State did not hold hospital to account

Patients languished on trolleys in the corridors of one of the country’s busiest hospitals with nobody responsible for their care, the State’s health safety watchdog has found.

The Health Information and Quality Authority (Hiqa) found that the State failed to hold Tallaght Hospital to account for the quality and safety of services it provided.

The investigation reveals a history of longstanding “challenges” in leadership, governance, performance and management at board and executive level of the hospital which received €180m in funding from the State last year.

Hiqa chief executive Tracey Cooper said the challenges resulted in the persistent and generally accepted tolerance of patients lying on trolleys for long periods with a lack of clarity as to who was accountable for them.

“This puts patients at risk, is not acceptable and should not be tolerated in any hospital in Ireland,” she said when the report was published yesterday.

Hiqa had concerns about the control and management of patients on a corridor adjacent to the emergency department since 2009.

The authority launched an investigation last summer after a patient died on a trolley while waiting on the corridor for a hospital bed.

Hiqa found that 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 in-patient bed. The longest period reported was 140 hours.

The authority said it was an unacceptable situation for patients.

An analysis of all hospitals providing emergency department services nationally over a 24-hour period in August last year also raised serious concerns about how they were being managed.

Patients attending the majority of emergency department waited over six hours, with the longest waiting times up to 137 hours for admission at Portiuncula Hospital, Ballinasloe, Co Galway.

Hiqa’s analysis identified significant concerns about the quality of the data and the amount of absent information with which to manage the performance of an emergency department.

The investigation also found that the board of Tallaght Hospital did not have adequate arrangements to direct and govern the facility

It was also critical of the HSE for allowing the hospital to struggle on. Insufficient action was taken to address the way the hospital was run.

Hiqa was particularly critical about the awarding of €1.8m by the hospital to external consultants in 2010.

There was no evidence provided to suggest written quotations were sought or tenders invited from other interested parties for the work. At the time, the hospital was forecasting a deficit of €7.2m.

There were also people in the hospital receiving substantial amounts of money for “additional duties”. One such payment was over €150,000.

“There was no decision process around it, no oversight around it,” said Dr Cooper, who said that such information had been sent to the Comptroller and Auditor General earlier this year for forensic examination.

The findings and the 76 recommendations from the investigation focus on the improvements needed in the hospital and similar hospitals nationally, as well as the changes needed to improve the accountability of the health system by the State and modernise the way in which the health system is run.

“Ignoring persistent poor performance in the quality, safety and timeliness of patient care and financial management should no longer be acceptable and must change,” said Dr Cooper.

Hiqa report: The main findings

* There was significant concern about Tallaght 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 Nov 2011.

* 14% of patients who attended Tallaght’s emergency department during the first six months of 2011 left without completing their care but Hiqa was not provided with information from the hospital to show it was effectively monitoring those who turned up within seven days with the same condition.

* Some patients were waiting in the emergency department for up to 61 hours before being discharged.

* More than 80% of the admitted patients were accommodated on the corridor adjacent to the emergency department and waited a further 13 hours for an inpatient bed, with the longest waiting reported as 140 hours. This was an unacceptable situation for patients. 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 discharge and 137 hours for admission.

* The lack of an out-of-hours GP service or primary care service in the area meant that patients and/or their GPs may have felt they had no other option but to attend or refer the patient to the emergency department to accelerate their treatment.

* Some patients were waiting up to nine months for imaging tests and in June last year, 525 of all patients were waiting more than three months to be seen in the out-patients department by a specialist team.

* The hospital had a monthly average of 63 patients over 65 years of age awaiting discharge to a step-down, rehabilitation, or long-term care placement facility.

* Hospital board did not have adequate arrangements in place to direct and govern the hospital.

* Board did not function in a sufficiently effective way to assure itself that the hospital was providing safe care to patients including patients receiving care in the emergency department.

* A contract costing €1.8m was awarded that raised serious concerns about the effectiveness of the governance arrangements for financial management, transparency, and contract control in the hospital.

— Evelyn Ring

Way forward

Main recommendations from the Health Information and Quality Authority inquiry into Tallaght Hospital:

* Hospitals should stop using inappropriate space, such as corridors or trolley parking areas, to accommodate patients.

* Hospitals must ensure there is a named consultant clinically responsible and accountable for a patient’s care.

* The total patient time spent in the emergency department should be less than six hours.

* An independent process established by the State should be used to select and appoint hospital boards.

* The health minister should consider introducing a payment for board members that takes account of performance, attendance, and contribution.

* The role and functions of boards must be clearly defined and it should hold executives accountable for performance.

* A clear scheme of delegation of accountability from the board to chief executive and executive directors should be in place.

* The chair of a board must be accountable for ensuring that there is an effective process in place to support, develop and manage the performance of the chief executive.

— Evelyn Ring


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