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Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals June 2014 Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals Health Information and Quality Authority About the Health Information and Quality Authority The Health Information and Quality Authority (HIQA) is the independent Authority established to drive high quality and safe care for people using our health and social care services. HIQA’s role is to promote sustainable improvements, safeguard people using health and social care services, support informed decisions on how services are delivered, and promote person-centred care for the benefit of the public. The Authority’s mandate to date extends across the quality and safety of the public, private (within its social care function) and voluntary sectors. Reporting to the Minister for Health and the Minister for Children and Youth Affairs, the Health Information and Quality Authority has statutory responsibility for: Setting Standards for Health and Social Services – Developing person-centred standards, based on evidence and best international practice, for those health and social care services in Ireland that by law are required to be regulated by the Authority. Supporting Improvement – Supporting health and social care services to implement standards by providing education in quality improvement tools and methodologies. Social Services Inspectorate – Registering and inspecting residential centres for dependent people and inspecting children detention schools, foster care services and child protection services. Monitoring Healthcare Quality and Safety – Monitoring the quality and safety of health and personal social care services and investigating as necessary serious concerns about the health and welfare of people who use these services. Health Technology Assessment – Ensuring the best outcome for people who use our health services and best use of resources by evaluating the clinical and cost-effectiveness of drugs, equipment, diagnostic techniques and health promotion activities. Health Information – Advising on the efficient and secure collection and sharing of health information, evaluating information resources and publishing information about the delivery and performance of Ireland’s health and social care services. 1 Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals Health Information and Quality Authority Our mission The mission of the Authority is derived from the statutory functions described in the Health Act 2007 and can be summarised as: “Drive high quality and safe care for people using our health and social services.” Our values Open an e d tiv A c cc je o b u n O t d a b n l a e r i a F PUTTING n o PEOPLE FIRST i t a v o n W n I o d r n k a in g ce T n og lle et ce her Ex Putting people first – we will put the needs and the voices of service users, and those providing them, at the centre of all of our work. Fair and objective – we will be fair and objective in our dealings with people and organisations, and undertake our work without fear or favour. Open and accountable – we will share information about the nature and outcomes of our work, and accept full responsibility for our actions. Excellence and innovation – we will strive for excellence in our work, and seek continuous improvement through self-evaluation and innovation. Working together – we will engage with people providing and people using the services in developing all aspects of our work. Find out more on the Authority’s website: www.hiqa.ie. 2 Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals Health Information and Quality Authority Table of Contents About the Health Information and Quality Authority 1 Our mission 2 Chapter 1 – Introduction 4 Chapter 2 – Methodology of the review 12 Chapter 3 – Leadership, governance and management 17 Chapter 4 – Quality and patient safety 28 Chapter 5 – Prevention and control of healthcare associated infections in ULH 48 Chapter 6 – Effective care (fractured neck of femur) 58 Chapter 7 – Conclusions 67 Glossary of terms and abbreviations 74 Appendix 1 – Specified Features focused on in this review 80 Appendix 2 – St John’s Hospital Governance Structure 87 References 88 3 Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals Health Information and Quality Authority Chapter 1 – Introduction This report presents the findings from the review of the governance of UL Hospitals (referred to in this report as ULH or University of Limerick Hospitals) that has been undertaken by the Health Information and Quality Authority (the Authority). This review was undertaken in order to monitor progress with the implementation of the Authority’s National Standards for Safer Better Healthcare(1) (referred to subsequently in this report as the National Standards). The Authority used the National Standards to identify specific features that should be in place in acute hospitals to achieve safe, high quality governance, the absence of which would be a cause for concern. The specific features selected for this review are outlined in Appendix 1. This is the first hospital group in the newly established hospital group structures(2) to be reviewed against the National Standards. It was selected because a number of issues were identified as concerns. These are outlined in the background to the review. Background to the review The Authority had extensive engagement with the Health Service Executive (HSE) about a range of patient safety issues and the effectiveness of the governance arrangements in hospitals in the midwestern region since the 2009 publication of its Report of the Investigation into the Quality and Safety of services and supporting arrangements provided by the HSE at the Mid-Western Regional Hospital, Ennis Hospital(3). On 25 November 2010, the Authority wrote to the General Manager at the Mid- Western Regional Hospital, Limerick – now called University Hospital Limerick – regarding concerns about delayed access to emergency surgery and the management of mechanically ventilated patients in the Emergency Department (ED). A meeting was held in January 2011 to discuss these concerns. The Authority, the HSE Regional Director and senior management from the then Mid-Western Regional Hospital Group participated in that meeting. A letter was subsequently written to the Chief Executive Officer (CEO) of the HSE in February 2011, informing him that a special reporting framework was being established by the Authority to monitor the following in Mid-Western Regional Hospitals Group: n risk management n service change and transition in relation to: - capacity and demand - impact of change - resilience and reliability. 4 Report of the review of the governance arrangements as reflected in the safety, quality and standards of services at UL Hospitals Health Information and Quality Authority Terms of reference for the special reporting framework stipulated that the process was under the direction of the Authority, and that: n the Mid-Western Regional Hospital, Limerick would provide updates prior to meetings n the Authority would provide constructive challenges to initiatives and n the Chairperson (Regional Director of Operations, HSE West) would summarise the progress and report recommendations at the final meeting. A series of monitoring meetings between the Authority and Mid-Western Regional Hospital, Limerick ensued throughout 2011. In February 2012, the Minister for Health announced that the hospitals of the Mid-Western Regional Hospital Group, now formally called UL Hospitals, would become one of the new (shadow) trusts. It was announced that the hospitals would come together on an administrative, non-statutory basis, into one hospital group, with one overall group management team, one financial budget and one whole-time equivalent (WTE) ceiling. At that point, a CEO was appointed to the group. In May 2012, the Department of Health’s Special Delivery Unit(4) became involved with an ‘Intensive Support Group’ to support the transition. A chairperson was appointed to ULH in June 2012 and an interim Board was appointed on a non- statutory basis pending new legislation in February 2013. In August 2012 the Authority requested an update on the Department of Health’s Special Delivery Unit’s progress in a parallel process. Meetings were also held that month between the Authority and the Mid-Western Regional Hospital Group to discuss ongoing developments in the context of the special reporting framework. The Authority had significant concerns about the absence of interim formal clinical governance structures across the group. Information was also requested about the ED in the Mid-Western Regional Hospital, Limerick. In October 2012, in accordance with the terms of the special reporting framework, the Authority wrote to the Director General Designate of the HSE, advising that the level and speed of progress that had been made to mitigate persistent and serious risks regarding leadership, governance and management, effective care, and use of resources, was slow and unsatisfactory. The letter stated that there were insufficient assurances to demonstrate that persistent shortcomings in the way that the hospital group was leading, governing and managing its services were being resolved. Recognising that it was essential for the HSE to progress the mitigation of risk in the region, the Authority highlighted key issues for action by ULH and formally handed over the special reporting framework to the Department of Health’s Special Delivery Unit at that point. In January 2013, a meeting was held between the Authority and Mid-Western Regional Hospital Group to review the governance arrangements, the quality and safety of services in the Emergency Department and maternity services, bi-directional patient flow within the hospital group and financial governance.

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