Treatment, Discharge/Transfer and lower than the national average on the themes of Admissions and Care on the ward. All hospitals in DNE scored 8 or greater in the theme of Overall Experience.
Connolly
- Connolly Hospital scored the same as the national average on the theme of Admissions and lower than the national average on Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience. Connolly scored higher than 2022 survey on Overall Experience (8.2 in 2024 v 7.7 in 2022).
Cavan
- Cavan Hospital scored higher than the national average on the themes of Admissions and Patient Safety. Cavan Hospital scored the same as the national average on the theme of Care on the Ward and lower on Examinations, Diagnosis and Treatment, Discharge/Transfer and Overall Experience. Cavan scored lower than 2022 survey on Overall Experience (8.2 in 2024 v 8.3 in 2022).
Drogheda
- Drogheda Hospital scored lower than the national average on the theme of Admissions, Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience. Drogheda scored lower than 2022 survey on Overall Experience (8.0 in 2024 v 8.1 in 2022)..
Beaumont
- Beaumont Hospital scored lower than the national average on the themes of Admissions, Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience. Beaumont scored higher than 2022 survey on Overall Experience (8.0 in 2024 v 7.7 in 2022).
Louth County
- Louth County Hospital scored higher than the national average on the theme of Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience.
- No data available on the theme of Admissions
Mater
- Mater Hospital scored higher than the national average on the themes of Admissions, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety, Overall Experience and lower than the national average on Care on the Ward.
Cappagh
- Cappagh Hospital scored higher than the national average on the themes of Admissions, Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience.
Navan
- Navan Hospital scored higher than the national average on the themes of Admissions, Care on the Ward, Examinations, Diagnosis and Treatment, Discharge/Transfer, Patient Safety and Overall Experience.
MATERNITY PATIENT SATISFACTION SURVEYS
Introduction
The National Maternity Experience Survey (NMES) offers eligible new mothers the opportunity to share their experiences of all aspects of Ireland’s maternity services from antenatal through labour and birth to postnatal care. The first National Maternity Experience Survey took place in October and November 2019. The NMES Programme is a joint initiative by the Health Information and Quality Authority (HIQA), the Health Service Executive (HSE) and the Department of Health.
Rationale for Measurement
Feedback from the NMES will be used to improve the safety and quality of care provided to women and their babies in the RCSI HG.
Measurement Methodology and Data Sources
The NMES included 68 structured, tick-box questions and three open-ended (free-flow) questions. The survey covered the full pathway of maternity care — from antenatal care, through labour and birth, to postnatal care in the community. Women aged 16 or over who gave birth in October or November 2019 and had a postal address in the Republic of Ireland were invited to participate in the NMES.
The final datasets are listed below and have been broken into 7 themes:
-
Antenatal Care – Experiences of the type of maternity care offered and chosen, information provided and communication with healthcare professionals in the antenatal care period
-
Labour and Birth – Experiences of interactions with healthcare professionals, pain management and involvement in decisions during labour and when giving birth
-
Care after Birth – Experiences in hospital, such as the support and assistance provided by staff, and information provided on care and recovery
-
Specialised Care – Experiences of support in the neonatal unit and overall ratings of the care received by the baby while in the unit
-
Feeding – Experiences of receiving information and support from healthcare professionals on feeding the baby
-
Care at Home – Experiences of support and advice from GPs and public health nurses while at home after the birth
-
Overall Experience
Cavan General Hospital
- Cavan has demonstrated above national average standards in 6/6 themes
Drogheda Hospital
- Drogheda has demonstrated above national average standards in 5/6 themes
Rotunda Hospital
- Rotunda has demonstrated above national average standards in 5/6 themes
RCSI Hospital Group
- the patient feedback received for RCSI Hospital Group has demonstrated the highest level of patient satisfaction in the National Maternity Experience Survey 2020
MATERNITY BEREAVEMENT EXPERIENCE SURVEY (NMBES) 2022
Introduction
The National Maternity Bereavement Experience Survey (NMBES) offered women and their partners the opportunity to share their experiences of Ireland’s maternity bereavement care services. The survey is part of the National Care Experience Programme, which is a joint initiative by the Health Information and Quality Authority (HIQA), the Health Service Executive (HSE) and the Department of Health (DoH).
Rationale for Measurement
The willingness of participating parents to share their experiences of such a difficult and painful time helps identify areas where care can be improved, particularly in relation to information and support relating to grieving, physical recovery, and mental health after leaving hospital.
Measurement Methodology and Data Sources
Women and their partners who experienced a second trimester miscarriage, a stillbirth or the early neonatal death of a baby in one of Ireland’s 19 maternity units or hospitals between 1 January 2019 and 31 December 2021 were invited to participate in the Survey. In total, 655 women and 232 partners or support persons participated in the NMBES questionnaire. The survey explored the pathway of maternity bereavement care from communication and information at the time of antenatal diagnosis, through to maternity hospital care, and follow-up care provided in the community after leaving hospital.
The datasets have been broken into 11 stages of care:
- Communication and Information at the time of diagnosis – experiences of care, support, interactions and provision of information at the time of baby’s diagnosis
- Admission care – experiences of care when admitted for induction of labour or delivery, focusing on admission planning and the hospital environment
- Labour and Birth – experiences of interactions with healthcare professionals, pain management and involvement in decisions while in labour and giving birth
- Care after birth and meeting the baby – experiences of meeting the baby, and the support and privacy provided
- Neonatal Care – experiences of care in the neonatal unit, involving visiting, involvement in decisions and communication
- Postnatal Care – experiences of hospital care after the birth, including physical and emotional support
- Bereavement Care – experiences of support with practical and emotional aspects of dealing with the bereavement
- Post-mortem Examination and Investigations – experiences of the post-mortem examination process, including timeframes and communication
- Discharge – experiences of preparation for leaving the hospital and provision of information and support for returning home
- Follow-up Care – experiences of care at home after the discharge, including care from a GP or Public Health Nurse
- Partner or Support Person – experiences of a partner or support person, including involvement in decisions and provision of support
National Average
Cavan Hospital
- Cavan Hospital demonstrated above national average in 6 stages of care
Drogheda Hospital
- Drogheda Hospital demonstrated above or equalled national average in 4 stages of care
Rotunda Hospital
- Rotunda Hospital demonstrated above or equalled national average in 6 stages of care
Introduction
A feature of high reliability organisations is their ability to identify, report and respond to patient safety incidents in a timely manner.1 Once they are identified, patient safety incidents should be immediately reported via the line management structure and corrective actions should be put in place to minimise and prevent further harm. Patients and their families should be fully informed of this process. These actions should be documented.
It is mandatory for services to report all incidents onto the National Incident Management System (NIMS) which is a database maintained by the State Claims Agency
Rationale for measurement
To determine whether patient safety incidents are being escalated and reported in a timely manner, this metric will outline:
- % and number of SREs and SIs entered onto NIMS within 30 days of the incident occurring
- length of time between the date of incident occurrence for Serious Reportable Events (SREs) and Serious Incidents (SIs) and the date of Escalation to the RCSI Hospital Group
Definitions
- Serious Reportable Events (SRE) are defined in the HSE Incident Management Framework as a subset of incidents which are either serious or that should not occur if the available preventative measures have been effectively implemented. SREs are mandatorily reportable by services to the Senior Accountable Officer (SAO)
- Serious Incident (SI). A list of SIs is provided by the Group Senior Incident Management Fora ((1) Women’s and Children’s, (2) Peri-operative and (3) Medicine)2
Measurement methodology and data sources
- all SREs and SIs escalated to the RCSI Hospital Group from 01/01/2024 to 31/03/2024 (Data source RCSI Hospital Group, Escalation Tracker which is maintained at Hospital Group level & validated with each site)
- all SREs & SIs, created on NIMS from 01/01/2024 to 31/03/2024 (“Create date”), Data source NIMS
- incidents which occurred in 2023 but escalated in Q1 2024 are included.
- calculations are based on a 5-day working week (Monday to Friday)
Targets
- % of SREs and SIs entered onto NIMS within 30 days of notification. Target 70%3
- there is no defined timeframe for escalation to the HG but this should occur as soon as possible following identification of the incident
References
1 Incident Management Framework, (2020), HSE
2 Trigger Lists SREs and SIs, Serious Incident Management Fora, RCSI Hospital Group
3 Integrated Guide to NIMS Reporting (2023), HSE
Performance
Number and % of Reported SRE/SI Incidents entered to NIMS within 30 days of Date Identified
Timeframes for Reporting onto NIMS
Escalation to the RCSI Hospital Group
Introduction
Patients expect to be safe when using health services. However, sometimes the delivery of care falls below an acceptable standard and this may lead to a patient safety incident or harm. If this happens patients, families and staff are entitled to ask why an event happened and to be assured that steps have been taken to prevent a similar incident occurring in the future1.
In the Hospital Group all Serious Reportable Events (SREs), Serious incidents (SIs) are reviewed utilising a Systems Analysis Review (SAR) Methodology in line with the HSE Incident Management Framework2. During a SAR, a structured analysis is conducted using best practice methods, to determine what happened, how it happened, why it happened, and whether there are learning points for the service, wider organization, or nationally. In the Hospital Group, new SREs and SIs are discussed firstly at the Local Incident Management Forum in each site and then at the Serious Incident Management Forum at Hospital Group level. Completed reviews are also discussed within this governance structure enabling shared learning across the Hospital Group.
Rationale for measurement
To ensure a responsive and timely approach to reviews which benefits patients, families, staff and the organisation, reviews should be completed within the shortest possible timeframe. For SARS this should not exceed 125 days from the date the Senior Accountable Officer is notified of the incident.
Measurement methodology and data sources
Numbers of comprehensive, concise and aggregate reviews completed per quarter*(Reviews of Serious Falls & Grade 3 & 4 Pressure Injuries are measured separately).
NIMS data extrapolated for analysis and publication and then validated with the relevant hospital.
Performance
- Connolly, Mater and Rotunda Hospitals had no completed Systems Analysis Reviews within the time period
References:
1 National Standards for the Conduct of Reviews of Patient Safety Incidents, (2017), HIQA
2 Incident Management Framework, (2020), HSE
Introduction
Patients expect to be safe when using health services. However, sometimes the delivery of care falls below an acceptable standard and this may lead to a patient safety incident or harm. If this happens patients, families and staff are entitled to ask why an event happened and to be assured that steps have been taken to prevent a similar incident occurring in the future1.
In the Hospital Group all Serious Falls and Grade 3&4 Pressure Injuries are reviewed utilising an Incident Specific Review Tool. The Incident Specific Review utilises a Systems Analysis Review (SAR) Methodology in line with the HSE Incident Management Framework2. Use of the Incident Specific Review Tool enables staff at the point of care delivery to conduct a structured analysis of the incident using best practice methods, to determine what happened, how it happened, why it happened, and whether there are learning points for the service, wider organisation, or nationally. In the Hospital Group, new Grade 3&4 pressure ulcers and serious falls are discussed firstly at the Local Incident Management Forum in each site and then at the Serious Incident Management Forum at Hospital Group level. Completed reviews are also discussed within this governance structure enabling shared learning across the Hospital Group.
Definitions
- Serious fall: a patient fall associated with patient death or disability (includes fractures and intracranial bleeds) whilst being cared for in a health service facility.
- Stage 3 pressure injury: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. This stage may include undermining and tunneling.
- Stage 4 pressure injury: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. This stage often includes undermining and tunneling. Exposed bone/muscle is visible or directly palpable.
Rationale for measurement
To ensure a responsive and timely approach to reviews which benefits patients, families, staff and the organisation, incident specific reviews in the HG should be completed within 30 days from the date the Senior Accountable Officer is notified of the incident.
Measurement methodology and data sources
Numbers of incident specific reviews of serious falls and hospital acquired grade 3&4 pressure injuries completed per quarter.
NIMS data extrapolated for analysis and publication and then validated with the relevant hospital.
Performance – Pressure Ulcer Reviews
- Cappagh, Cavan, Mater and Navan Hospitals had no Incident Specific Pressure Ulcer Reviews within the time period
Performance – Serious Fall Reviews
- Navan had no Incident Specific Serious Fall Reviews within the time period
References:
1 National Standards for the Conduct of Reviews of Patient Safety Incidents, (2017), HIQA
2 Incident Management Framework, (2020), HSE
- Patient complaints have been identified as a valuable resource for monitoring and improving patient safety.
- RCSI Hospital Group staff work hard to get everything right first time, but understand that not all patients may be happy with service provision and that problems can occur. However, if staff can get their response to complaints right in terms of explanation of problem experienced and efforts introduced to prevent further reoccurrence, then patients effected are less likely to be unhappy and equally important future problems can be prevented.
Measurement methodology and data sources
- Local data set from monthly hospital performance metrics. No national data.
- Complaints must be acknowledged within 5 working days of receipt. A complaint should then be investigated
and concluded within 30 working days of it being acknowledged1
Target
- 75% of complaints investigated and response sent to the complainant within 35 days – RCSI Hospital Group target (S.I. No 652/2006 – Health Act 2004 (complaints) Regulations 2006).
Performance
RCSI Hospital Group
- RCSI Hospital Group are collating % of all complaints responded to within 35 working days
- national data excludes complaints which relate solely to Clinical Judgement, therefore comparison is not possible
Reference:
1S.I. No. 652/2006 – Health Act 2004 (Complaints) Regulations, 2006
Parliamentary Questions (PQs) can be posed by any members of the Oireachtas and provide Ministers with regular opportunities to report publicly on matters for which they are responsible.
There is a statutory requirement for all state bodies to respond in full to all referred PQs within a maximum of 10 working days as per Dáil Éireann Standing Orders relative to Public Business 2016, section 41(A).
Representations (Reps) can be posed by any members of the Oireachtas and concern individual patients and operational matters relating to local issues.
The national response target for Reps is 15 days as per DPER Circular 25/2016.
Measurement methodology and data sources
- Compliance % with <10 working days for PQs and <15 days for Reps
- HSE National database
- RCSI Hospital Group database
Target
- RCSI Hospital Group set target is <10 days. National PQ response target is <10 days for response letter to be issued.
- RCSI Hospital Group set target is <15 days. National Rep response target is <15 days for response letter to be issued.
Performance
RCSI Hospital Group Performance
- Parliamentary Affairs Division (PAD) ceased reporting national data in Dec 2019
- RCSI Hospital Group merged PQs and REPs and introduced target of <10 days in March 2020
