National Healthcare Quality Reporting System Annual Report 2018 Prepared by the National Patient Safety Office 22 The National Patient Safety Office (NPSO) was established in December 2016 by the Minister for Health, to provide the required leadership for patient safety policy and relevant legislation for the healthcare system. The NPSO has three workstreams which together interface to create a co-ordinated approach to patient safety in health policy. These are: - Patient Safety Surveillance - Patient Safety Advocacy and Policy - Clinical Effectiveness This report now forms part of the patient safety surveillance work stream of the NPSO. This surveillance system is under development and is likely to include, although not be limited to, elements on clinical activity, healthcare acquired conditions, clinical outcomes, complaints trends, and information from a number of other sources. Information on the work of the NPSO and Patient Safety Surveillance is available from https://health.gov.ie/national-patient-safety-office/patient-safety-surveillance/ Published by the Department of Health, July 2018 Copyright: Department of Health 2018 ISSN: 2009-9223 Electronic copies of this report are available from the website: www.health.gov.ie Table of Contents Minister’s Foreword 8 Chief Medical Officer’s Foreword 9 Executive Summary 10 Glossary 12 Chapter 1: The National Healthcare Quality Reporting System 14 Background 14 NHQRS monitoring and reporting 15 NHQRS governance 16 Chapter 2: The National Healthcare Quality Reporting Framework 17 Selection of indicators 18 Domains and indicators 18 Sources of data 21 Presentation and analysis of data 22 Domain 1: Helping people to stay healthy and well 25 Overview of selected indicators 26 Immunisation rates 27 Cancer screening rates 43 Domain 2: Supporting peoplewith long term conditions 53 Overview of selected indicators 54 Ambulatory care sensitive conditions 55 Domain 3: Helping people when they are being treated and cared for in our health services 75 Overview of selected indicators 76 Cancer survival rates 78 Cancer surgery 88 Acute hospital care 94 Domain 4: Supporting people ot have positive experiences of healthcare 119 National Patient Experience Survey 120 Domain 5: Treating and caring for people in a safe environment 129 Overview of selected indicators 130 Healthcare associated infections 131 Antibiotic consumption 135 Appendix 1: Metadata sheets 142 Appendix 2: Governance committee members 179 Appendix 3: Technical group members and role 180 References 181 3 NHQRS Annual Report 2018 List of Figures 1 Immunisation rate for MMR for children at 24 months, percentage uptake, 2008 - 2017 2 Immunisation rate for MMR for children at 24 months by Community Health Organisation, 2017 3 Immunisation rate for MenC for children at 24 months, percentage uptake, 2008 – 2017 4 Immunisation rate for MenC for children at 24 months by Community Health Organisation, 2017 5 Percentage of influenza immunisation uptake in the population 65 years and older with a medical card or GP visit card, 2007/2008-2017/2018 6 Immunisation against influenza in populations over 65 for selected OECD countries, 2015 (or nearest year) 7 Immunisation against influenza among healthcare workers in hospitals 2011/12 – 2017/2018 8 Immunisation against influenza among healthcare workers by staff category in HSE-funded hospitals, 2017/2018 9 Immunisation rate for HPV among girls in first year of second level schools and their age equivalents4 by county, for academic year 2016-2017 10 Immunisation rate for HPV among girls in first year of second level schools and their age equivalents, academic years 2014/2015-2016/2017 11 Uptake of breast screening by the eligible population, 2007-2016 12 Percentage of eligible women screened for breast cancer by county of residence for the period 1st January 2015 – 31st December 2016 13 Uptake of breast screening in women aged 50-69 in OECD countries, 2015 (or nearest year) 14 Five-year coverage of the cervical screening programme in Ireland by age group, 01/09/2011 – 31/08/2016 15 Five-year coverage of the cervical screening programme in Ireland by county, 2011-2016 16 Cervical screening in women aged 20 – 69 in OECD countries, 2015 (or nearest year) 17 Percentage of eligible population screened for bowel cancer by county of residence for the period 1st January 2015 – 31st December 2016. 18 Age-sex standardised hospitalisation rates for COPD per 100,000 population in Ireland, 2008 - 2017 19 Age-sex standardised hospitalisation rates for COPD per 100,000 population for selected OECD countries, 2015 20 Age-sex standardised hospitalisation rates for COPD per 100,000 population by county of residence, 2015 – 2017 21 Age-sex standardised hospitalisation rates for asthma per 100,000 population in Ireland, 2008 - 2017 22 Age-sex standardised hospitalisation rates for asthma per 100,000 population for selected OECD countries, 2015 (or nearest year) 23 Age-sex standardised hospitalisation rates for asthma per 100,000 population by county of residence, 2015 – 2017 24 Age-sex standardised hospitalisation rates for diabetes per 100,000 population in Ireland, 2008-2017 25 Age-sex standardised hospitalisation rates for diabetes per 100,000 population for selected OECD countries, 2015 (or nearest year) 26 Age-sex standardised hospitalisation rates for diabetes per 100,000 population by county of residence, 2015 – 2017 27 Age-sex standardised hospitalisation rates for heart failure per 100,000 population by county of residence, 2015 – 2017 4 NHQRS Annual Report 2018 28 Age-sex standardised hospitalisation rates for heart failure per 100,000 population for selected OECD countries, 2015 (or nearest year) 29 Age-sex standardised hospitalisation rates for heart failure per 100,000 population by county of residence, 2015 – 2017 30 Cumulative 5-year age-standardised net survival in Ireland for female breast cancer patient diagnosed in 2010-2014 31 Cumulative 5-year age-standardised net survival, female breast cancer, 2010-2014 (or nearest period), OECD countries 32 Cumulative 5-year age-standardised net survival in Ireland, cervical cancer, 2010 – 2014 33 Cumulative 5-year age-standardised net survival, cervical cancer, 2010-2014 (or nearest period), OECD countries 34 Cumulative 5-year age-sex standardised net survival in Ireland, colorectal cancer, 2010 – 2014 35 Cumulative 5-year age-standardised net survival, colon cancer, 2010-2014 (or nearest period), OECD countries 36 Cumulative 5-year age-standardised net survival, rectal cancer, 2010-2014 (or nearest period), OECD countries 37 Number of breast cancer surgeries undertaken in designated cancer centres in patients whose principal diagnosis is breast cancer, 2008-2017 38 Proportion of breast cancer surgery nationally in patients whose principal diagnosis is breast cancer undertaken in designated cancer centres, 2008-2017 39 Number of colon cancer surgeries undertaken in designated cancer centres in patients whose principal diagnosis is colon cancer, 2008-2017 40 Proportion of colon cancer surgery nationally in patients whose principal diagnosis is colon cancer undertaken in designated cancer centres, 2008-2017 41 Number of rectal cancer surgeries undertaken in designated cancer centres in patients whose principal diagnosis is rectal cancer, 2008-2017 42 Proportion of rectal cancer surgery nationally in patients whose principal diagnosis is rectal cancer undertaken in designated cancer centres, 2008-2017 43 Age-sex standardised in-hospital mortality rates within 30 days of admission for AMI, 2008 – 2017 44 Age-sex standardised in-hospital mortality rates within 30 days of admission for AMI for selected OECD countries, 2015 (or nearest year) 45 Age-sex standardised in-hospital mortality rates within 30 days of admission for AMI by hospital group and hospital, 2015-2017 46 The proportion of patients whose principal diagnosis is stroke who were admitted to a hospital with a stroke unit, 2017 47 Age-sex standardised in-hospital mortality rates within 30 days of admission for haemorrhagic stroke, 2008 – 2017 48 Age-sex standardised in-hospital mortality rates within 30 days of admission for haemorrhagic stroke for selected OECD countries, 2015 (or nearest year 49 Age-sex standardised in-hospital mortality rates within 30 days of admission for haemorrhagic stroke by hospital group and hospital, 2015 – 2017 50 Age-sex standardised in-hospital mortality rates within 30 days of admission for ischaemic stroke, 2008 – 2017 5 NHQRS Annual Report 2018 51 Age-sex standardised in-hospital mortality rates within 30 days of admission for ischaemic stroke for selected OECD countries, 2015 (or nearest year) 52 Age-sex standardised in-hospital mortality rates within 30 days of admission for ischaemic stroke by hospital group and hospital, 2015 – 2017 53 In-hospital waiting time for hip fracture surgery - proportion of cases undergoing surgery within 2 days of admission, 2008 – 2017 54 In-hospital waiting time for hip fracture surgery - proportion of cases undergoing surgery within 2 days of admission for selected OECD countries, 2015 or latest year 55 In-hospital waiting time for hip fracture surgery - proportion of cases undergoing surgery within 2 days of admission by hospital group and hospital, 2015 – 2017 56 Caesarean section rates per 100 live births, 2007 – 2016 57 Casarean section rates per 100 live births for selected OECD countries, 2015 or latest year 58 Caesarean section rates per 100 live births by hospital group and hospital, 2016 59 Patient Reported Average Overall