Driving Better Safer Care

25 April 2008

Background

Established May 2007Independent – reporting directly to Minister for Health and Children

FunctionsSetting Standards Monitoring Quality and Safety in Healthcare Inspecting Social Services Health Technology AssessmentHealth Information

High Reliability Healthcare

Systems

Patient Safety Events - a Global Problem:

10% of hospital patients suffer an adverse event each year (UK, New Zealand, Canada and Europe)16.6% of hospital patients suffer an adverse event (Australian study)1.4 million hospital patients worldwide acquire Healthcare Associated Infections (HAI) 100,000 cases of HAI lead to 5,000 deaths a year (UK)1 out of every 135 hospital patients acquires HAI (USA) 98,000 hospital deaths every year through medical error (USA)

Needlestick Injuries - a Global Problem:

Health Protection Agency UK: 1996 - 2004, 2140 incidents of significant occupational exposure to blood bourne viruses reported: 47% exposed to Hepatitis C and 26% to HIV UK – up to 2005, 5 reported cases of seroconversion to HIV through occupational exposureNew England Journal of Medicine 2007: 83% surgeons had needlestick injuries in trainingIreland: estimated 6000 needlestick injuries per year, up to 70% unreported

Key Ingredients

Person-centred servicesOpen and transparent learning cultureEffective, strong leadership, governance, accountability, management and team workingFit for purpose workforceClinicians in Executive managementEffective relationships, behaviours and communicationEffective information management and measurementRobust quality assurance – internal and external

Safe, high quality care

Provider Market

Evidence Based

Practice

Governance

Regulatory

Framework Political Legislative

Commissioning for Quality

Insurers

Service

Users, Public

Key Levers and Drivers

Quality Interventions

Setting standards, guidelinesEstablishing quality performance indicators – balanced scorecardBenchmarking and reporting on performanceQuality assuring services - regulationTools for data mining and analysis Learning from adverse events, complaints, best practice

Open and Transparent Culture

“…as soon as we knew we’d made the mistake we met with the family and told them”

“…telling relatives – well you see, we don’t do that here it’s not in our culture”

“…I thought I’d told you, I don’t speak to patients I have people who do that for me”

Quality Activities

Quality Programme 1

National review of symptomatic breast disease servicesDevelopment of Infection Prevention and Control standardsNational Hygiene review 2008Review acute hospitals standards frameworkCommence development of performance indicatorsDiscussion in primary care quality assurancePatient safety programme – WHO, EU Network

Quality Programme 2

Completed Health Technology Assessment and commenced colorectal screening programme HTAEstablish technical standards for interoperability, review the National Health Information StrategyCommence inspection nursing homesComplete residential care standards for people with disabilitiesPublish all

High Reliability Culture Where…

People are at the centre of their care Staff are continuously developed and are supported when things go wrong Intelligent information is used to drive and demonstrate improvements in patient experienceStrong leadership, governance, accountability and management emanate throughout our servicesLearning, openness and transparency are inherent in the way we do businessWe can all be assured, with confidence, that high quality, safe services are provided across Ireland

Thank You