NMH

NMH | 2024 169 Quality & Safety Services provider is satisfied that a notifiable incident has occurred in the course of the provision of health services via the National Incident Management System. • Appointment of a designated person. • Open Disclosure Meeting. • Written statement/record of the open disclosure meeting to be provided at the meeting or within 5 calendar days of the meeting. • Record keeping throughout all stages of the process. Legal protections apply automatically when open disclosure is managed in accordance with the legislation. The QRPS Department fosters a strong culture of incident reporting by all staff. They are encouraged to report in a safe environment without fear of blame. The SCA has commended the Hospital for its high level of reporting, achieving a Grade A target. The Hospital is also engaged with the SCA for its claims review process. The QRPS Department works closely with the Hospital's Claims Coordinator, Nicole Kennedy, who liaises with the SCA and follows each clinical claim from notification to resolution. There are currently 81 active claims. In 2024, 19 claims were resolved and 15 new claims notified. Risk Registers In line with the HSE Enterprise Risk Management Policy the hospital risk registers are regularly reviewed. Each department creates its own register and updates it as appropriate. Ownership remains with the head of each department. Where necessary, the more significant risks are escalated to the hospital corporate risk register. The operational risk registers are divided into clinical and nonclinical. A thorough review of the clinical risk register was undertaken throughout the year by Kim Ryan. Beginning in January 2024 the register contained 512 clinical risks. This has now been rationalised to 144 active risks with 35 yet to be reviewed. Martin Creagh has commenced work on the non-clinical register (345 risks) and hopes to rationalise this over the next year. Risk register reporting occurs to the Clinical Governance Executive Committee, Executive Management Team and various committees of The NMH Board. Quality The Quality team is responsible for many different work streams which include: • Patient liaison (Advocacy, Complaints, Meetings, Patient Surveys both local and national) • Quality Improvement Projects • Quality and Safety Walk Rounds • Q Pulse Administration and Support • Audits (Internal and External e.g. HIQA) They engage with our community partners and coordinate the GP liaison committee and the Patient Voice Advisory Group. They also convened the Annual NMH GP Study Day held in November 2024. Patient feedback is essential for us to improve our quality of care. The hospital continues to receive significant positive feedback with a continuing Net Promoter Score (NPS) of 78. The NPS measures patient satisfaction. The hospital goal is to achieve >/= 40. A score of >/= 70 is graded excellent. Negative feedback is responded to, preventing recurrence. Close liaison with complainants is a vital part of the process. While 2024 showed some increase in both written complaints and review requests, the Department had 99% compliance in dealing with complaints in the designated timeframe, see Table 1. The quality team work hard to resolve as many of these as expeditiously as possible. The assistance of colleagues across the Hospital, by listening and responding to such patient feedback is essential and appreciated. 2023 2024 Complaints received 93 135 Written Complaints* Stage 2 Stage 1 73 20 114 21 General Feedback 22 18 Information Requests 11 14 Debriefs 9 9 Complaints closed % closed within 30 days 97% 99% Complaints locally resolved at Unit/ Department/Service level 43 33 Patient Meetings held 15 19 Requests to IEHG for further review incl. Stage 3 Internal Review (since Oct 2024) 5 8 Requests to Ombudsman for further review 2 0 Table 1: Patient Feedback 2023-2024 * Stage 2 complaints are formally investigated and the patient is provided with a written response. Stage 1 complaints are resolved at the point of contact with the QRPS Department.

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