Improving the review of serious incidents

Recent figures have highlighted the difficulty experienced across the health service in completing category 1 incident reviews on time. Paul Mulholland reports

When reviewing adverse incidents that occur within the health service, HSE, and HSE-funded services apply the Incident Management Framework (IMF) 2020. The framework provides guidance on the reporting, management, and review of incidents. A ‘category 1’ incident is described as clinical and non-clinical incidents rated as ‘major’ or ‘extreme’ on the HSE’s risk management table. Such incidents generally involve cases where severe harm or death is reported.

Less than half of HSE reviews of these incidents are being completed within the Executive’s 125-day key performance indicator (KPI) timeframe, according to recent figures.

The KPI was designed to measure if a review is completed within 125 days from when the service becomes aware of the incident. The end date is measured as the date when the commissioner accepts the review report.

The HSE Management Data Report for April shows that, nationally, just 42.2 per cent of category 1 incident reviews were completed within the timeframe.

The HSE target is for 70 per cent of these reviews to be completed within this period.

Breakdown

The report shows that performance varied significantly between hospitals, with several sites recording zero per cent against the KPI.

These included: The Mater Misericordiae University Hospital, Dublin; St James’s Hospital, Dublin; Beaumont Hospital, Dublin; University Hospital Waterford; Wexford General Hospital; and Galway University Hospitals.

In a reply to the Medical Independent (MI), a spokesperson for the Mater Hospital said that approximately 9,000 incidents in all categories are reported each year at the site.

“While we strive to meet the 125-day target for category 1 reviews, current demands on our staff have impacted the availability of key personnel required for committee investigation participation,” according to the spokesperson.

A spokesperson for St James’s Hospital told MI that while the hospital endeavours to complete all reviews in a timely manner, the quality of the review is prioritised over time-based targets, “which can lead to delays.”

“St James’s Hospital has raised this matter directly with the Dublin and Midlands Health Region and the hospital understands that the HSE Quality and Patient Safety Directorate are to review current targets in the updating of the national incident management framework.”

The HSE report also states that a number of community services reported zero per cent against the KPI, as well as National Social Care (Section 38). The National Ambulance Service recorded 50 per cent against the KPI.

In the acute sector, other sites recording low percentages against the KPI included Cork University Hospital (12.5 per cent); University Hospital Limerick (20 per cent); Cavan General Hospital (20 per cent); St Luke’s General Hospital, Kilkenny (20 per cent); Tallaght University Hospital, Dublin (28.6 per cent); and Our Lady of Lourdes Hospital, Drogheda (45.5 per cent).

However, a small number of hospitals exceeded the HSE target.

These included the National Maternity Hospital, Dublin (100 per cent); the Rotunda Hospital, Dublin (96.9 per cent); the Coombe Women and Infants University Hospital, Dublin (88.9 per cent); and St Vincent’s University Hospital, Dublin (84.2 per cent).

The report does not disclose the number of category 1 incidents or reviews at each site, or service, only the percentage against the KPI.

Challenges

A spokesperson for the HSE told MI that feedback from services highlighted a number of recurring difficulties in completing reviews within the target timeframe.

Common themes included competing operational priorities and challenges in securing appropriately trained reviewers within required timeframes and the complexity of coordinating multiple stakeholders, including review teams, subject matter experts, and affected individuals.

“Many reviews relate to serious and complex incidents that can involve multiple services or organisations and may require additional specialist input, factual accuracy checks, or parallel external processes,” according to the HSE.

Feedback also emphasised that reviews were progressing and that delays were not due to a failure to initiate reviews. “There was a consistent focus on ensuring reviews were thorough, meaningful, and supported robust learning and quality improvement outcomes,” according to the spokesperson.

“Services also highlighted the importance of engaging patients, families, and relevant persons appropriately throughout the review process, recognising that this can require additional time, but is essential to delivering high-quality reviews and enhancing safety.”

Another issue is that a number of hospitals do not have health and safety officers. As a result, some hospitals need to share health and safety resources.

Against a backdrop of a “difficult recruitment space internationally for health and safety officers”, the spokesperson said the HSE’s National Health and Safety Function (NHSF) ensures that any hospital without a current officer has access to resources. These include the NHSF national helpdesk, and ‘safety clinics’, which are facilitated by a health and safety professional.

“There is now a nationally agreed job specification for the health and safety officer role and recruitment is ongoing across the regions,” the spokesperson added.

MI recently reported on how the “wide variation” in meeting targets in relation to serious incident reporting was discussed by a HSE committee earlier this year.

According to minutes of the HSE performance committee meeting in January, Chief Clinical Officer Dr Colm Henry said the reason for this variation was because the KPI “is based on timeliness, which does not capture the quality of the reports”.

The HSE spokesperson said it is actively implementing a range of measures to improve both the timeliness and quality of serious incident reviews. These measures include strengthening quality and patient safety structures, increasing capacity and expertise, enhancing oversight and monitoring arrangements, improving data quality, and expanding reporting mechanisms.

“This enhanced reporting focuses not only on performance against the 125-day target, but also on progress throughout each stage of the review process to identify opportunities for targeted improvement,” according to the spokesperson.

“The HSE is also supporting access to specialist clinical and subject matter expertise where required.”

“While we strive to meet the 125-day target for category 1 reviews, current demands on our staff have impacted the availability of key personnel required…”

Revised framework

A central element of this work is a revision of the IMF. The KPI timeframe is under review as part of the overall IMF revision.

According to the spokesperson, the revised framework will place “a much stronger emphasis on the meaningful involvement of those affected by incidents” and, in line with international best practice, supports a “proportionate approach” to incident management.

The revised framework, which was informed by consultation and engagement with stakeholders, will also propose a strengthened workforce model. The model is intended to support consistency and expertise in the review process and to enhance capacity for review activity, alongside increased opportunities for training, professional development, and dedicated time for review-related work.

The HSE hopes that these measures will deliver “significant improvements in the timeliness, consistency, and quality of incident reviews”.

In parallel, training, development, and support programmes for lead incident reviewers and other staff involved in incident management “will continue to be enhanced”.

“Looking ahead, the vision is to leverage digital technologies to provide staff with easier access to relevant information and more streamlined review processes,” stated the spokesperson.

“In addition, the move towards a more integrated healthcare system will support a more integrated approach to incident management, ultimately improving the experience for patients and their families, while strengthening organisational learning and patient safety outcomes.”