REGIONAL HOSPITAL MULLINGAR Longford Road, Mullingar, Co Westmeath Tel: 044 9340221 RReeggiioonnaall HHoossppiittaall MMuulllliinnggaarr SSttaatteemmeenntt ooff PPuurrppoossee 22001177 Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 1 of 33 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 Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 2 of 33 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 Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 3 of 33 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 Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 4 of 33 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 Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 5 of 33 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. Doc Owner: Sharon Gorman Quality & Patient Dept & Location: Doc. No: STMT-M/HOSPQ/2 Safety Manager RH, Mullingar Doc Title: RH, Mullingar Statement of No. Of Rev. No: 4 Active Date: 02/2017 Purpose Pg: 6 of 33 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