Rationale for measurement

The National Vetting Bureau (Children and Vulnerable Persons) Acts 2012-2016 came into effect on 29 April 2016. This legislation makes it mandatory for people who carry out relevant work or activities in respect of children or vulnerable adults to be vetted by the National Vetting Bureau (NVB) of the Garda Siochana. The Acts define relevant work or activities as ‘any work or activity which is carried out by a person, a necessary and regular part of which consists mainly of the person having access to, or contact with, children or vulnerable adults’.

Section 21 of the Act provides for the retrospective vetting of employees who are carrying out ‘relevant work or activities’ and who were not previously vetted. The Regulations (SI No. 223 of 2016) provide that applications for retrospective vetting disclosures shall be made not later than March 2018.

Measurement methodology and data sources

• Local data set from monthly performance metrics

Target

• 100% of employees engaged in ‘relevant work’

Performance

• in line with legislation members of staff are not allowed to work until their Garda vetting is completed
• national data not published

OPEN DISCLOSURE TRAINING

Introduction

Open Disclosure is an open and consistent approach to communicating with patients and their families when things go wrong in healthcare. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event. Open Disclosure is important for building patient and public trust in the health system. This is supported by relevant legislation,

• The Civil Liability (Amendment) Act, 2017, provides the legal framework to support voluntary open disclosure.
• Draft Patient Safety Legislation is awaited. This legislation which will provide a legal framework for mandatory open disclosure

The HSE Open Disclosure Policy, 2019 also provides a framework for open disclosure in the health service.

Rationale for measurement

It is government policy that open disclosure is in place and is supported across the health system in line with relevant legislation and HSE Policy. Training is provided in the form of

a) briefing sessions face to face or via online module on HSE land

b) skills workshops

c) bespoke MPS/RCSI HG Training

Measurement methodology and data source

Quarterly local data extracts, extrapolated for analysis and publication

Numerator: Number of relevant staff trained (Expressed as %)

Denominator:  Total number of relevant staff (Expressed as %)

Target

100% of relevant staff have completed either a briefing session or a skills workshop in Open Disclosure

Performance

• RCSI HG hospitals are not achieving the target of 100%
• national dataset not published for comparative purposes

 

EARLY WARNING SCORE

Rational for measurement

National Early Warning System (INEWS), Irish Maternity Early Warning System (IMEWS), Paediatric Early Warning System (PEWS).

Introduction

Acute physiological deterioration is a time-crucial medical emergency. Failure to detect and treat patient deterioration in a judicious manner poses a threat to patient safety. Early recognition of clinical deterioration by regular measurement and documentation of physiological parameters, followed by prompt and effective action, can minimise the occurrence of adverse events such as cardiac arrest.

Measurement methodology and data sources

The following guidelines guide clinical practice (NEWS, PEWS, IMEWS)

• In September 2020 the Irish National Early Warning System Clinical Care Guideline was revised and updated to INEWS V2 (previously NEWS). This National Clinical Guideline is relevant to all healthcare professionals working in acute settings. This guideline applies to adult (≥ 16 years) non-pregnant patients in acute settings
• Clinical Practice Guideline – Irish Maternity Early Warning System (IMEWS) should be used for women who are clinically pregnant or who were delivered within the previous 42 days
• The Paediatric Early Warning System (PEWS) should be used for patients < 16 years of age

These guidelines endorse the concept that facilitates the timely assessment of, and response to, the deterioration of acutely ill patients by:

• Classifying the severity of a patient’s illness
• Providing prompts and structured communications tools to escalate care
• Following a definitive escalation plan
• Providing a clear, structured response model

The above tools utilised by trained staff lead to a reduction in instances of unanticipated admission and/or readmission to ICU and in instances of unanticipated cardiac arrest.

Target

100% of Medical, Nursing & Midwifery professionals trained in the appropriate tool/tools depending on work speciality. Staff may require training on multiple tools depending on the patients they care. Training is a once off for each tool.

• compliance measuring staff trained on INEWS since its introduction in Sep-20. Staff would have previously been trained in NEWS
• RCSI HG hospitals are not achieving the target of 100%, with the exception of Nursing in Drogheda/LCH

• Drogheda Hospital achieving target of 100% for both Medical and Midwifery staff
• Cavan Hospital not achieving target of 100% for Medical and achieving target of 100% for Midwifery staff
• Rotunda Hospital not achieving target of 100% for Medical or Midwifery staff

• Drogheda Hospital achieving target of 100% for Medical and Nursing Staff
• Cavan Hospital achieving target of 100% for Medical and Nursing Staff
• national data currently not published
• Rotunda use NeoNEWS tool

 

PATIENT MONITORING AND SURVEILLANCE 

Rationale for measurement

Early detection and timely management of patients admitted to hospital acutely unwell, or those who deteriorate while in hospital is essential in promoting the best outcome possible for the patient. The National Early Warning System facilitates anticipation, early recognition, escalation, and the required clinical response to appropriate care and treatment of the acutely ill patient. 

The Quality Care Metric indicators below check that the nursing assessment, patient review, necessary escalation, and documentation are completed. This is in accordance with local policies, procedures, protocols and guidelines (PPPGs) and in accordance with standards set in the National Irish National Early Warning System (INEWS) National Clinical Guideline No. 1, and National Sepsis Management for Adults (including maternity) National Clinical Guideline No. 26: 

• The patient’s baseline physiological observations were assessed and recorded on admission/transfer using the National Early Warning System (INEWS) 
• The patient’s physiological observations have been reassessed and recorded using the NEWS at the appropriate frequency 
• There is documented evidence of an increased frequency of monitoring and recording of vital signs in response to any deterioration in the patient’s condition 
• In the event of a deterioration there is documented evidence of escalation of care as per (INEWS) Escalation Protocol 
• The ISBAR tool was used to document the escalation of care 
• The nursing care provided to manage a deterioration in the patient’s condition has been recorded 
• If infection is suspected to be the cause of the patient’s deterioration, care is escalated using the sepsis screening form in accordance with the (INEWS) Escalation Protocol 
• The indicators 3, 4 & 5 will be used to assess the recognition and escalation (including communication) of all charts audited listing each indicator and compliance separately to identify the key areas achieving lower compliance.

Measurement methodology and data sources 

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit. 

Target 

100% compliance of the key indicators identified. 

Performance – % Compliance – 2023

• RCSI Hospitals did not achieve target of 100% in Mar-23 with the exception of Louth County Hospital

 

ASSISTED DECISION MAKING

Introduction

The Assisted Decision Making (Capacity) Act, 2015 reforms the law relating to persons who require or may require assistance in exercising their decision-making capacity. The legislation is intended to support decision-making and to maximize a person’s capacity to make decisions. This Act applies to everyone and is relevant to all health and social care services. The Act is expected to commence in April 2023.

In line with this legislation, everyone is presumed to have decision-making capacity at all times. In some circumstances there may be a reason to question a person’s capacity to make a certain decision. Health and social care workers are expected to take all practical steps to help a person make a decision for themselves. A person’s capacity to make a specific decision is their ability to:

• understand information and facts relevant to the decision;
• retain that information long enough to make a voluntary choice;
• use or weigh up that information as part of the process of making the decision; and
• communicate the decision by any means, including by assistive technology

The assessment of capacity used under the new legislation is called a ‘Functional Test’ for capacity. This means the assessment is about a specific decision that needs to be made at a specific time. There cannot be a blanket assessment that a person has no capacity¹.

Rationale for measurement

In order to support the implementation of the legislation, an audit has been conducted in the acute hospitals of the RCSI HG. The rationale for the audit is as follows:

• to obtain baseline data on assisted decision making in the RCSI HG
• to identify areas of good practice
• to identify areas for improvement

Measurement methodology and data source

Health care records (HCR) of patients who had a reported Serious Reportable event (SRE) or Serious Incident (SI) during the period 1st January 2022 to 31st January 2023 were audited in each acute hospital. Audit data was then, extrapolated for analysis and publication.

Target

100% of relevant patients have evidence of assisted decision making documented

Performance – 1^st January 2022 – 31^st January 2023

¹ https://www.hse.ie/eng/about/who/national-office-human-rights-equality-policy/assisted-decision-making-capacity-act/faqs

 

CHILDREN FIRST TRAINING COMPLIANCE

Rationale for measurement

The Children First Act 2015 puts elements of the Children First: National Guidance for the Protection and Welfare of Children (2011,) on a statutory footing and places a wide range of responsibilities on HSE and its funded services. All staff are required to complete the E-Learning Module on “An Introduction to Children First”.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed online Children First Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

• national data not available

 

STANDARD PRECAUTIONS AND HAND HYGIENE TRAINING COMPLIANCE

Rationale for measurement

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect healthcare workers and prevent healthcare workers from spreading infections among patients.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed Standard Precautions and Hand Hygiene Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

• national data not available

 

MANUAL AND PATIENT HANDLING TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with manual handling and people handling activities. The Safety, Health and Welfare at Work, (General Applications) Regulations 2007 Act requires that training and instruction be provided to relevant staff. The theory component requires completion of the online training course.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed (practical & theory) Manual / Patient Handling Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

• national data not available

 

FIRE SAFETY AWARENESS TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with Fire. The Health and Welfare at Work Act 2005 states that employers must ensure so far as is reasonably practicable, that sufficient information, training and supervision is provided to ensure the safety of employees.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed the online component of Fire Awareness Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance. This target comprises of an online and practical element to the training. Compliance figures below relate currently to the online element only.

Performance

• national data not available

 

GDPR AWARENESS TRAINING COMPLIANCE

Rationale for measurement

The Data Protection Act 2018 states that all employees must comply with GDPR legislation including awareness training. All hospitals are legally required to comply with this legislation.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained.

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

• national data not available

 

CYBER SECURITY TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with Cyber Security. The HSE Executive Management Team have deemed that Cyber Security Awareness Training is mandatory for all staff.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed online Cyber Security Awareness Training in the last three years).

Denominator

Monthly Headcount (average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

• Beaumont Hospital re-configured GDPR Training to include Cyber Training. Compliance is reported under GDPR Training for this site
• national data not available

 

SEPSIS TRAINING

Background

Sepsis is a common and time-dependent medical emergency. It can affect a person of any age and from any social background. While it may occur more frequently in people with certain underlying medical conditions, it can also occur in healthy individuals. In 2016, the number of deaths amongst in-patients with a diagnosis of sepsis within Irish hospitals was 2,735. Sepsis is responsible for 37,000 deaths annually in the UK.

Internationally, approaches to optimal sepsis management, which are based on early recognition of sepsis with timely intervention within the first hour, have reported reductions in mortality from severe sepsis/septic shock in the order of 20-30%.

Rationale for measurement

In 2014 the National Clinical Effectiveness Committee (NCEC) introduced the National No 6 Sepsis Clinical Guideline. This guideline endorsed the concept of ‘Sepsis Six’ – a set of six tasks to effectively manage patients with sepsis. This was supported by Sepsis training on HSE-land.

The original guideline was replaced in 2021 by an updated version Sepsis Management for Adults (including maternity) National Clinical Guideline No. 26, (2021), DOH. This revised guideline outlines the tasks to be completed in patients with sepsis. These interventions are termed the ‘Sepsis Six’ and (include blood cultures, blood tests, administration of IV antimicrobials and intravenous fluids, monitoring of urine output and administration of oxygen if required) to be completed within one hour by practitioners. The revised guideline also outlines the concept of Sepsis Six + 1 for maternity patients which includes the Sepsis Six but adds in the assessment of fetal wellbeing for pregnant women.

This guideline is supported by a revised module Sepsis Management for Adults (including maternity) on HSE-land which needs to be completed by relevant staff every 3 years.

Methodology

Quarterly reports from individual hospitals on the number and category of clinical staff who have completed:

• Introduction to Sepsis Management for Adults (including maternity), HSE-land.
• Obstetrics & Gynaecology staff will also have completed PROMPT (or equivalent accredited Obstetrics & Gynaecology Sepsis Module, e.g. Rotunda Hospital Obstetric Emergency Training, RHOET)

Target

• 95% compliance

Performance

Sepsis training by staff discipline and site – Q1-23 data

• Cavan & Monaghan and Drogheda & Louth County Hospitals did achieve the target of 95% of staff trained in Sepsis management
• Connolly, Beaumont and Rotunda Hospitals did not achieve the target of 95% of staff trained in Sepsis management
• national data not published
• a total of 2,859 staff trained on the revised HSE-land module, Q1-23

 

COMPETENCY TRAINING

The delivery of safe, evidence-based care in maternity services ultimately depends on the competency of clinical staff. Consequently the RSCI Hospital Group will be measuring attendance rates at training in two key areas cardiotocography and neonatal resuscitation.

 

CARDIOTOCOGRAPHY (CTG) TRAINING

Rationale for measurement

CTG is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy. CTG monitoring is used to assess fetal wellbeing and allows early detection of fetal distress. The inappropriate use or interpretation of fetal surveillance can contribute to adverse obstetric outcomes therefore accurate interpretation of the CTG is a core skill for all staff providing antenatal and intrapartum care.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator: No of staff trained (Expressed as %)

Denominator: No of staff eligible for training (Expressed as %)

Target

100% of relevant clinical staff are up to date with CTG training within the 2 year period.

Performance

Performance data for monthly reporting period:

• Cavan Hospital is not achieving the target for NCHD (n=1) training compliance
• Drogheda Hospital is not achieving the target for Consultant (n=1), NCHD (n=2) and Midwife (n=5) training compliance
• Rotunda Hospital is not achieving the target for Consultant (n=4) and NCHD (n=1) training compliance

 

RESUSCITATION TRAINING

The Neonatal Resuscitation Programme® (NRP®) was developed by the American Heart Association and the American Academy of Pediatrics. The course conveys an evidence-based approach to care of the newborn at birth and facilitates effective team-based care for healthcare professionals who care for newborns at the time of delivery.

Rationale for measurement

Over 90% of babies born make the transition from life in the womb to life outside the womb at delivery, perfectly smoothly. A small percentage will require assistance. The NRP is intended to optimise the skills of staff in caring for these babies.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Target

100% of relevant clinical staff are up to date with NRP certification (or UK equivalent) within the 2 year period.

Performance

Performance data for monthly reporting period:

• Cavan Hospital is not achieving the target for Midwife (n=1) training compliance
• Drogheda Hospital is not achieving the target for NCHD (n=1) training compliance
• Rotunda Hospital is not achieving the target for Midwife (n=5) training compliance