Mayo University Hospital welcomes publication of HIQA report following inspection

Mayo University Hospital (MUH) welcomes the publication by Health Information Quality Authority (HIQA) of its report into its inspection of three areas at the hospital. An unannounced inspection was carried out at the hospital on the 21st and 22nd of June 2023.

The three clinical areas assessed were the Emergency Department, Orthopaedic Ward and St John’s Ward.

St John’s ward is an off-site medical ward governed and managed by the acute service it is located at the Sacred Heart Hospital in Castlebar. 

The focus of the inspection was to monitor compliance with the National Standards for Safer Better Healthcare.

As part of the assessment, HIQA focused on key standards relating to Capacity and Capability and Quality and Safety.

The inspection focused in particular, on four key areas; infection prevention and control, medication safety, the deteriorating patient (including sepsis) and transitions of care.

The hospital was found to be compliant in three areas, substantially compliant in five areas and partially compliant in five areas of the standards.

Catherine Donohoe, Hospital Manager at Mayo University Hospital said: “I initially want to thank the HIQA team for their time on the Visit in June of 2023 they did a very detailed inspection and gave staff and patients time to contribute to the findings. While we are disappointed to have some areas identified as partially compliant, an action plan was completed following receipt of the stage one report. All of the areas identified as partial compliance had a working stream in place prior to the inspection but some of the action at the time of visit were not completed. Many of these actions were subsequently completed in the months after the visit and many others are now completed. We are confident that many of the identified partial compliance would now be deemed as compliant and we will continue to work toward full compliance on all standards.

On a positive note there has been notable improvement in the 2023 inspection which was noted also by HIQA, MUH had no non-compliance in 2023, 8 of the standards inspected were noted to be either fully or substantially compliant with 5 partially compliant. I will take this opportunity to thank our staff for their efforts in achieving these improvements and their strong commitment to strive to have the hospital meet full compliance in all these standards.

“I want to assure the people who use our hospital that my management team and myself as the hospital manager will continue to focus on getting the hospital to the highest standards possible for your care to be delivered safely and effectively,” she added.

Significant work has been carried out on the five areas where the hospital was found to be partially compliant. In a number of areas this work had commenced prior to the HIQA Inspection in early 2023; this is evident in the report findings and also in the improving trend in trolley numbers and overall length of stay (LOS).

MUH increased its compliance with Ambulance Turnaround Times, this will be enhanced again with the implementation of secondary triage room in early 2024. MUH work closely with ambulance services at quarterly interface meetings. This is leading to a number of improvements including raising awareness through an ambulance arrival screen which is available to management teams and is visible in the ED.

To reduce the number of patients waiting admission on trolleys in ED and to the wards, MUH has put in place a length of stay working group in April 2023.  This group has achieved improvements with a reduction in Length of Stay across all specialties. There has also been improvement in MDT discharge planning and this is being progressed in specialty wards. A discharge lounge was opened in July and operates from Monday to Friday.

MUH with the assistance of national funding opened two new isolation rooms on one of the medical wards, improving isolation facilities and also putting more beds into the system.

The Acute Medical Assessment Unit has been predominantly used for acute medical assessment including direct access from GP and fast tracking patients from the emergency department. The Unit has a new clinical committee in place to implement the national acute medical programme target KPIs in 2024. They are also managing a new ambulatory medical review unit to facilitate early discharge of patients.

An electronic dashboard providing real-time health data of the emergency department is being utilised and staff in ED have access to this system showing triage and other status of ED patients at a glance. This system also helps identify a patient at risk of breaching time targets in the ED. The implementation of the electronic discharge letter, which incorporates e-prescription, is also being progressed in the ED and through the hospital.

A clinical communication and handover committee is currently putting an annual hospital wide audit plan in place to measure its compliance and effectiveness rates.  Policies incorporated into the hospital wide audit plan include; early warning score, sepsis policy, all infection prevention and control policies and procedures, medication safety and nutrition among others.

There are monthly update on compliance rates with mandatory training in all clinical standards identified in the inspection with targeted action where compliance is not at 100%.

Plans for a new ED/AMU are progressing. This will increase space for patients, double the resuscitation bay capacity and free up the AMAU for full use, reducing length of stay for patients and increasing standards of care. It will also provide audio visual separation for paediatric patients attending the ED.

Plans for a 75 bedded ward block with 50 new and 25 replacement beds are also progressing. A brief has been completed on the ward block and this now awaits capital plan approval under the national acute bed allocation plans.

Several improvements were noted since the last inspection, such as the reconfiguration of the quality and safety department, recruitment of quality and patient safety personnel, and the introduction of a patient advisory liaison service.

HIQA was satisfied that the hospital had systems and processes in place to respond promptly, openly and effectively to complaints and concerns raised by people using the service and noted good practice in relation to in-house patient satisfaction surveys.

HIQA noted the hospital was compliant on standard 1.7 relating to service providers promoting a culture of kindness, consideration and respect. It stated that overall HIQA were satisfied that hospital management and staff promoted a culture of kindness, consideration and respect for people accessing and receiving care at the hospital.