On behalf of the Health Information and Quality Authority (HIQA), I would like to thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss the Tallaght Investigation Report, and I am joined today by Marty Whelan, our Head of Communications and Stakeholder Engagement.

When we appeared before you in January, members raised our investigation into Tallaght Hospital and I gave a commitment to come back before the Committee when our investigation had been completed and the Report published. We very much welcome the opportunity to appear before you and I would like to thank the Committee for suspending its scheduled meeting today to have this important discussion. As you know, we published the Report last Thursday and I am pleased to be here to discuss the Report and the recommendations, some of which relate specifically to the Hospital, others relate to similar hospitals nationally and a number of our recommendations relate to the governance of the wider health and social care system.

During this presentation I will briefly summarise the main findings of the investigation. I would also like to consider some of the important lessons from this investigation and to explore with you some ideas on how we can use this report to further modernise our health system.

1 Background

Last June, the Board of the Authority took the decision to instigate an investigation into the quality, safety and governance of the care provided to patients who required acute admission to the Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital. I will refer to the Hospital as Tallaght Hospital throughout this presentation.

In carrying out the investigation, the Authority looked in detail at the quality, safety and governance of the system of care in place for patients requiring both acute (unscheduled) and planned (scheduled) care in the Hospital and, in particular, those patients admitted through the Emergency Department.

The Authority also investigated the effectiveness of the Board of the Hospital and the corporate and clinical governance arrangements that it had in place to assure itself that the risks to patients were being appropriately managed by the Hospital – particularly the risks to patients receiving care in the Emergency Department and requiring acute admission.

We investigated the effectiveness of the planning, accountability and oversight arrangements that were in place between the Health Service Executive (HSE) and Tallaght Hospital, as a service provider in receipt of State funds, with a focus on how the HSE held the Hospital to account for the quality and safety of the services that it was providing.

We also considered the national context for patients receiving similar services across the country in order to compare the performance of the Emergency Department in Tallaght Hospital with other hospitals in the same period and to inform national learning for the purposes of improving the quality and safety of care for these patients.

2 Findings

2.1 Unscheduled care

The patient referral pathway to the Emergency Department of the Hospital was considered to be similar to those of other hospitals in Ireland with a similar profile and with the majority of patients being self referrals. The lack of an out-of-hours general practitioner (GP) service or primary care service in the area meant that patients and/or their GPs may have felt that they had no other option but to attend or refer the patient to the Hospital’s Emergency Department to accelerate their treatment.

Whilst the patient was in the Emergency Department they were under the care of the emergency medicine consultant. However, at the commencement of the investigation, effective arrangements were not in place at the Hospital to ensure the seamless transfer of clinical responsibility for a patient from their clinical assessment in the Emergency Department, to their clinical assessment by the relevant speciality Hospital team through to their admission to a Hospital ward. This raised a significant concern about the Hospital’s ability to ensure that patients, at all times, had a designated consultant who was clinically responsible and accountable for their care. This deficit was subsequently addressed by the Hospital in November 2011.

The average waiting time in the Emergency Department for a non-admitted patient at the Hospital, from January to August 2011, was 6 to 7 hours and the Authority found that some patients were waiting up to 61 hours before being discharged. Patients who attended the Emergency Department, and subsequently required inpatient admission whilst awaiting transfer to an inpatient bed, were accommodated either within a designated area within the Department or on the corridor adjacent to it. Over 80% of the admitted patients were accommodated on the corridor adjacent to the Emergency Department and waited, on average, a further 13 hours for an inpatient bed, with the longest waiting time reported as 140 hours. This was an unacceptable situation for patients.

Following an unannounced inspection of the Hospital’s Emergency Department by the Investigation Team on 24 August 2011, the Authority identified a number of serious concerns specific to the use of the corridor adjacent to the Emergency Department as a waiting area for admitted patients awaiting an inpatient bed. These concerns had the potential to compromise the quality and safety of care for these patients and the capacity of the Emergency Department staff to provide a timely assessment of newly arriving patients in the Department. The Authority wrote to the Chief Executive of the Hospital who confirmed that the use of the corridor adjacent to the Emergency Department ceased on 29 August 2011. This type of situation is not satisfactory for patients and the public and, in the view of the Authority, is a serious risk to patient safety and should cease in every emergency department in Ireland.

• National Emergency Department Services

Waiting times for patients in Ireland’s emergency departments has been a longstanding concern from a patient safety and quality perspective. From a national perspective, the Authority compared the performance of emergency departments across the country for the same 24-hour period on 23-24 August 2011 and, through the data provided by the HSE, found that patients attending the majority of emergency departments in Ireland experienced waiting times of greater than six hours, with the longest waiting times of up to 115 hours for patients who were discharged and 137 hours for patients who were admitted.

We also found inconsistencies in the level and quality of data that was provided by the HSE in relation to the 33 public hospitals delivering emergency care, and the adequacy of the information gathering and analysis processes in place to performance manage emergency departments from a patient’s experience and timeliness perspective.

At that time, these findings identified serious issues of quality of care and patient safety and raised serious concerns in relation to how these services were being managed.

2.2 Scheduled Care

The investigation found that the resource capacity for the radiology services was under pressure to efficiently respond to the demand from unscheduled, scheduled, outpatient and community care services. The Hospital had contracted a third-party provider to reduce the waiting time for ultrasound scans. However, it was reported to the Authority that some patients were waiting long periods for imaging tests. For example, it was reported that outpatients could be waiting up to nine months for a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan. The Authority concluded that the extended waiting times for reporting, for both inpatient and outpatient diagnostic imaging tests, required further review and improvement.

At the time of the investigation, an Outpatient Turnaround Project was in progress at the Hospital which included addressing the issue of outpatient waiting lists. In June 2011, 52% of all patients were waiting beyond 90 days to be seen in the OPD by a specialist team. Excessive waiting times for outpatient appointments can result in GPs referring patients, or patients self referring, through alternative pathways in order to access care – including patients being referred or self referring themselves to the ED.

The Hospital had exceeded the national overall figure for day case patients waiting less than six months and was in line with other hospitals in relation to patients waiting less than six months for elective admission and same-day admission. The Authority found that the Hospital was outside the national average of 5.9 days for the average length of patient stay.

The length of a patient’s stay can be safely and significantly reduced by hospitals ensuring that structured early morning ward rounds by senior clinical decision makers are undertaken. The Authority found that proactive patient discharge planning, to include early morning ward rounds, use of estimated date of discharge and timely patient discharge planning were not consistently supported by the range of clinical disciplines in Tallaght Hospital. In addition, the Authority found that the historic lack of an integrated approach to patient admission and discharge planning had contributed to challenges at the Hospital with the timely discharge of patients.

In June 2011, 69% of scheduled patients at the Hospital were waiting less than six months for an inpatient appointment. Nationally, at the time of the investigation, no hospitals’ waiting times for inpatient waiting lists had been published. This is of concern to the Authority and it recommends that these figures are nationally published and that all service providers should, as a priority, ensure that they have the appropriate arrangements in place to formally review and prioritise patient waiting lists in a structured manner.

2.3 Leadership, Governance and Management

• Board Governance

The investigation found that the Board of Tallaght Hospital did not have effective arrangements in place to adequately direct and govern the Hospital nor did it function in an effective way. The Hospital’s governing Charter is not in line with modern corporate governance principles.

The Hospital lacked an organisation-wide strategic vision and culture and failed to adequately respond to the significant changes in healthcare delivery and advances in modern corporate governance.

The collective membership of the Board did not reflect the relevant diversity of knowledge, skills and competencies required to carry out the full range of oversight responsibilities, nor was the appointment process in line with modern governance principles.

The Charter provided for the establishment of a number of committees which were required to report to the Board in relation to their activities. These Board committees, with the exception of the Transitional Board of Management, had no executive powers but rather advised, reported to and made recommendations to the Board. We found little information as to how the Board, or any of its committees, oversaw and sufficiently assured themselves that the Hospital was delivering services in line with the service plan agreed with the HSE as articulated in the Section 38 (Health Act 2004) Service Agreement for the resources provided.

During the course of the investigation, information came to the attention of the Authority that raised concerns about the effectiveness of the governance arrangements in place for financial management, financial transparency and commitment control. In particular, the Authority was concerned that the Hospital did not have the internal controls in place to ensure its compliance with public procurement legislation.

In October 2011, because of significant concerns we had in relation to the corporate and clinical governance arrangements in place at the Hospital and, in particular, the effectiveness of the Board’s governance arrangements, we met with the Minister for Health to advise him of these concerns and subsequently issued preliminary draft recommendations to the Minister to help mitigate the risks at that time. Subsequently, we also met with and wrote to the Comptroller and Auditor General highlighting our concerns about the financial and corporate governance arrangements at the Hospital.

On 9 November 2011, the Minister for Health and the Church of Ireland Archbishop of Dublin announced a series of initiatives to reform the governance structure of the Hospital. A new interim Board was established in December 2011.

• Executive Management

The Executive Management arrangements at the Hospital had, over the last three years, gone through a number of significant changes with four members of staff acting in the role of Chief Executive. There was no clear scheme of delegation from the Board to the Chief Executive or to the Executive Management Team for delegating accountability in relation to the delivery and performance of the Hospital’s functions.

It was of concern to the Authority that there was a reported ambiguity as to who had overall executive accountability for the quality and safety of the services delivered and an apparent lack of integration across the corporate and clinical governance arrangements that were in place. The effective management arrangements that were needed to facilitate the delivery of high quality, safe and reliable care and support, by allocating the necessary resources through informed decisions and actions, were not sufficiently in place.

The turnover of senior executives in the Hospital, and the ongoing ‘acting’ status of individuals in key positions, created challenges in the leadership and management of the Hospital.

• Planning, Accountability and Oversight Arrangements

We found that the accountability and oversight arrangements in place to govern the relationship between the HSE and the Hospital were not sufficiently effective. Also, the Service Arrangement between the HSE and the Hospital was not used by the HSE to its full potential to seek the necessary assurances from the Hospital that the services that it was funded to provide, on behalf of the HSE, improved, promoted and protected patients in the most efficient and effective manner possible.

Furthermore, there was no reconciliation between the funds available, the budgetary overspend, catchment areas, innovation and research, demand and capacity and the core business of delivering high quality safe care to patients.

There was no evidence available to the Authority to demonstrate a clear understanding of the collective roles and responsibilities of each statutory and non-statutory hospital’s contribution to the overall delivery of the HSE’s Dublin Mid Leinster service plan as part of the HSE’s National Service Plan. The HSE did not describe a service model and there was no clear direction provided for the Hospital.

• The National Perspective

Given the substantial amount of public money that is entrusted to service providers that are in receipt of State funds, the Authority has recommended that there should be a robust mechanism in place to oversee the recruitment, appointment, performance and replacement of board members, chief executives and other executives of these service providers.

We also believe that there should be greater involvement in the performance management of the chairperson of a board by the State, and of the chief executive by the chairperson of the board and also by the State, to ensure that any service provider in receipt of State funds is providing good, safe services within the resources available.

In a system that is facing considerable challenges, the effectiveness of the governance arrangements through which public funds are allocated, defined and performance managed is critical. This requires the establishment of a clearly defined ‘Operating Framework’ for the State that outlines the key elements of the effective governance and operation of a high quality, safe and reliable health and social care service which is designed to deliver the most accessible service in the most cost and clinically effective way within the resources available.

A Special Measures Framework should also be established to actively address and act on circumstances in which substantial and persistent poor performance of the board and/or executive management of a service provider in receipt of State funds occurs. This Framework should contain the provisions for intervention orders whereby the Minister for Health believes that a hospital, or any other service provider, is not performing one or more of its functions adequately, or that there are significant failings in the way it is being run – including quality of care, patient safety and financial management issues.

3 Conclusion

The findings of this investigation reflect a history of longstanding challenges in the leadership, governance, performance and management of the Hospital which were manifest in the persistent, and generally accepted, tolerance of the unacceptable practice of patients lying on trolleys in corridors for long periods of time.

It also reflects a history of a Hospital providing care to a substantial number of the population that was allowed to struggle on despite a number of substantial governance and management issues in relation to quality, safety, planning and budgetary management which were present over a number of years.

Despite a number of attempts to address the governance of the Hospital, and a number of improvement reviews having been undertaken, sufficient action was not taken by the Hospital itself or the HSE to address these issues. This reflected a failure not only in the governance of the Hospital but also in the governance of the health system that should effectively hold a service provider in receipt of State funds to account.

As we stated in our report, every day there are patients who receive good, safe care at Tallaght Hospital and there are patients who could receive better and safer care at the Hospital. Since the investigation commenced, there have been significant changes and improvements in the leadership and governance in the Hospital.

We believe that this investigation is a seminal point in the journey to modernising the way we run our health system. The business of person-centred healthcare is far too important to be run, managed and governed in a way that does not reflect a high performance, high quality and high delivery mindset – from patient to policymaker. Ignoring persistent poor performance, and not having or using the levers and drivers to address this, is no longer acceptable in a modern day health and social care system. This must change.

4 Next Steps

This investigation includes recommendations for improvement that are specific to Tallaght Hospital, recommendations that relate to hospitals nationally, and also those that relate to the governance and performance of the wider health system. Tallaght Hospital will be required to develop an implementation plan for the recommendations which should support the improvement programme currently in place at the Hospital. Other hospitals are also required to assess themselves against these recommendations and develop an implementation plan for improvement in order to meet them.

Specifically, in relation to the existing boards of service providers in receipt of State funds, and the recommendations that relate to these boards assessing themselves against the relevant recommendations within the report, the Department of Health should establish a mechanism to review the assessment and arising action plans and consider the mechanism for modernising the constitutional basis and composition of such boards where applicable.

The HSE should monitor all hospitals and social care providers in receipt of State funds against the implementation plans as part of the service arrangement and as part of its ongoing performance delivery reviews with each provider.

Last week the Minister for Health approved the National Standards for Safer Better Healthcare. The Authority will shortly begin providing support to providers to implement the Standards and will subsequently commence a substantial monitoring programme which will also include the implementation of these recommendations as part of that process. These Standards will be the first step in the trajectory of a licensing system being established in the Irish healthcare system.

The recommendations contained in the Tallaght Hospital investigation report are consistent with the objectives of the above National Standards and the future healthcare licensing requirements in Ireland.

Given the significant system-wide governance recommendations outlined in this Report, it is essential that there is clinical, managerial and political commitment to their implementation in order to drive further improvements in the quality, safety and governance of the care provided to our population.