Introduction

On behalf of the Health Information and Quality Authority, I would like to thank the Joint Oireachtas Committee on Health and Children for giving me the opportunity to discuss with you today our programme of work. I am joined by Phelim Quinn, our Director of Regulation, and Marty Whelan, our Head of Communications and Stakeholder Engagement.

We very much welcome the opportunity to appear again before the Committee and engage with you. I appreciate there are a number of members who we have not met before and we look forward to working with you all. The Authority was established just over six years ago and we are very conscious of our responsibilities to Government, the Oireachtas and the public. We look forward to hearing the Committee’s views both today and over the coming years.

HIQA was established as an independent Authority reporting to the Minister for Health, and latterly also the Minister for Children and Youth Affairs, with a wide range of regulatory and non-regulatory functions, most of which are set out in the Health Act 2007. All of our functions contribute towards driving continuous improvement in the safety and quality of care and support for people using our health and social care services. While many of the members may be familiar with our work, I would like to describe briefly the functions of the Authority and then focus today on a number of topical issues, including the commencement of the regulation of residential services for adults and children with disabilities, the patient safety issue of Healthcare Associated Infections and what we plan to achieve over the coming years with our next Corporate Plan.

If there are any other specific areas of our work that members of the Committee would like us to address, I will be happy to take any questions following this presentation.

The role of the Authority is to promote safety and quality in the provision of health and social services for the benefit of the health and welfare of the public. This means the Authority has responsibility for setting quality and safety standards for people using our health and social care services (with the exception of mental health services), regulating health and social care services for adults and children – including the registration and inspection of designated residential centres for older and dependent people, inspecting children’s services and healthcare services and, in a couple of weeks’ time, we will begin the regulation of residential services for adults and children with a disability.

We are also responsible for promoting the better use of resources in our health system and do this through undertaking health technology assessments to evaluate the cost and clinical effectiveness of new and existing drugs, devices and services, in order to inform and guide decision making on how and what we invest and disinvest in as a health service. We also set standards for inter-operability for health information systems and provide and inform health information advice and policy.

We also have responsibility for supporting providers and staff in bringing about improvements in the safety and quality of services for people. This has been an important and increasing focus for us over the last year and we achieve this through the setting of standards, providing customised guidance and helping to build capacity and capability in the workforce through delivering quality and patient safety initiatives.

As a learning organisation, we also have a duty to ensure that we learn from similar organisations and healthcare challenges in other jurisdictions in order to ensure that, both individually and collectively as a health system, we do not replicate issues of concern that have already been identified elsewhere.

A particular example is the circumstances that have resulted in two public inquiries being undertaken into significant quality and safety failings that took place at the Mid Staffordshire NHS Foundation Trust in England. The reports of these inquiries identified significant issues at hospital, regional and national level including the response of the healthcare regulators. Such learning includes ensuring that robust systems are in place to effectively risk assess information at local and national level, the need for collaborative approaches with other regulators and, more importantly, the need to ensure that our assessment and monitoring activities have a clear and unambiguous focus on the quality and safety of care as experienced by patients and other service users.

Regulating Residential Services for People with a Disability

In today’s presentation, I wish to focus on one of our newest functions, namely the regulation of residential services for children and adults with a disability. We will commence this new function in the coming weeks and I wish to share with the Committee details on how we will be undertaking this extremely important activity.

By means of context, there are approximately 9,800 people with a disability who live in residential care services in Ireland. These services are provided in approximately 1700 residential services that are run by 88 service providers across Ireland which includes a mix of State – which is the Health Service Executive, private and voluntary providers.

Almost five years ago, I addressed the Committee on the development of Standards in this area and I outlined the importance of having Standards that promote good safe practice and also safeguard the rights of both adults and children with disabilities. I would like to place on the record my thanks and appreciation to current and former members of this Committee, and many other people, for your ongoing support and encouragement in bringing us to where we are today. It is important that we are now in a position to begin this vital work and I believe that this is a landmark moment for people with a disability living in Ireland and their family members.

It is the first time that residential services for people with a disability will be subject to independent scrutiny by a regulator in this country. From now on, people who use disability services and/or their families will know what they should expect from residential services, and service providers will know what is expected of them in delivering a person-centred, high quality and safe service. The National Standards for Residential Services for Children and Adults with Disabilities that we published before the summer will be used as a framework to drive continuous improvements in these services. I will refer to them as the National Standards during this presentation.

We in HIQA passionately believe that children and adults using residential services have the right to be safe, to receive good care and support, and to have access to the services they need to enable them to live a fulfilling life in as independent a way as possible.

The National Standards will apply to all residential services provided to children and adults with a disability, whether the service is operated by public, private or voluntary agencies. Following the publication of the regulations by the Government, all services providing residential services for people with a disability will have to be registered with HIQA and we will be assessing providers against the requirements in the Health Act 2007, the underpinning regulations and the National Standards published in May.

The National Standards focus on the outcomes to be achieved for the adults and children receiving services. The Standards are grouped under eight key themes and cover a number of areas including respecting peoples’ autonomy, privacy and dignity and promoting their rights. They are also aimed at ensuring the facilitation of choice and safeguarding and protecting people from abuse. They require that people who live in residential services should enjoy a good quality of life and live in a place that feels like their home. It is vital that all services are of a consistently high quality, regardless of which provider is running them.

In advance of this new function, the Authority has initiated a process of engagement with providers and advocacy groups. For providers, we have held a series of information sessions and focused engagements. Following commencement, we will also organise a number of focused meetings with providers on such topics as preparing for inspection, responding to inspection reports, action plans and submitting notifications.

The purpose of regulation is about supporting continuous improvement in the quality and safety of services and we will support providers to this end. However, services must be safe for people. Failure to comply with the Act, regulations and Standards is an offence and persistent failure to comply reflects on the fitness of the provider and other key senior managers. As with our inspection of residential services for older people, if the Authority is not satisfied that the provider is sufficiently addressing non-compliances then further action will be considered. These actions are set out in the Act and may include refusal to register the centre, prosecution, the placing of additional registration conditions and, in situations where there is significant risk to the life or to the health or welfare of residents, immediate cancellation of the centre’s registration. Repeated noncompliance with the requirements may also impact on the continued registration and operation of the centre.

We look forward to beginning this important function and, most importantly, to making a difference to people with a disability living in residential care across the country and providing assurance to their family members and the public.

Healthcare Associated Infections

In relation to the Authority’s function to help improve patient safety, I would like to focus on the area of the prevention and control of Healthcare Associated Infections which is a significant priority for us and the health system. Healthcare Associated Infections (or HCAIs) represent the most frequent adverse event during healthcare delivery and no institution or country can claim to have fully solved the problem yet.

Based on data from a number of countries, it can be estimated that each year, hundreds of millions of patients around the world are affected by Healthcare Associated Infections.

Every day, Healthcare Associated Infections result in prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobial drugs, high costs for patients and their families including unnecessary deaths and massive additional costs for health systems. For example, in high-income countries, approximately 30% of patients in intensive care units are affected by at least one Healthcare Associated Infection during their stay. It is also important to note that these infections are not exclusive to hospitals. They can be prominent in every health and social care facility including community hospitals, nursing homes and also people being cared for in the home.

In addition to the significant patient safety issues and unnecessary harm that may arise with Healthcare Associated Infections, annual financial losses due to these infections are also significant. The World Health Organization (WHO) reports an estimate of annual costs due to Healthcare Associated Infections at approximately €7 billion in Europe, including direct costs only and reflecting 16 million extra days of hospital stay, and of about 6.5 billion US dollars in the United States.

Ireland has made continued progress in reducing Healthcare Associated Infection rates over the last number of years and, like many countries, more needs to be done. For example, the Health Protection Surveillance Centre in the HSE has reported that the number of reported Methicillin-Resistant Staphylococcus aureus (MRSA) bloodstream infections has decreased steadily over the last six years from 592 in 2006 to 242 in 2012, representing a reduction of 59%. Although the overall trend in the proportion of MRSA observed in Ireland is decreasing, it is still relatively high, albeit similar to the United Kingdom and Southern European countries. In 2011, Ireland ranked 10th out of 28 countries reporting MRSA figures through the European reporting network.

Many infection prevention and control measures, including hand hygiene, do not require monetary investment. This is about leadership and behavioural change, about staff taking responsibility and being held accountable for what is a simple modern day duty of care. It is also about the empowerment of patients and their families to take personal responsibility for safeguarding themselves and to be comfortable in actively seeking assurance from staff that they have cleaned their hands. This must be a priority for the leadership of a health and social care facility. In 2013, it is inexcusable for this fundamental and avoidable patient safety and costly issue not to be considered as a priority by every member of staff working in a health or social care facility, by every chief executive, by every board and by every health system.

Over the last number of months the Authority has inspected 36 hospitals, and published the associated findings, against the National Standards for the Prevention and Control of Healthcare Associated Infections. Twenty eight of these were unannounced and eight were announced inspections. Given that hand hygiene is recognised internationally as the single most important preventative measure in the transmission of Healthcare Associated Infections in healthcare services, the primary focus of these inspections was on the standards in relation to hand hygiene and environmental hygiene. It is important to note that these findings only represent a single point in time. The main findings of these inspections were that:

• Overall, 1045 opportunities to perform hand hygiene were assessed. 67% of opportunities were taken (72% of which were compliant with best practice) and 33% of opportunities were not taken. This demonstrates that a third of all hand hygiene opportunities did not take place.
• Of the six hospitals that have had more than one monitoring assessment, there have been demonstrable improvements in the hand hygiene culture.
• Other general areas requiring improvement included waste and laundry management practices, the securing of ‘clean’ utility rooms and access to needles, syringes and medication, and the securing of ‘dirty’ utility rooms and access to chemicals such as cleaning products.

In 2013, these aspects of preventing and controlling Healthcare Associated Infections should be embedded into the culture of all health and social care facilities. This patient safety area will continue to be a priority for the Authority and will become increasingly so when we begin a licensing system for healthcare facilities. We will expect avoidable and unnecessary harm to patients to be substantially reduced at that time.

Corporate Plan 2013 - 2015

HIQA has been in existence now for just over six years. We are absolutely committed to discharging the responsibilities bestowed on us by the Oireachtas in a person-centred, robust, professional, objective and independent manner. In so doing our focus is, and always will be, on driving high quality and safe care for people accessing our health and social care services. With this in mind, and following a public consultation process, we have developed a new Corporate Plan with a time frame of up until 2015. Our approach to the development of the Plan is outlined below.

The Plan is influenced by the Authority’s vision, mission and values. It includes a strategy map on one page that articulates the direction that the Authority will take during the three-year period and the outcomes we want to achieve in order to add value and have a maximum impact during what are challenging times for the country and our health system. The expansion programme for the allocation of new functions to the Authority, envisaged in the Government’s health reform plan and by other policy decisions, is significant. The Authority will be regulating previously unregulated areas such as services for people with disabilities that I’ve just mentioned. It is also envisaged that the Authority will take on further additional functions that include a substantive monitoring programme of healthcare facilities against the National Standards for Safer Better Healthcare, the supervisory authority for research ethics, the competent authority for medical ionising radiation protection and the registration of children’s special care units while we will also move towards the development and implementation of a licensing system for healthcare facilities.

Over this period, an increasing focus for us is also informing decision making through the provision of advice in relation to the assessment of new and existing technologies and health information systems and management, while also the supporting improvements through providing quality and safety development opportunities. To address these challenges, we will ensure that any new functions are properly planned for, are as cost-effective as possible and that there are adequate systems and resources in place to support them. We will also work to ensure that such functions are undertaken in a well managed way that takes account of the impact of increasing regulation on the health and social care sector.

Our new Corporate Plan will commit us to working with our stakeholders in a collaborative and constructive manner. In some instances we will develop memoranda of understanding (MoUs) which are formal commitments to collaborate with key stakeholders, including other regulators, to ensure that there is clarity around our respective roles and responsibilities, that information is exchanged to safeguard patients and that the overall burden that regulatory activity places on service providers is reduced wherever possible.

Finally, it is a difficult time for providing and maintaining good quality and safe health and social services. However, there are also opportunities in these times to ensure that services are as efficient and as effective as possible with an uncompromising focus on safety. The impact of economic and fiscal constraints is significant and continues to be a challenge and a concern. Therefore, it will be more essential than ever that what we do and how we do it will have a maximum impact on people receiving services and that our focus is real, relevant and appropriate. In this climate, the focus for those providing services, and for us regulating services, will be about safety – getting services safe and keeping them safe.

I thank the Committee for the opportunity to make this presentation and look forward to working closely with members in achieving our shared purpose.