REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

RReeggiioonnaall HHoossppiittaall MMuulllliinnggaarr SSttaatteemmeenntt ooff PPuurrppoossee 22001177

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Service Name (s) and Location(s):

Document Document Name and title: reference STMT-M/HOSPQ/2 developed by Fran Walsh, Laboratory number Manager RH, Mullingar

Revision Document Name and title: number 4 approved by Shona Schneemann General Manager Grace Donnelly, Clinical Director Anne Kelly, Director of Nursing Sharon Gorman, Quality & Patient Safety Manager

Approval Responsibility Name and title: date 02/2017 for Heads of Departments implementation Clinical Leads DNMs/CNMs

Revision Responsibility Name and title: date 02/2018 for review and Sharon Gorman, Quality & audit Patient Safety Manager

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

IMPLEMENTED CHANGE DETAILS FROM PREVIOUS REVISION Section of Document Description of Changes Change Applies to Cover Page Added 3 additional recent photos along with the Hospital Photo

Throughout Document Changed Name of Hospital from Midlands Regional Hospital Mullingar to Regional Hospital Mullingar (RH,M) Throughout Document Statement transferred into New RH,M PPPG Template-M/HOSPQ/8 Section 5 Added Glossary & Terms Section 6 Roles & Responsibilities of each individual, line managers & hospital management outlined Section 7 Added details on the Ireland East Hospital Group Updated population figures as per 2016 census Section 7.3 Added Neurology & Dermatology to visiting Consultants Section 7.4 Access to Services – list updated Section 7.6 Added Referral arrangements with external hospitals Section 8.1 Added Chart with Senior Management Directory Section 8.2 Added Chart with Clinical Leads Section 8.3 Added Chart with Full Clinical Directory Section 9.2 Added Process flow for PPPG Development (PROCESS-M/HOSPQ/1 Section 9.3 Added Process Flow for Complaints Process Section 11 Added Link to website for latest news Section 14 Added Reference to Statement of Purpose Wexford Hospital Section 14 Added healthy Ireland in the Health Services- National implementation plan 2015 – 2017

PEER REVIEW APPROVAL RECORD

Document Revision Date Approved Approved By Job Title No. No.

Table of Contents

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

POLICY ...... 6

PURPOSE ...... 6

1.1 VISION & MISSION STATEMENT, RH, MULLINGAR ...... 6

1.2 AIM ...... 6

1.3 STRATEGIC OBJECTIVES ...... 7

SCOPE ...... 9

LEGISLATION/OTHER RELATED POLICIES ...... 9

GLOSSARY OF TERMS AND DEFINITIONS ...... 9

ROLES AND RESPONSIBILITIES ...... 10

POLICY ...... 10

1.4 ABOUT THE RH, MULLINGAR ...... 10

1.5 DESCRIPTION OF SERVICES PROVIDED AT RH,M ...... 12

1.6 FURTHER SPECIALITIES/SERVICES AVAILABLE AT RH, M ...... 12

1.7 ACCESS TO SERVICES ...... 14

1.8 MODELS OF SERVICE PROVISION ...... 17

1.9 REFERRAL ARRANGEMENT WITHIN IRELAND EAST HOSPITAL GROUP (IEHG) ...... 18

1.10 REFERRAL ARRANGEMENT OUTSIDE IRELAND EAST HOSPITAL GROUP (IEHG) ... 19

GOVERNANCE ...... 20

1.11 SENIOR MANAGEMENT DIRECTORY RH, MULLINGAR ...... 20

1.12 FULL CLINICAL DIRECTORY ...... 22

QUALITY MANAGEMENT ...... 23

1.13 QUALITY OVERVIEW ...... 23

1.14 POLICIES, PROCEDURES, PROTOCOLS AND GUIDELINES ...... 24

1.15 COMPLIMENTS, COMMENTS & COMPLAINTS ...... 26

STAFFING & TRAINING ...... 28

NEW DEVELOPMENTS ...... 29

IMPLEMENTATION PLAN ...... 29

REVISION AND AUDIT ...... 29

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

REFERENCES ...... 30

APPENDICES ...... 30

1.16 ACKNOWLEDGEMENT RECORD ...... 31

1.17 CHANGE REQUESTS ...... 32

1.18 DOCUMENT DETAILS ...... 33

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

POLICY

It is the Policy of the Regional Hospital Mullingar to maintain a publicly available statement of purpose that accurately describes the services provided, including how and where they are provided to all it’s service users

PURPOSE

1.1 Vision & Mission Statement, RH, Mullingar

Our Vision is 'Quality in Patient Care' & Our Mission is ' to Improve the Health and Quality of Life of the Individuals and Communities we Serve'

by: -

 Providing an integrated health service supported by our partners in the Ireland East Hospital Group (IEHG), Community Health Office Area 8 (CHO8) and General Practitioners (GPs).  Adapting to the changing needs of the individuals we serve and is driven by continuous quality improvement, striving towards excellence.  Using our resources in an equitable and responsible manner striving to meet the highest possible standards and level of efficiency, effectiveness and quality in all its efforts.  Treating everyone in the manner we would like to be treated ourselves with dignity and respect at it’s core.  Recognizing performance, encouraging feedback and striving to `be an organisation of which we are proud and in which people have confidence and pride.  Operating in accordance with our Hospital Principles and Values of Accessibility, Safety, Hygienic, Appropriateness and Accredited best Practice Standards.

1.2 Aim

The Regional Hospital Mullingar aspires to improve the health and Wellbeing of the population served by this hospital.

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.3 Strategic Objectives

The Regional Hospital Mullingar have developed their strategic quality objectives in line with the eight themes of HIQA’s National Standards for Safer Better Healthcare (June 2012) [1].

1. Theme1: To achieve person centred care and support that prioritises the service user. The Regional Hospital Mullingar will continue to work with service users, staff, community partners and the public in advocating for the needs of services users and actively involving them in the provision of their care. 2. Theme2: The Regional Hospital Mullingar strives to continually improve its service through monitoring the effectiveness of care & support from customer feedback so that the effectiveness of care is monitored & areas for improvement can be highlighted & addressed. 3. Theme3: To provide Safe care & support for service users. The Regional Hospital, Mullingar has embedded systems and processes that ensure it can be proactive in identifying risks and implement changes to ensure a high standard of quality care & support. For example at the monthly Clinical Governance meeting incidents, complaints, risks & findings from audits are reviewed and improvements made to the safe delivery of care. The sepsis committee monitor Hospital Acquired Infection (HAI) Care bundles are in use where appropriate e.g. Safe Surgery Checklist The hospital has an CSSD department responsible for the decontamination of reusable medical devices in the hospital Staff have been trained in the Early Warning Score and hand hygiene The hospital employs a Risk Manager, Clinical Quality and Patient Safety Manager , Infection Control officers, a Surveillence scientist and an Antimicrobial pharmacist to monitor risks, infection and resistance rates. An Open disclosure policy has been implemented across the hospital where if an error is made it is discussed at senior level so that learnings can be implemented. 4. Theme4: To provide better health & wellbeing by working with the service user to improve their experience. The Regional Hospital, Mullingar aims to provide an environment & culture that promotes better health & well being for its workforce & service users. A healthy Ireland initiative was launched in the hospital in 2016 based on the healthy Ireland in the Health Services- National implementation plan 2015 –

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

2017 [9]

Initiatives within Regional Hospital, Mullingar include:- Tobacco free hospital & Smoking cessation support Operation transformation Calorie listings at hospital canteen Positive Ageing Week

5. Theme5: To ensure effective leadership, governance and management arrangements are in place to ensure a sustainable Quality & Safe Service. A directorate organisational structure is in place within the hospital with named individuals who are responsible for the quality & safety of the service they provide. Refer to CHART-M/HOSPQ/1 titled “Hospital Senior Management Team” current revision within this document. Reporting structures are communicated to new Staff on induction. Details on all services are publically available on the internet for the Service User including location of services, details of the profile of services provided & contact details of the accountable Staff in all areas. 6. Theme6: To provide a skilled, knowledgeable competent workforce committed to providing a high quality, person centred and safe service. The Regional Hospital, Mullingar will endeavour within the resources available to it to ensure its workforce have the required competencies to deliver high quality, safe and reliable healthcare. 7. Theme7: To use the resources (budgets & workforce) available to the Hospital to provide high quality, safe care to support the services both now and into the future. Regional Hospital, Mullingar aims to plan, manage and deliver service through effective responsible direction and decision making on allocation of resources to deliver a high quality, safe and reliable care and support. 8. Theme8: To use quality information to assist in the planning, managing, delivery and monitoring of healthcare to ensure high quality safe services are provided. Quality information is accurate, valid, reliable, timely, relevant, legible and complete within an information governance framework in line with current best standards and legislative requirements. The PPPG steering committee ensures all procedures, policies, protocols and guidelines follow a standard format and are reviewed by the appropriate staff prior to distribution.

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

SCOPE

This Statement Applies to all Service Users of the Regional Hospital, Mullingar

LEGISLATION/OTHER RELATED POLICIES

This document was written in compliance with HIQA’s National Standards for Safer Better Healthcare (June 2012) [1].

The National Healthcare Charter [2], which is titled ‘You and Your Health Service’, has been developed with input from many interested parties, including patient advocacy groups and individual advocates, many of whom also assisted in the development of the National Strategy for Service User Involvement in the Irish Health Services 2008-2013.

GLOSSARY OF TERMS AND DEFINITIONS

AvLOS = Average Length of Stay CEO = Chief Executive Officer CHO8 = Community Health Office Area 8 COO = Chief Operations Officer DC = Day Case EPU= Early Pregnancy Unit ERCP = Endoscopic Retrograde Cholangio Pancreatography FAU = Foetal assessment Unit GPs = General Practitioners GM = General Manager HAI = Hospital Acquired Infection HIQA = Health Information and Quality Authority HR = Human Resources IEHG = Ireland East Hospital Group IP = Inpatient OP = Outpatient PET = Patient Experience time PPPG = Policies, Procedures, Protocols & Guidelines RH, M = Regional Hospital Mullingar SATU= Sexual Assault & Treatment Unit Service User =’People who use health and social care services as patients Carers, parents and guardians organisations and communities that represent the interests of people who use health and social care services Members of the public and communities who are potential users of health services and social care interventions. The term service user also takes account of the rich

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

diversity of people in our society whether defined by age, colour, race, ethnicity or nationality, religion, disability, gender or sexual orientation, and may have different needs and concerns’. [8] UCD = University College Dublin

ROLES AND RESPONSIBILITIES

The Statement of Purpose is based on the understanding that each individual is responsible for the quality of their contribution to the Health Service and that each supervisor and Head of Department (HOD) has a responsibility to ensure that this policy is understood and followed at all times. This policy must be made known to all new staff on induction. Any changes/updates to this policy must be communicated to all Staff and service users.

It is the responsibility of the executive Hospital Management team or named deputies to ensure that this policy is updated at least annually & changes are highlighted to Senior Management for dissemination to all Hospital Staff and published for all external Service users.

POLICY

1.4 About the RH, Mullingar

The Regional Hospital Mullingar (RH,M) is a model 3 Statutory Hospital and is part of the Ireland East Hospital Group (IEHG) which is in academic partnership with University College Dublin (UCD). This IEHG comprises of the following hospitals:-

Mater Misericordiae University Hospital St Vincent's University Hospital, Regional Hospital Mullingar St Luke's General Hospital, Kilkenny Wexford General Hospital National Maternity Hospital Our Lady's Hospital, Navan St Columcille's Hospital St Michael's Hospital, Dun Laoghaire Cappagh National Orthopaedic Hospital Royal Victoria Eye and Ear Hospital The RH,M is a large acute Hospital located in the town of Mullingar on the Longford Road. It provides a wide range of healthcare and social services for more than 130,000 people in Westmeath and Longford and specialised services to a broader population of 291,000 including Laois/Offaly and the surrounding areas. (2016 Census Figures)

There are currently 206 beds (this includes Day Beds & AMAU beds (Acute Medical

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Assessment Unit)).An additional 10 beds will be available shortly in ward 4. The hospital has 6 critical care beds (ICU/CCU).

Patients are admitted to the hospital via the following routes:  As emergency admissions through the dedicated Emergency Department, Acute Medical Assessment Unit  On a day case basis  Inpatient via the Day Ward for planned elective procedures.  Via the outpatients department  Via the maternity services including Foetal Assessment Unit (FAU) & Early Pregnancy Unit (EPU)

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.5 Description of Services Provided at RH,M

The Regional Hospital, Mullingar provides a comprehensive range of Services targeted at ensuring the safety and wellbeing of patients, the public and staff employed within the service. The hospital provides the following Acute range of services: -

 Emergency Department  Critical Care  General Medicine  General Surgery  Obstetrics and Gynaecology  Paediatrics/Special Care Baby Unit  24 hour CT scanning service

These services are provided 24 hours a day throughout the year. The hospital provides a comprehensive medical, surgical investigation, diagnosis and treatment service for physical illnesses, conditions, injuries or disease for adults and children, and comprehensive maternity service for women and their partners. The hospital also provides diagnostic Radiological and Pathology services as well as Physiotherapy, Occupational Therapy, Speech & Language Therapy, Nutrition and Dietetics, Cardiac Diagnostic and Rehabilitation Services, Pulmonary Function Laboratory and Respiratory Services.

1.6 Further Specialities/Services available at RH, M

Further specialities delivered include:-  Acute Medical Assessment  Antenatal / Parent Craft  Cardiology  Chest Pain Clinic  Early Pregnancy Service  Endocrinology & Diabetes Clinic  Diabetes in Pregnancy Universal Screening & Management  Endoscopy Service  Foetal Assessment Service  Gerontology  Inflammatory Bowel Disease  Newborn hearing screening  Osteoporosis  Palliative Care (2 Beds)

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

 Phlebotomy  Podiatry / Diabetes Podiatry  Regional Endocrinology & Immunology Laboratory Services  Regional Respiratory Service  Respiratory including Sleep Lab Investigations  Smoking Cessation  Special needs - Paediatric  Stroke Service  Teen Clinic  Warfarin Clinic

Visiting Consultants provide the following services in an Out Patient capacity: -  Dermatology  Haematology  Neurology  Ophthalmic  Orthopaedics

Community based services that are also located on the Hospital site include:-  Child & Adolescent Psychiatry  SATU (Sexual Assault Treatment Unit, 24 hour)  STI Clinic  MiDoc based in OPD

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.7 Access to Services Regional Hospital Mullingar designs and delivers its services to enable health care professionals and auxiliary staff to provide consistent and effective services to all its service users. Please refer to LIST-M/HOSPQ/7 below titled ‘List of Services available at Regional Hospital Mullingar’ Speciality Where When Acute Medical Ground Floor, Acute Floor Mon-Fri Assessment (Prefab to Right of Main 08:30 – 20:00 Entrance) Ante Natal Ground Floor, Level A, Mon Wed Thurs PM Clinic 2nd Floor, Level C Fri AM Bereavement Service Oratory/Chapel 24/7 Ground Floor, Level A Cardiology Ground Floor, Level A 24/7 IP 2nd Floor, Level C Wed PM OutPatient Chest Pain Clinic Ground Floor, Level A Tues & Thurs (AM) Chaplaincy Service Oratory/Chapel 24/7 Ground Floor, Level A Dermatology Ground Floor, Level A Mondays & Fridays

Diabetes Ground Floor, Level A Thursdays PM (Gestational) Emergency Medicine Ground Floor, Level A 24/7

Endocrinology Ground Floor, Level A Mon PM

Endoscopy Day Ward Mon-Fri 2nd Floor, Level C General Surgery Theatre 24/7 IP, Tues Wed & 2nd Floor, Level C Thurs OutPatient (PM) Gerontology 4th Floor, Level E Ground Floor, Level A Thurs PM Gynaecology 4th Floor, Level D Mon Tues Thurs (AM) Ground Floor, Level A Haematology Ground Floor, Level A Alternate Thursdays (AM) Intensive/ 2nd Floor, Level C 24/7 Coronary Care Inflammatory Ground Floor, Level A Every 2nd & 4th Thursday of Bowel Disease the month MiDoc Ground Floor, Level A OPD 18:00- 08:00 Full days weekends and Bank Holidays. Neurology Ground Floor, Level A OPD Every Thursday

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Speciality Where When Obstetrics incl Early 2nd Floor, Level C EPU: Mon Wed Fri Pregnancy Unit (EPU) 08:00-12:30 & Foetal Assessment FAU: Mon, Tue, Thurs, Unit(FAU) Fri (PM) Ophthalmic Ground Floor, Level A Every Second Wed Surgeon Weekly Ophthalmology OPD clinics Weekly

Orthoptist Orthopaedics Ground Floor, Level A Once a Month Fri AM

Osteoporosis Ground Floor, Level A 1st & 3rd Thurs of the month

Paediatrics 1st Floor, Level B Mon, Tue,(AM & PM) Ground Floor, Level A Wed PM Every Second Thurs - Special needs Pathology Separate Building at the 08:00 – 20:00 rear of the Hospital >20:00 Emergency On-Call Palliative Care 4th Floor, Level E Suite Phlebotomy Daily Clinics Ground Floor, Level A

Child Psychiatry Separate Building to the 8:30 – 18:00 Mon- rear of the Hospital Thurs 8:30 – 17:15 Fri Radiology Ground Floor, Level A 24/7 (including CT scanning) Respiratory

(including Ground Floor, Level A 08:30 – 17:30 Mon- Fri Pulmonary 1st Floor, Level B Tuesday Clinic Function Testing

laboratory) Resuscitation 2nd Floor, Level C, Ash Mon – Fri Staff Training Unit Sexual Assault Treatment Unit 2nd Floor, Level C 24/7 (SATU)

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Speciality Where When Sleep Lab Ground Floor, Level A Investigations 1st Floor, Level B Monday Clinic Special Care Baby 1st Floor, Level B 24/7 (IP) Unit (SCBU)

Paediatric Special Ground Floor, Level A Thurs Alternate Weeks Needs Sexually Transmitted 2nd Floor, Level C Every Thursday AM Infections Clinic(STI) 24/7 (IP) Stroke Unit Ground Floor, Level A Thurs (PM)

Warfarin Clinic Ground Floor, Level A Every Day (All Day)

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.8 Models of Service Provision

Clinical Care Programmes have been established to improve and standardise patient care throughout the HSE by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to every service user. A number of National Clinical Care Programmes have been established and these are applied to each acute hospital, based on three main objectives:

- To improve the quality of care we deliver to all service users - To improve access to all services - To improve cost effectiveness

A List of Clinical Care programmes are available at the following website http://www.hse.ie/eng/about/Who/clinical/natclinprog/

The Regional Hospital Mullingar are proactive in implementing Clinical Care programmes for the benefit of all it’s service users. The Following Clinical care programmes have been implemented in Mullingar Regional Hospital:- **email sent on 15/2 to confirm CCPs implemented in RH,M, to be updated***

Acute Coronary Syndrome (ACS) Acute Medicine Anaesthesia Asthma Chronic Obstructive Pulmonary Disease (COPD) Critical Care Dermatology Diabetes- confirmed Emergency Medicine (EMP) Epilepsy Heart Failure Medicines Management Programme Mental Health National Transport Medicine Programme Neurology Obstetrics and Gynaecology Older People Ophthalmology Trauma and Orthopaedic Surgery Paediatrics and Neonatology Palliative Care Pathology confirmed

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Radiology Rare Diseases Rehabilitation Medicine Renal Rheumatology Sepsis Stroke confirmed Surgery

1.9 Referral Arrangement within Ireland East Hospital Group (IEHG)

Mater Hospital:

Plastics Lung Transplant Nerve Conduction Studies Hepatobiliary PET Scans Breast Care Spinal Care Vascular ERCP / EUS / Argon Beam Oncology Cardiothoracic Rectal Cancer Colorectal MDT Urology Neurology / EEG Nuclear Medicine, Diagnostics Nuclear Medicine, Therapeutics (Radioiodine)

Holles Street

Maternity Services

Temple Street

Paediatric Service

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

St Vincent’s Hospital

Pulmonary Fibrosis Pancreatic Cancer

1.10 Referral Arrangement Outside Ireland East Hospital Group (IEHG)

Cardiology St. James’s Hospital

Angiogram Cardiac MRI PCI Cardiac Stenting Reveal Devices Pacemakers

Respiratory St. James’s Hospital

PET – CT Scans Cardiothoracic Lung Cancer Thoracic Surgery Oncology (St James’s Hospital & Midland Regional Hospital Tullamore) ERCP, St James’s Hospital Burns, St James’s Hospital

Neurology / EEG, Tallaght Hospital Neurosurgery, Beaumont Hospital Radiotherapy, Beaumont Hospital Orthopaedic Midland Regional Hospital Tullamore ENT, Midland Regional Hospital Tullamore Oncology, Midland Regional Hospital Tullamore MRI, Midland Regional Hospital Tullamore Pathology Laboratory Mullingar– Regional liaison with Midland Regional Hospitals Tullamore & Portlaoise Nuclear Medicine, Diagnostics, St James Hospital Nuclear Medicine, Therapeutics (Radioiodine), St Luke’s Hospital Dublin

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

GOVERNANCE

During 2016 the Regional Hospital, Mullingar has implemented and developed its Governance structure. The General Manager (GM), Shona Schneemann has overall responsibility for the management and delivery of all services. The General Manager reports to the Chief Executive Officer (CEO) and Chief Operations Officer (COO) of Ireland East Hospital Group (IEHG). Clinical services within the Regional Hospital, Mullingar are delivered under the governance of Clinical Director, Dr Grace Donnelly and the Director of Nursing & Midwifery Anne Kelly. The GM is responsible and accountable for quality and safety operations, business performance, finance and Human Resources (HR).

The governance includes a directorate structure in the following areas:- o Medical Directorate including Emergency Medicine o Perioperative Directorate o Women and Children Directorate Also included in the Senior Executive team are: - o Operations & Clinical Services Manager o Finance Manager o Human Resources Manager o Quality & Patient Safety Manager o Facilities & Safety Manager Please refer to CHART-M/HOSPQ/1 current revision within this document titled “Hospital Senior Management Team”

1.11 Senior Management Directory RH, Mullingar Name Position General Manager Shona Schneemann Clinical Director Grace Donnelly Director of Nursing Anne Kelly Medical & ED Directorate Business Manager Kay Slevin Divisional Nurse Manger Margaret Williams Perioperative Directorate Business Manager Yvonne Kane Divisional Nurse Manger Clare Conway Women & Children Business Manager Danny Connaughton Directorate Divisional Nurse Manger Marie Corbett Operations & Clinical Services Manager Pending Finance Manger Antoinette McMenemy HR Manager Martina Gill Quality & Patient Safety Manager Sharon Gorman Facilities & Safety Manager William Harding

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REGIONAL HOSPITAL, MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.12 Full Clinical Directory Name Position Anaesthesia Dr. Anne Bergin, Dr. Ron Charles, Dr. Mohammad Faheem, Dr. M. Farooq, Dr. Grace Donnelly, Cardiology Dr Inam Khan

Child & Adolescent Psychiatry Dr. Caroline Noone,

Dermatology Dr. Bairbre Wynne,

Emergency Services Dr Sam Khan, Dr. Anna Moore, Dr Richard Lynch Medicine Dr Mark Sheehy; Dr. Shu Hoashi; Dr. Claire Fallon, Dr. Hilary Cronin, Dr. Murat Kirca, Dr Naqesh Krishnan, Dr Inam Khan, Dr. Senan Glynn Neurology Dr Shane Smyth

Obstetrics & Gynaecology/Women Health Prof. Michael Gannon, Dr. Nandini Ravikumar, Dr. Sam Thomas, Opthalmic Dr. Sheena Creaven, Dr. McGettrick, Dr. Salma Bashir,Dr Emer Mulhall Paediatrics Dr. S. O’Doherty, Dr. Imelda Lambert, Dr. Farhana Shariff, Dr. Michael O’Grady, Pathology Dr Kanthi Perera,(Haematology & Blood Transfusion) Dr. Miriam Walsh, Dr Nurul Nor, Dr Margaret Lynch, Dr. Charles d’Adhemar,(Histopathology) Dr Graham Lee, (Clinical Chemistry) Prof Con Feighery,(Immunology) Dr. Cathal O’Sullivan,(Microbiology) Radiology Dr Hugh Logan, Dr. James Slattery, Dr. Nazia Amer, Dr. Maria Jadrickova,

Surgery Mr. Ejaz Tallat, Mr. Shahbaz Mansoor, Mr. Declan Buckley, Dr. Hashim Elsheikh, Mr. Desmond P. Toomey

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REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

QUALITY MANAGEMENT

1.13 Quality Overview

The Regional Hospital Mullingar endeavour to provide a sustainable high quality & safe Service for the Population it serves. The Quality & Safety of it’s services are routinely measured by: -  Key Performance indicators reviewed monthly to ensure achievement of our hospital and Ireland East Hospital Group and National targets.  For example these include: -  ED attendances  PET (Patient Experience Time) Compliance to 6hrs/9hrs  Readmission Rates  AvLOS (Average Length of Stay)  OPD attendance activity & waiting times  Radiology waiting times etc..

 All Procedures, Policies, Protocols and Guidelines are drafted using a standardised template adapted from the National HSE template to ensure standardisation of processes throughout the hospital. Refer to section 9.2 for further details  Internal & External Audits of our Services by National bodies resulting in implementation plans for further improvements  Continuous Risk assessment is performed to identify and reduce/eliminate potential risks to Staff & Service Users  Routine Staff and Patient Surveys are completed with feedback also sought through a suggestion box at Hospital reception and from Service Users via http://www.hse.ie/eng/services/yourhealthservice/feedback/ Refer to section 9.3 for further details

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 23 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.14 Policies, Procedures, Protocols and Guidelines

Policies, procedures, protocols and guidelines are an essential tool in improving the quality of health care provision. They articulate consistent approaches for best practice. They serve to:  Promote best practice  Standardise practice and service delivery  Ensure that legislative and regulatory requirements are met  Ensure employees and line managers are clear on their roles and responsibilities  Facilitate effective staff induction  Act as educational tools  Act as a basis for audit and evaluation There is a PPPG steering group established in the hospital to provide transparent and accountable leadership for the management of Policies, Procedures and Guidelines at the Regional Hospital Mullingar in line with evidence based practice. All Policies Procedures, Protocols & Guidelines (PPPGs) used in the Regional Hospital Mullingar are drafted & Approved using TEMPLATE-M/HOSPQ/8 titled “Template for PPPG Development Regional Hospital, Mullingar” current revision. This is based on the National HSE OQR029 Rev 3 March 2012.

PPPGs are communicated to Staff on induction & when revised. Most PPPGs are reviewed every 2 years unless change warrants more frequent review or in the case of the Statement of Purpose which is reviewed annually. All current approved PPPGs are forwarded to the PPPG Steering committee to ensure correct formatting, relevant approvers & legislative or guidance documentation has been researched. Refer to PROCESS-M/HOSPQ/1 within this document titled “Process Flow for PPPG development in the Regional Hospital, Mullingar” current revision

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 24 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

Proposed Process Flow for PPPG Development in RH, Mullingar

Planning/Evaluation of Document Requirements

Review Available literature, legal requirements, best practice guidelines

New document required Change required to an existing document

Generate New Draft document Revise document to include using National TEMPLATE- changes. List the change details M.HOSPQ.8 at the front of the document

Send Document to Peer Review Approver(s) for Approval

Rejected Approved

Send Document to PPPG Committee for Approval Performed by Designated Member of the Rejected Approved PPPG Committee

Activate document Document Number issued to Owner of Document. Doc Type-M.Dept.next Seq No. Staff sign Signature Sheet of Master Hard Copy to state that they have read & Understand the document New/Revised Document put up on Active Shared Folder & relevent staff notified. Relevant Staff trained in procedure as per ‘Implementation plan’ Section 8 of PPPG Previous soft Revisions are moved into an obsolete folder Previous hard copies are shredded by owner. This action is Review doc at least every 2 recorded in the doc details page years for continued suitability & (back pg of PPPG) record review in document details back page of PPPG

Audit to ensure compliance with Document control Doc. No:PROCESS-M/HOSPQ/1 Doc Owner: Fran Walsh Dept & Location: PPPG Governance Committee RH, Mullingar Rev. No:0 Active Date: 08.07.2016 Doc Title:Process Flow for PPPG Development in RH,M Page 1

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 25 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.15 Compliments, Comments & Complaints

The Regional Hospital Mullingar manage all feedback through their Consumer and Legal Affairs Office & in accordance with the National ‘Policy on management of Consumer feedback to include Comments, Compliments and complaints in the HSE’. The options for giving feedback are outlined at http://www.hse.ie/eng/services/yourhealthservice/feedback/ Feedback can be communicated in the following ways:-

 In Person: Talk to any member of HSE staff, service manager or complaints officer  Online Form: Send your complaint securely through the online feedback form  By Email: E-mail [email protected] with your feedback.  By Letter: Send a letter or fax to any HSE location. Staff can help you put your complaint in writing, if you require assistance.  Ring us: LoCall 1890 424 555: Your call will be answered by a staff member from the National Complaints Governance and Learning Team.  Contact our Confidential Recipient for Vulnerable Persons (any vulnerable person receiving residential care in a HSE or HSE funded facility ), Leigh Gath, LoCall 1890 100 014 Mobile 087 6657269 Email [email protected]  Through Advocacy Services: Contact an Advocacy Service.  National Specialist in Accessibility: The HSE has appointed a National Specialist in Accessibility who will provide guidance, advice and strategic support in the promotion of access for people with disabilities. The purpose of the role is also to develop a strategic framework for the implementation of Part 3 of the Disability Act 2005 in the HSE.

Verbal complaints received are dealt with as soon as possible and the complainant is verbally advised of the outcome. Every effort is made to acknowledge all written complaints (ie letter, email, YSYS form) within 5 working days of receipt of same. A copy of the complaint is sent to the relevant staff members ( eg. clinician, nurse manager, head of department, etc) for review and comments. On receipt of comments from the relevant staff a response is sent to the complainant including details of their right of review. Every effort is made to respond to complainants within 30 days however this is not always possible. Where a complaint cannot be answered within the 30 day period a letter is issued to complainant advising that the complaint is still being investigated and a response will issue as soon as possible. Refer to PROCESS-M/HOSPQ/2 within this document titled “Process Flow for investigation of Complaints in the Regional Hospital, Mullingar” current revision

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 26 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

PROCESS-M/HOSPQ/2 “Process Flow for investigation of Complaints in the Regional Hospital, Mullingar

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 27 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

STAFFING & TRAINING

The HSE is the largest employer in the state, with over 100,000 employees. More than 67,000 are direct employees, the remainder are employed by agencies funded by the HSE. The HSE aims to be an Employer of Choice, and offers a wide range of challenging career opportunities that enable our staff to make an important contribution to the health services, to public service and to the lives of everyone living in Ireland. All positions in the HSE are advertised on the HSE Website www.hse.ie. Since 2009, all recruitment has been centralised to the HSE National Recruitment Service (NRS), Arás Sláinte Chluainín, Manorhamilton, Co. Leitrim. All Staff within the Regional Hospital, Mullingar are employed in line with the Public Service Management (Recruitment and Appointments) Act, 2004 (the Act)[3] and is regulated by the Commission for Public Service Appointments (CPSA.) Applicants complete a competency based Application form. All applications will be screened for eligibility using the essential qualifications, experience and skills outlined in the Job Specification. Only those applicants who possess the required essential criteria will be progressed to the next stage of the selection process which is the interview stage. Under Section 22 of the Health Act, the HSE has responsibility for setting and approving qualifications for appointments to HSE posts. Assurance checks are undertaken to confirm that all appointees have appropriate qualifications, relevant statutory registration, Garda vetting and are medically fit for the role. Staff undergo extensive induction programmes & a probation period of 12-18months`. Staff training is provided to ensure staffs are supported in maintaining competencies required for professional registration. To find out more about getting a job with the HSE please click on the links below. http://www.hse.ie/eng/staff/Jobs/

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 28 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

. NEW DEVELOPMENTS

Future development plans for the Regional Hospital Mullingar include: - Capital development of an MRI Unit, fundraising is ongoing Development of Respiratory & Cardiac Day Services Development of Paediatric Day Unit Development of Diabetes & Endocrine Service Development of Educational Centre Major Capital Development : Theatre, ICU, Endoscopy and Rehab unit

For the most recent Hospital developments please refer to http://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/mullingar/

IMPLEMENTATION PLAN

This statement of purpose will be communicated in the following ways: All Staff will be informed of the Statement of Purpose during the induction process Intranet for Staff & Internet for both Staff & Service Users Email to Departmental Heads/ CNM’s Ward / Department meetings Shared PPPG Folder

REVISION AND AUDIT

This document will be reviewed on a yearly basis to ensure all information is accurate & up to date.

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 29 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

REFERENCES

[1].HIQA, National Standards for Safer Better healthcare June 2012 http://www.hiqa.ie/standards/health/safer-better-healthcare

[2] http://www.hse.ie/eng/services/yourhealthservice/hcharter/National_Healthcare_Charter.pdf

[3] Public Service Management (Recruitment and Appointments) Act, 2004 http://www.irishstatutebook.ie/2004/en/act/pub/0033/index.html

[4] Medical News ‘Prolonged ED wait time is associated with poor Clinical Outcomes’ November 10, 2009

[5] Cora Murphy Clinical Director, The Care Team ‘Leadership, Governance & Management Presentation

[6] Statement of Purpose St Lukes Hospital Kilkenny

[7] Statement of Purpose Wexford General Hospital

[8]http://www.hse.ie/eng/services/publications/Your_Service,_Your_Say_Consumer_Affairs/ Strategy/Service_User_Involvement.pdf

[9] healthy Ireland in the Health Services- National implementation plan 2015 – 2017

APPENDICES

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 30 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.16 Acknowledgement Record

I THE UNDERSIGNED ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT

Print Name Signature Job Title Date

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 31 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221

1.17 Change Requests

PROPOSED CHANGE REQUEST TO THIS DOCUMENT REVISION

Date Change Details Change Change Proposed By Implemented in Rev No.

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 32 of 33

REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 93940221

1.18 Document Details

DOCUMENT DETAILS for MASTER HARD COPY There should be at least one entry on the document details page every 2 years. This Document detail page should be transferred to the most recent Active Master Copy. Date Version Reviewed Indicate if Distribution List Active Revision Previous Previous Reviewed Reviewed by Revision State Soft or Hard Copy Distributed by Revisions have Revisions have of been removed been removed Document Soft Copies moved Hard Copies Needed to ‘Obsolete’ have been (Y/N) Folder by shredded by 01.2017 3 F Walsh Y Soft Copy F Walsh Yes – removed n/a no controlled http://www.hse.ie/eng/services/list/3/acuteho from intranet & ‘official’ spitals/hospitals/mullingar/ internet on hardcopies XX/XX/2017 Soft Copies only http://hsenet.hse.ie/Hospital_Staff_Hub/mull ingar/MRHM.html

Document No.: STMT-M/HOSPQ/2______

Doc Owner: Sharon Gorman Doc. No: STMT-M/HOSPQ/2 Quality & Patient Safety Manager Dept & Location: MRH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 33 of 33