Speech by Minister Harris at the launch of the National Patient Safety Office
**check against delivery**
Good Morning, Ladies and Gentlemen,
I am delighted to be here at this National Patient Safety Conference.
Today, in a venue that has been at the heart of Irish history for over 800 years, we are marking a significant event for our patients, the public and health service providers. Today, I am launching the National Patient Safety Office which will be located in my Department.
The World Health Organisation has declared patient safety as a global public health problem. One-in-ten patients will develop a healthcare acquired condition and international studies indicate that 3-4% of deaths in acute hospitals are avoidable.
While we can be confident that much of care we provide is of high quality, we all know that the delivery of healthcare and health systems is never without risk.
The challenge we face is not the achievement of perfection, but the development of a service in which: the risk of harm and medical error occurring is minimised; the capacity to identify it when it does occur is maximised; and the systems we have ensure that lessons are learned and inform quality improvements.
We face this challenge in a world of more complex care where, thanks to improvements in medicine, patients are living longer, with multiple illnesses, and where technology is playing a bigger role.
The CEO of the State Claims Agency estimates that the cost of claims in Ireland will exceed €300 million in 2017. Consider the magnitude of that. It is clear we need to change this picture. We need a vision where we are preventing patient safety incidents and introducing patient safety measures to promote and assure safe health systems in a system that listens and learns.
Programme of Patient Safety
I and my Department are fully committed to progressing a programme of major patient safety initiatives. This has been an important year for patient safety and we are making significant strides in a number of areas.
The establishment of the National Patient Safety Office is a key milestone in providing sustainable leadership for patient safety policy and innovation. This Office will focus on patient safety legislation; the establishment of a national patient advocacy service; introduction of a patient safety surveillance system; extending the clinical effectiveness agenda; a national patient experience survey ; and the setting up a National Advisory Council for Patient Safety.
Within the programme of legislation, we intend to progress the licensing of our public and private hospitals, the Health Information and Patient Safety Bill and provisions for Open Disclosure.
Another key marker for a health service is how we listen to patients in order to continuously improve our health system. Later this morning you will hear more about how my Department, HIQA and the HSE have joined forces and are working towards the launch of the national patient experience survey in 2017. For the first time, we will get a broad input from patients themselves to inform planning and delivery of a better health service.
This builds on our commitment to moving towards a system that is less closed and more open and transparent. Disclosure and reporting are opportunities to learn, to improve, to address errors that have happened and to apply the lessons to make the service safer for the next patient and the patient after that.
The open disclosure provisions that we are progressing in the Civil Liability (Amendment) Bill form part of a number of initiatives to improve the management of patient safety incidents.
HIQA and the Mental Health Commission are at an advanced stage of developing Standards on the Conduct of Reviews of Patient Safety Incidents which expand on the National Standards for Safer Better Healthcare. This set of standards, along with the mandatory reporting of serious reportable events provided for in the Health Information and Patient Safety Bill and the provisions intended for open disclosure, will provide a comprehensive patient-centred approach towards preventing, managing and learning from incidents in a consistent manner, and in line with best practice.
Whole Systems Approach to Patient Safety
Tackling Patient Safety will require the whole system to prioritise key initiatives, working with colleagues within and across services for the better good of the patient. I would like to acknowledge the new and enhanced commitment in the HSE Service Plan for the delivery of a coherent and planned patient safety programme across all divisions and services.
Earlier this week HIQA published its report on progress at the Midland Regional Hospital, Portlaoise. It is clear that the maternity services in Portlaoise have come a long way. We can see that implementation of standards and guidelines such as early warning systems, clinical audit, reporting of adverse events, and publication of safety statements can be implemented successfully and verifiably.
In addition, Portlaoise maternity services are reporting monthly maternity patient safety statements and are participating in national data collections including the Irish Maternity Indicator System. This has led to a confirmation by HIQA that the hospital’s maternity services are performing in line with nationally reported rates.
There are lessons here for other services. In order to create system-wide change we have to return to the basics, look at our areas of most risk and plan for scale. The introduction and adoption system-wide of National Clinical Effectiveness Guidelines has the potential to save many lives.
Some of our patient safety leaders, Dr John Fitzsimons and Dr David Vaughan, together with our NCHD Lead Dr Catherin Diskin, and nursing leaders are demonstrating, over the two days of this conference, how to take quality guidelines for patient safety and bring them to life in our health system. This is how we will make actual change at the patient’s bedside, where it matters.
I would like to acknowledge Professor Hilary Humphreys who has ably led the national clinical effectiveness agenda and brought it to a place where it is now at the heart of decision making for our health system. As he steps down as the National Clinical Effectiveness Committee Chair, I also welcome Dr Karen Ryan who is the clinical lead for palliative care and will I am sure continue to further develop the work and influence of the national clinical effectiveness agenda.
Patient Safety Surveillance
A significant challenge for our system is to gather and use the information available to enable us to measure and track patient safety, to allow us to identify the areas in which we have made progress and most importantly, to identify the areas where further attention is required.
As part of the new National Patient Safety Office, a National Patient Safety Surveillance System will be established in 2017. This will produce patient safety profiles by bringing together data from various health information resources, and the intelligence gathered will inform the setting of priorities for the HSE and the monitoring of implementation of such priorities.
Similarly, such intelligence will be used by my Department to inform the agreement of priorities with regulators such as HIQA, the Medical Council, CORU and the Nursing and Midwifery Board of Ireland.
An example of such information is the maternity patient safety statements which have now been introduced in all 19 maternity units. The next phase is to introduce a patient safety statement across all acute hospitals.
These statements which will report monthly on key patient safety trends, like complaints, infection rates and falls, will be published monthly by hospitals and will be the basis for on-going patient safety improvement programmes.
Robust clinical audit at a national level provides further opportunities to examine our practice for quality improvement. Supports for professionals undertaking clinical audit are included in the forthcoming Health Information and Patient Safety Bill that is currently with the legal drafters.
To support this legislation and to create national standards for conducting clinical audit the NCEC has developed a clinical audit quality assurance framework. Later today, the Chief Medical Officer will introduce the first NCEC quality assured national clinical audit, the trauma audit
In time, we can look forward to the Irish health system having a set of prioritised and quality-assured NCEC national clinical audits in place. This ensures that we are developing a health system that will be more evidence-based, with clear clinical leadership, moving forward our agenda for a patient-centred service.
My Department will also continue to build the National Healthcare Quality Reporting System. This report makes clear that many areas of our health services are performing well. Immunisation rates have improved and cancer screening rates continue to improve. We continue to see a downward trend for hospitalisation for heart failure and for diabetes. It also shows that survival rates for breast and colorectal cancer are improving. A further positive is the continuing downward trend of the last decade in deaths following admission to hospital with a heart attack or a stroke.
This analysis also identifies areas where further room for improvement exists. In particular, considerable variation can be seen between counties in rates of hospitalisation for common chronic diseases such as chronic obstructive pulmonary disease, asthma, diabetes and heart failure. Identifying this variation is a first step to addressing the reasons why this variation exists and to improving it.
Evidence-based Decision Making
Ensuring safe, high quality care services requires all of us, including the Department, to consider the most appropriate evidence-based decision making processes for policy and practice that can promote the achievement of best possible health outcomes for a given level of investment.
The National Clinical Effectiveness Committee has worked in partnership with the HRB to on the best ways of meeting this requirement and, today, we are announcing a collaborative hub, the HRB Collaboration in Ireland for Clinical Effectiveness Reviews, to support the work of the NCEC. I am pleased to hear that Dr Graham Love will introduce Dr Mairin Ryan as the new Director of the Hub this morning.
An example of good work supported by the HRB was the publication earlier this year of the Irish National Adverse Event Study and I understand there will be a presentation later today on this research. The National Patient Safety Office will work with the Health Research Board to build our baseline patient safety information and in parallel develop and implement effective new methodologies to address patient safety challenges as healthcare evolves.
The ambitious programme I have outlined to you this morning is intended to provide the leadership and continuity to drive patient safety actions in our health service into the future. Above all, these initiatives are for our patients and the wider public – to improve their experiences of the healthcare service, reduce harm and where possible save lives.
I will appoint a National Advisory Council for Patient Safety in 2017 to guide this work. This Council will have an independent chair, significant representation from healthcare leaders and from patients. I see this Council as providing advice and guidance to inform the policy direction for my Department’s new National Patient Safety Office in its delivery of three core functions; patient safety surveillance; patient advocacy; and building further the work of the National Clinical Effectiveness Committee.
Nationally, I expect that the HSE will place particular emphasis on patient safety. Sometimes, in the midst of much review and criticism, we can forget that we get a lot of things right. At the heart of patient safety is the professionalism of the staff who operate our health services – that is you – the frontline health professionals, managers and leaders of services. Your presence here today in great numbers confirms your commitment to your patients and your role as leaders for the patient safety agenda.
This Conference is a showcase for the ongoing work taking place at local and national level on improving patient safety. We need to take pride in what we are achieving, commit to continuous improvement and learn from each other and that is what this event is all about.
Thank You for being here.