ANNUAL REVIEW master Final3a - St Vincent's University Hospital

St. Vincent’s Healthcare Group Limited - Annual Review 2007
Reports
Quality, Risk and Consumer Affairs Department
Introduction
The Quality, Risk and Consumer Affairs Department was developed in 2007 and has evolved throughout the
year in an effort to meet the needs of patients and staff and ensure compliance with relevant statutory and
best practice requirements. The main components within the division are: Quality and Accreditation,
Insurance, Risk & Legal Affairs, Communications and Consumer Affairs.
Significant Developments
In 2007, there was a significant change nationally with regard to the accreditation process. The Irish Health
Services Accreditation Board (IHSAB) was integrated into the Health Information and Quality Authority
(HIQA). St. Vincent’s Healthcare Group accreditation teams through monthly meetings completed selfassessment
against the national acute care accreditation standards in October 2007. The teams identified
a number of team specific and organisation wide strengths and areas for improvement. The external survey
planned for November 2007 was postponed until clarification was received with regard to the status of the
national accreditation scheme. A number of teams continued to meet throughout the rest of 2007 to identify
opportunities for improvement and local quality improvement initiatives.
The Hospital Hygiene Quality Improvement Group (HHQIG) continued to meet in 2007 to ensure compliance
with the national hygiene assessment scheme. A peer review survey was carried out in March 2007 resulting
in an overall score of ‘good’ for St. Vincent’s University Hospital.
Insurance, Risk & Legal Affairs staff strived to deliver a cohesive and collaborative risk management culture
to ensure the structures are directed towards the effective management of incidents with the aim of
constantly improving patient safety. By continuing to develop and expand the level of compassionate and
coordinated support offered, effective compliance with risk management was ensured by implementing a
number of local and organisational quality improvement initiatives. The latter quarter of 2007,a Management
and Governance Review was carried out.
Equally, the Communication’s division continued to grow and expand. In late 2007, the a robust and
comprehensive communication’s strategy was developed that outlines St. Vincent’s Healthcare Group’s main
communication projects, in line with its mission and values, for the next two years. All current communication
pathways and processes were evaluated and an all inclusive action plan was then devised in conjunction with
the Senior Management Team to improve and expand these practices.
The Consumer Affairs division continued to facilitate the development of positive and proactive consumer
engagement. This included aiming for best practice in complaints management, ensuring that complaints are
investigated thoroughly and impartially, while ensuring compliance with the relevant legislation, HSE policies,
and the hospital’s mission and philosophy. Quality improvement and learning are an integral component of
effective complaints management and greater emphasis is now placed on quality improvement, aiming to
address the issues highlighted through complaint investigation.
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