Documentation obtained through Freedom of Information law shows the challenges in improving quality and patient safety in a large tertiary hospital. Paul Mulholland reports
Quality and patient safety (QPS) has become an increasingly prominent issue in healthcare in recent years.
While expectations around standards of care continue to grow, efforts to strengthen quality and safety are often constrained by staffing pressures, capacity limits, and financial challenges across health systems.
In Ireland, many voluntary hospitals have reported significant recurring deficits, underlining the difficulty of delivering sustained improvement in this context.
An external review obtained by the Medical Independent (MI) under Freedom of Information law provides insight into how these pressures have shaped the Mater Misericordiae University Hospital’s (MMUH) approach to QPS, and the challenges involved in translating ambition into practice.
An executive QPS committee was established several years ago to strengthen oversight and deliver improvements in this area.
The development of a comprehensive QPS programme for the hospital was one of the 15 objectives listed in MMUH’s Strategic Plan 2022–2025. As part of achieving this aim, MMUH commissioned an independent review of its QPS governance in 2023.
A spokesperson for the hospital told MI the review was procured to ensure compliance with good governance practices.
The spokesperson said one motivating factor for the focus on QPS was the Covid-19 pandemic.
“In the period following the Covid-19 pandemic the delivery of healthcare underwent significant change,” according to the spokesperson. “In response, the Mater Hospital decided to pause and carefully assess how these changes impacted its approach to quality and patient safety.”
The review, which was carried out by Deloitte, was intended to help understand how the hospital managed QPS issues and identify any potential structural gaps that may have emerged during “this challenging period”.
The review commenced in July 2023 and concluded in mid-2024, with its findings subsequently considered by hospital management and the board.
Structure and governance
The review examined the hospital’s governance structures for the area. It noted the QPS committee had already been established to provide assurance to the MMUH board that the hospital delivered high standards of care and maintained appropriate governance structures and controls.
At an executive level, the hospital also had a QPS directorate, represented by the Director of Quality Assurance and Organisational Design.
The review found it maintained regular communication with key executive groups, including the medical executive, the serious incident management team (SIMT), and the clinical directorate leads forum through the Clinical Lead for QPS.
According to the report, the executive quality and patient safety steering group (EQPS), chaired by the CEO and comprising senior leaders such as the Chief Operations Officer, Director of Nursing, Executive Clinical Director, and the Clinical Director for QPS, played a central role in supporting the CEO in securing assurance on the effectiveness of the QPS model.
The SIMT fulfilled a critical clinical function within this framework, it stated.
Ten multidisciplinary QPS sub-committees reported to the EQPS steering group and appeared to be “well balanced” in their composition.
However, the report noted that there was “variance in the efficiency and effectiveness of meetings” held by the sub-committees.
They were “often largely dependent on the experience and connections of the Chair to drive the quality of the conversation and action-orientated output, and the availability of administrative support to circulate pre-reading materials, record and circulate minutes and follow up on actions”.
There was a “varied and inconsistent” approach to reviewing and signing off on policies and procedures within committees.
“Meetings may divert from the pre-defined agenda, run over time or be cancelled at short notice on occasion,” according to the review.
“Committees are not subject to review, either self-review or by an independent reviewer.”
It noted MMUH had no active patient representative on any QPS-orientated committee given the sensitive nature of the discussions during these meetings.
“The Mater may consider periodically inviting a patient representative to speak about a particular experience or event and test the acceptability of their current approach in the future,” stated the review.
“This individual would not be [a] formal recurring member. This will be considered as part of the design of the future model and new ways of working.”
Reactive
A key finding of the review was the “reactive nature” of the hospital’s QPS directorate.
“[F]orward planning and strategy development does not appear to receive the level of prioritisation that QPS directorate representatives might wish to take place,” according to the review. “There is no clear evidence of a recurring cycle of QPS operational planning being undertaken.”
The review found it was acknowledged that a commitment to this type of activity was beyond the capacity of the existing team given the breadth of its current remit.
“This represents a constraint to delivering on the strategic ambition for the QPS directorate as outlined in the strategic plan.”
The review also found that the approach to QPS-specific strategy development and service planning was “varied across clinical directorates”.
At the time the consultation process was undertaken by Deloitte, no clinical directorate had a designated representative to support the planning and delivery of QPS commitments and responsibilities or to explicitly assist with the design and development of improvement strategies and initiatives.
There is no clear evidence of a recurring cycle of QPS operational planning being undertaken
Capacity and skillset
According to Deloitte, the core QPS team at MMUH was widely respected for its organisational knowledge and specialist expertise across all areas of quality and patient safety.
The Clinical Lead for QPS, the QPS Manager, and the Risk Manager sat on most QPS-related committees.
“This investment of time and resources provides a strong asset to the organisation from a QPS viewpoint.”
However, the review found the level of involvement placed significant pressure on these roles, which needed to be balanced with their day-to-day responsibilities.
The review highlighted several capacity gaps.
There was no dedicated analytics support to interpret the substantial volume of QPS data or to provide meaningful, data-driven insights for reports to the board, executive steering group, or sub-committees.
The QPS team also lacked technical support for configuring Datix – the hospital’s recently acquired incident reporting and risk management system.
MMUH’s current systems and business intelligence capability were often cited as a “source of frustration” among staff during the review process.
Deloitte found the procurement of and roll-out of Datix offered the basis to significantly overhaul and expand the business intelligence capability of the QPS function.
This could also have a positive impact on associated workflows and business processes, across QPS specifics such as risk management, incident management, complaints and claims, for example.
“The approach by the QPS directorate to designing and delivering custom modules is recognised as a significant undertaking,” according to the review.
“The overall pace of Datix implementation and the change management approach to support implementation was noted as a concern by senior leaders. A dedicated resource is required as a matter of urgency to support the implementation of the tool and increase its utilisation to derive the full value on offer for the hospital.”
When the review was conducted, the time commitment associated with individual training – which often took the form of one-on-one sessions in areas such as risk management and the appropriate use of a risk register – was high.
Also, patient liaison services operated largely in a reactive mode, focused primarily on managing complaints.
In addition, the QPS directorate did not have the capacity to drive a sustained quality improvement agenda, nor the tools or methodologies needed to build quality improvement (QI) capability across the workforce.
The directorate functioned with ‘lean’ resources, relying heavily on team members to cover for colleagues during leave or absence.
Succession planning was limited or absent, and key positions – such as the clinical director – lacked formal processes for handover or shadowing.
“This presents risk to the Mater and may be damaging to staff retention, continuity and knowledge retention, and development objectives,” according to the review.
Responsibilities and accountability
Deloitte found that key roles and responsibilities within the QPS directorate were clearly defined.
However, the day-to-day operational demands and the reactive nature of the directorate meant that some responsibilities were deprioritised.
The review stated the directorate took a “hands-on” approach to service delivery. For example, the Risk Manager and QPS Manager were heavily involved in one-to-one training, provided early guidance on incident responses, and managed update reports for the EQPS and the board.
While thorough, this approach was time-intensive and, according to the report, may not be the most efficient use of senior QPS leadership time.
Each QPS sub-committee had terms of reference outlining its purpose, membership, chair, and reporting lines.
Although the review stated some duplication existed, this was not thought to be pervasive or problematic.
However, there was a lack of complete clarity among senior leadership regarding the specific function of the board’s QPS committee, which Deloitte said needed to be addressed.
Clinical Directorate Leads met bimonthly at a dedicated operations meeting, but due to the variable agendas, QPS matters were not consistently discussed.
These leads also met separately with the CEO to review key issues, risks, and priorities within their directorates.
“However, it was noted that this siloed arrangement does not allow for the cross-pollination of ideas or co-creation of solutions to common issues experienced amongst directorates,” according to the review.
“It is acknowledged, however, that the EQPS steering group does provide a focus on a pan-hospital viewpoint.”
Another observation from the consultation process was the inconsistent approach taken by the clinical directorates in relation to QPS activities.
“Clinical directorates would benefit from enhanced structure and standardisation regarding QPS responsibilities.”
Processes
The creation of QPS policies generally fell within the remit of the QPS directorate. However, once developed, policies were not always consistently distributed, and their interpretation could vary across services. At a hospital level, the use of Q-Pulse – the hospital’s electronic system for managing policies, procedures, and compliance documentation – was inconsistent. It was unclear whether a standardised review cycle existed or was adhered to, the review found.
Approaches to risk management also varied across specialties, departments, and clinical directorates, highlighting the need for a more standardised process across the hospital.
Each risk register was at a different stage of maturity, with some long-established and others more recent. The risk manager provided hands-on oversight, monitoring the registers closely and frequently challenging or reassigning risk ratings where appropriate.
Education and training on the fundamentals of risk reporting were being delivered alongside the Datix implementation, in the form of one-to-one, hour-long sessions for each Operations Manager within their clinical directorate or department. While thorough, the report stated this reliance on individual sessions was neither a sustainable way to meet internal requirements nor an efficient use of senior QPS expertise.
In the consultation process, “[a]n element of frustration was raised regarding the lack of communications to ‘close the loop’ following a SIMT review.”
“Equally, the inconsistent manner to which recommendations and remedial measures are implemented post-review represents a potential area of focus within a future updated QPS model for MMUH,” according to Deloitte.
“Additional rigour is required to ensure the recommendations and review findings are widely communicated and that the accompanying implementation plan is executed in full per agreed timeframes.”
Further work was also required to formalise the various forms of clinical audit which were underway across the hospital, and for all proposals to come before the clinical audit effectiveness committee for consideration and/or approval.
“The approach to clinical audit should follow the seven stages of clinical audit whenever possible/appropriate,” according to the review.
Deloitte found that the “initial positioning” and subsequent escalation of QPS issues and concerns were “not sufficiently clear”.
“Staff most often directly escalate risks in the first instance to one of a number of potential points – for example, directly with the QPS directorate or the Nursing Quality and Patient Safety Lead. This practice is indicative of a system that is not sufficiently mature across directorates.”
Pan-hospital relationships
Deloitte said that “significant potential exists to further leverage and ‘formalise’ forms of collaboration with other MMUH structures and teams relevant to the QPS agenda”.
The hospital’s Transformation Office was commonly cited as a strategic asset and a driver of transformational change within the hospital.
“It would be beneficial to both parties, the QPS directorate and the Office, to consider future ways of working to optimise future involvement and shared ways of working,” according to the review.
Given their shared purpose, Deloitte recommended that the nursing quality and patient safety team and the QPS directorate should explore opportunities to collaborate more strategically and deliver shared objectives in a planned manner.
It said all QPS-focused fora should adopt a more structured approach to communication, guided by principles of closed-loop communication, and carefully consider the methods used to engage staff to ensure messages are clearly and effectively conveyed.
Development and training
Individual directorates and services had established their own curricula and induction materials covering elements of QPS to support patient safety education. For example, the pharmacy and medication optimisation (PAMO) directorate had developed specialised training on viral vector handling for all staff within PAMO.
While such local initiatives were valuable, according to the review, it was important as the hospital grows that the QPS directorate is actively involved in these developments to ensure consistency in QPS standards across the organisation.
At the time of the review, the use of the new learning management system (LMS) ‘Mater Learn’ was limited in terms of QPS.
However, the system did “present significant potential to support and promote access to QPS learning”.
“Opportunities to expand beyond compulsory modules should be explored and planned for in the future.”
It was noted that the LMS was not sufficient nor appropriate for the end-to-end delivery of all training and some QPS programmes would always be supplemented with toolkits and methodologies and other supports.
“Resource considerations around this will need to be appropriately factored into the future design of the QPS directorate,” according to the review.
Overall, QPS education was managed within the newly established learning & development (L&D) function.
While the QPS Manager and Risk Manager collaborated with the L&D team to develop QPS module content, competing day-to-day operational demands meant this work was not always prioritised.
“Training in terms of quality improvement methodologies and toolkits requires planning and delivery if the ambition to enhance a hospital-wide focus on QI is to be realised,” according to the review.
Culture
Deloitte said the importance of quality and a strong patient safety culture was evident from all consultations conducted during the review process.
“Stakeholders spoke with pride regarding the high-quality clinical care provided to patients,” it stated.
While the review process did not entail a specific culture audit, discussions conducted consistently gave a strong sense of the values and practices that support the positioning of and commitment to high quality and safe care.
The review found “quality and [the] patient experience” were centrally positioned in terms of the stated strategic priorities of the hospital.
“However, the patient’s voice is notably absent at committee level within the hospital and there is no evidence of engagement with a patient council or equivalent in the design and development of services or programmes within the organisation,” according to the review.
“This is an input to the QPS agenda that remains significantly underdeveloped relative to local and international peers.”
Deloitte recommended that consideration should be given to the best approach to capturing the patient’s voice and how this can be disseminated throughout the system and be reflected in the operation of MMUH.
The commitment of the hospital to establish people, culture and organisational development programmes was also acknowledged.
“It will be important that QPS is appropriately represented within these and that future initiatives are constructed with targeted QPS gains at the core.”
Stakeholders spoke with pride regarding the high-quality clinical care provided to patients
Recommendations
The review was completed in 2024. The final report outlined 48 recommendations centred around: Structures and processes; resourcing; education and training; and clinical governance.
Some nine of these were deemed ‘high priority’. These included the need to ensure “that the future design of the QPS directorate considers all aspects of the existing role and remit with the objective to reassign responsibilities (and the associated resources) if such are not deemed core to the QPS objectives of the Mater”.
Another high priority recommendation was that the future QPS model at MMUH should consider incorporating additional capacity to the directorate, such as a dedicated lead for QPS improvement, and additional “time-capped” support to accelerate the implementation of Datix.
The introduction of a standard approach across clinical directorates to ensure that QPS “is suitably prioritised” was another issue of high priority, as was revising clinical audit procedures.
The review also said work was required to drive a more standardised approach to risk management procedures/processes across the hospital ecosystem.
In addition to other high priority recommendations, the review recommended the development of an overall QPS strategy.
Board discussion
QPS and the Deloitte review were regularly discussed by the hospital’s board. In addition to the external review, MMUH’s internal audit committee was undertaking work in the area, which was also discussed.
At its meeting in July 2024, it was confirmed that the Deloitte review would be presented and summarised to the board in September.
MMUH CEO Ms Josephine Ryan Leacy told board members that two WTEs had been appointed to assist with the project.
The then Chair Mr David Begg said that “this has to be progressed as much as possible”.
Non-Executive Director Ms Anne Vaughan confirmed that MMUH “wants to be a leader in QPS”.
“It was noted that it is a challenge with current resources, but putting two positions in place is important,” according to the minutes.
“The board noted that the senior responsible officer has to be identified to drive the priority recommendations.”
Ms Vaughan said that MMUH was expanding “at a significant rate” and “given the level of services and the increase in the patient cohort there are significant challenges”.
As a result of growing levels of activity, Executive Clinical Director Prof Jim Egan said that MMUH had “ongoing challenges with surges”.
In September 2024, Director of Quality Assurance and Organisational Design Ms Suzanne Dempsey provided an update on the Deloitte report.
“There were a number of recommendations which are now being assessed in terms of available resources,” according to the minutes.
The board noted that this was an important strategic investment that MMUH has to resource given how important it is for patient care.
“It was noted that the board wants to see momentum and progress in this area.”
At the December 2024 meeting, Ms Ryan Leacy and Ms Dempsey agreed to “drive and progress” the recommendations from the external QPS review, as well as those contained in a relevant internal audit report.
Director of Finance Ms Brid Cosgrove explained that assurance mapping was “a very important exercise so that the board understands what the risks are and where they are coming from”.
The new “comprehensive” QPS strategy was discussed. Ms Dempsey sought approval for the document.
“The board confirmed that the strategy is approved subject to the understanding that no additional resources are available… noting that MMUH has to use the resources available to drive this strategy forward,” according to the minutes.
Implementation
A spokesperson for the hospital confirmed to MI the QPS strategy was completed and launched in 2024.
“It outlines the hospital’s vision and ambition for the next five years, with the goal of becoming a global leader in patient safety,” according to the spokesperson.
Since the strategy was developed, the spokesperson said that progress has been made across several areas in implementing the Deloitte report’s recommendations.
Two roles, an Operational Manager and a Quality Improvement Lead within the QPS directorate, were recommended in the review. However, due to restrictions on recruitment in the HSE’s Pay and Numbers Strategy, no funding was available to fill these roles, MI was told.
“In response, an Executive Lead was reassigned to support the QPS directorate, reflecting the hospital’s renewed focus on enhancing quality and patient safety,” according to the spokesperson.
The QPS directorate is led by a consultant clinician whose role is split evenly between clinical practice and QPS leadership (0.5 WTEs each).
“This represents an increase from the previous allocation of 0.25 WTE to the QPS Clinical Director role and aligns with the resourcing model used for other clinical director roles within the hospital,” said the spokesperson.
Of the recommendations identified as high priority, three have been completed and a further three are currently in progress.
Completed recommendations include the introduction of a standardised approach across clinical directorates to ensure that QPS is suitably prioritised within existing leadership discussions; enhancements to board-level QPS committee oversight; and the universal use of a centralised repository for QPS documentation to streamline policy deployment, governance, review and sign-off processes.
A new performance meeting, chaired by the CEO and involving each hospital directorate, has also been established to strengthen clinical accountability for QPS. This forum focuses on quality metrics, risk management, clinical audit, and shared learning from incidents.
In addition, funding has been secured to connect HSeLanD – the Executive’s online learning and development platform – with MMUH’s own system to enable improved reporting and oversight of completed staff education programmes.
The QPS directorate has also been building links with the HSE Dublin and North East Health Region, holding a series of meetings with quality and patient safety leads for the region.
“The Mater Hospital continually strives to improve its services to patients and work to implement the remaining QPS recommendations is ongoing, through established governance and management structures,” according to the spokesperson.
The spokesperson also pointed out a quality and patient safety showcase is currently being planned for April 2026.
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