Only 42% of HSE serious incident reviews completed on time

Less than half of HSE reviews of the most serious patient safety 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 of the date the service becomes aware of the incident.

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.

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: “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.”

A St James’s Hospital spokesperson said that while it 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.” The spokesperson added that the hospital has raised the matter directly with HSE Dublin and Midlands.

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).

A HSE spokesperson 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.

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

Earlier this year, HSE Chief Clinical Officer Dr Colm Henry told the Executive’s performance committee that the KPI “is based on timeliness, which does not capture the quality of the reports”.

The HSE is currently updating its Incident Management Framework (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.