1. Driving Better Safer Care 25 April 2008

2. Background Established May 2007 Independent – reporting directly to Minister for Health and Children Functions Setting Standards Monitoring Quality and Safety in Healthcare Inspecting Social Services Health Technology Assessment Health Information

3. High Reliability Healthcare Systems

4. Patient Safety Events - a Global Problem: 10% of hospital patients suffer an adverse event each year (UK, New Zealand, Canada and Europe) 16.6% of hospital patients suffer an adverse event (Australian study) 1.4 million hospital patients worldwide acquire Healthcare Associated Infections (HAI) 100,000 cases of HAI lead to 5,000 deaths a year (UK) 1 out of every 135 hospital patients acquires HAI (USA) 98,000 hospital deaths every year through medical error (USA)

5. Needlestick Injuries - a Global Problem: Health Protection Agency UK: 1996 - 2004, 2140 incidents of significant occupational exposure to blood bourne viruses reported: 47% exposed to Hepatitis C and 26% to HIV UK – up to 2005, 5 reported cases of seroconversion to HIV through occupational exposure New England Journal of Medicine 2007: 83% surgeons had needlestick injuries in training Ireland: estimated 6000 needlestick injuries per year, up to 70% unreported

6. Key Ingredients Person-centred services Open and transparent learning culture Effective, strong leadership, governance, accountability, management and team working Fit for purpose workforce Clinicians in Executive management Effective relationships, behaviours and communication Effective information management and measurement Robust quality assurance – internal and external

7. Safe, high quality care Provider Market Evidence Based Practice GovernanceRegulatory Framework Political Legislative Commissioning for Quality Insurers Service Users, Public Key Levers and Drivers

8. Quality Interventions Setting standards, guidelines Establishing quality performance indicators – balanced scorecard Benchmarking and reporting on performance Quality assuring services - regulation Tools for data mining and analysis Learning from adverse events, complaints, best practice

9. Open and Transparent Culture “…as soon as we knew we’d made the mistake we met with the family and told them” “…telling relatives – well you see, we don’t do that here it’s not in our culture” “…I thought I’d told you, I don’t speak to patients I have people who do that for me”

10. Quality Activities

11. Quality Programme 1 National review of symptomatic breast disease services Development of Infection Prevention and Control standards National Hygiene review 2008 Review acute hospitals standards framework Commence development of performance indicators Discussion in primary care quality assurance Patient safety programme – WHO, EU Network

12. Quality Programme 2 Completed Health Technology Assessment and commenced colorectal screening programme HTA Establish technical standards for interoperability, review the National Health Information Strategy Commence inspection nursing homes Complete residential care standards for people with disabilities Publish all

13. High Reliability Culture Where…

14. People are at the centre of their care Staff are continuously developed and are supported when things go wrong Intelligent information is used to drive and demonstrate improvements in patient experience Strong leadership, governance, accountability and management emanate throughout our services Learning, openness and transparency are inherent in the way we do business We can all be assured, with confidence, that high quality, safe services are provided across Ireland

15. Thank You