4th National PATIENT P R

4th National
PATIENT SAFETY CONFERENCE
Croke Park Conference Centre
Friday, 7th November 2014
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8.30 – 9.15
REGISTRATION (tea/coffee)
9.15 – 9.25
Welcome Address
Dr Tony Holohan, Chief Medical Officer.
M
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SESSION 2
11.20 – 12.30
Good practise presentations
BREAK-OUT SESSION A (Main Auditorium)
Chair: Ms Triona Fortune, Deputy CEO, International Society for Quality in Health Care.
9.25 – 9.40
Opening Address
Mr Leo Varadkar, TD, Minister for Health.
Presentation 1
Methotrexate: A novel approach to safer use of a toxic medication.
Presenter: Dr Paul Ryan, Woodview Family Doctors, Glanmire, Cork.
SESSION 1
Plenary Chair:
Mr Phelim Quinn, Acting Chief Executive, HIQA.
9.40 – 10.10
Inspecting for improvement? Lessons from
evaluating the Care Quality Commission’s
new approach to acute hospitals.
Prof. Kieran Walshe, Prof. of Health Policy &
Management, Manchester Business School.
10.10 – 10.40
Being an agent for positive change in a time
of limited resources.
Dr Helen Bevan, Chief of Service
Transformation at the NHS Institute for
Innovation and Improvement.
10.40 – 10.50
Question and Answer Session
10.50 – 11.20
TEA/COFFEE (poster viewing)
Presentation 2
Mater Board on Board Quality Improvement Project.
Presenter: Prof. Mary Day, Mater Misericordiae University Hospital.
Presentation 3
Implementation of Care Bundles hospital-wide in Our Lady’s Children’s Hospital,
Crumlin – Not without its challenges!!!
Presenters: Ms Paula McGrath and Ms Tracey Wall, Our Lady’s Children’s Hospital, Crumlin.
Presentation 4
The development of an integrated quality and patient safety framework
to support a multi-sited hospital group.
Presenter: Mr John McElhinney, Group Quality and Safety Manager, WNW Hospitals
Group, Sligo Regional Hospital.
BREAK-OUT SESSION B (Ard Chomhairle Suite)
Chair: Dr John Fitzsimons, Clinical Director, Quality Improvement, Quality and
Patient Safety Division, HSE.
Presentation 5
PharmAceutical Care at Tallaght Hospital (PACT).
Presenter: Dr Tamasine Grimes, on behalf of the PACT Team, Tallaght Hospital and
Trinity College, Dublin.
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Presentation 6
Quality improvement in elective joint replacement surgery.
Presenter: Dr Louise Moran, Letterkenny General Hospital.
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12.30 – 13.30
LUNCH (poster viewing)
SESSION 3
Presentation7
Safety pause in action: A quality initiative.
Presenters: Ms Gillian Mullervy, CNMI and Ms Mary Traynor CNM2, Our Lady’s
Children’s Hospital, Crumlin.
Presentation 8
Improving the quality and safety of care for patients transferred by ambulance
to Emergency Departments.
Presenter: Ms Fiona Brady, CNM3, Emergency Department, Connolly Hospital.
BREAK-OUT SESSION C (Interconnecting Suite)
Chair: Ms Rosemary Smyth, Director of Training & Development, Mental Health
Commission.
Presentation 9
From pen to patient: Improving prescription-writing practise in a
psychiatric teaching hospital.
Presenter: Ms Dolores Keating, St John of God Hospital.
Plenary Chair:
Dr Philip Crowley, National Director of
Quality and Patient Safety, HSE.
13.30 – 14.30
National Issues
 The patient perspective (Ms Ann
Bridge).
 Open disclosure (Ms Angela Tysall,
National Lead for Open Disclosure, HSE
and Dr John Tiernan, Executive Director,
Member Engagement Division, Medical
Protection Society).
 National Clinical Effectiveness
Committee (Dr Kathleen MacLellan,
Department of Health).
Presentation 10
Implementation of a patient-centred clinician-led National Quality Assurance (QA)
Programme in Histopathology to enhance patient care and safety.
Presenter: Dr Niall Swan, Chair of the Histopathology QA Programme Working Group.
14.30 – 14.50
What does ‘care’ mean in and for health
care? Addressing the compassion and
safety deficit.
Dr Justin Brophy, Executive Clinical Director,
HSE Mental Health Services.
Presentation 11
Poor Influenza vaccine uptake in healthcare workers – an issue in need of address.
Presenter: Ms Siobhan O’Dea, Research Nurse, St James’s Hospital.
14.50 – 15.10
Complaints Driving Improvements.
Mr Peter Tyndall, Ombudsman.
Presentation 12
SKIN champions for kids.
Presenter: Ms Claire Lundy, Belfast Health & Social Care Trust (BHSCT), Northern
Ireland and Queen’s University, Belfast, Northern Ireland.
15.10 – 15.30
Panel Discussion
15.30 – 15.35
Closing Remarks
Dr Tony Holohan, Chief Medical Officer.
B
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4thHNational
PATIENT SAFETY CONFERENCE
Dr Helen Bevan has been a leader of large scale change in the English NHS for more than 20 years. She
Lledothe
c aground-breaking
l G o o d P"Business
r a c t i Process
c e O Reengineering"
r a l P r e s transformation
e n t a t i o nprogramme
s c o n t iatnThe
u e Leicester
d
Royal
Infirmary
in
the
1990s.
As
a
result,
she
was
asked
to
become
a
national
leader
of
initiatives
to
(11.20 – 12.30)
improve patient access to NHS care. She introduced the first nationwide collaborative programmes to
improve the delivery of cancer care across England in 2000. She designed the highly influential "Ten
Presentation 6
High Impact Changes for Service Improvement and Delivery" in 2004 and conceived the impactful
Methotrexate:
Astarting
novel approach
to saferWard"
use ofina2007.
toxicInmedication
"Productive Series",
with "The Productive
2010, Helen's team launched a call
Presenter:
Dr Paul
Woodview
Family
Doctors,
to action, utilising
socialRyan,
movement
leadership
principles,
whichGlanmire,
contributedCork
to a 51% reduction in
prescribing of antipsychotic drugs to people with dementia across the country. Helen initiated NHS
PChange
r e s eDay,
n t in
a tpartnership
i o n 7 with a group of young clinical and managerial leaders in 2012. NHS Change
Day 2014 was the largest ever voluntary collective action for improvement in the history of the NHS
Mater
Board
Board
Quality
Improvement
with more
than on
700,000
pledges
made
to take action toProject
improve experience and outcomes for
Presenter:
Mary
Mater
Misericordiae
Universitychallenge
Hospitalrun by Harvard
patients. NHSProf.
Change
Day Day,
also won
the global
"Leaders Everywhere"
Business Review and McKinsey. NHS Change Day and another initiative Helen conceived, The School
Pforr Health
e s e nand
t a Care
t i o Radicals,
n 8 are currently included in "Britain's 50 new radicals" list sponsored by The
Observer. Helen Bevan provides advice, guidance and training on transformational change to leaders of
Implementation of Care Bundles Hospital Wide in Our Lady’s Children’s Hospital,
health and care systems across the world. In 2008, the 60th anniversary of the National Health Service,
Crumlin
Not without
Helen was–recognised
as oneitsofchallenges!!!
the 60 most influential people in the history of the NHS.
P
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Presenters: Paula McGrath and Tracey Wall, Our Lady’s Children’s Hospital, Crumlin
Ms Ann Bridge is a member of Patients for Patient Safety Ireland, which is a World Health Organisation
P(WHO)
r e s einitiative
n t a t aimed
i o n at
9 improving patient safety in health care. Originally from England, Ann has
been living in Kerry since 1995. Ann has extensive experience of working in a variety of administrative
Improving influenza vaccine uptake in Health Care Workers in the Department of
roles in the financial services sector, IT and the hospitality industry, and is now retired. She has been
Genitourinary
Medicine
andSafety
Infectious
Diseases
(GUIDE),
involved with Patients
for Patient
since 2012
and received
WHO designation in 2013. She has
St
James’s
Hospital,
Dublin
been
very proactive
in her
work as a service user representative with Kerry General Hospital and has
been involvedTBC
in a number of initiatives, including patient surveys. Ann also presents to students in
Presenter:
Tralee IT sharing her perspective as a service user, carer and patient safety champion.
Presentation 10
Dr Justin Brophy is the appointed Consultant Psychiatrist and Clinical Director of the HSE Wicklow
The
development
ofand
an Executive
Integrated
Quality
and
Patient
FrameworkMental
Mental
Health Services,
Clinical
Director
of HSE
DublinSafety
South East/Wicklow
to
support
a
multi-sited
Hospital
Group
Health Services. He is a Fellow of The Royal College of Psychiatrists and Past President of the College of
Psychiatrists of
Ireland.
Dr Brophy isGroup
a Director
and Chairman
of the
Irish Association
Suicidology and
Presenter:
John
McElhinney,
Quality
and Safety
Manager,
WNWofHospitals
is Senior Sligo
Lecturer
in Psychiatry
at the Royal College of Surgeons of Ireland. He served on the Expert
Group,
Regional
Hospital
Advisory Group for Mental Health that drafted a Vision for Change, and currently serves on the
National Patient Safety Advisory Group.
Presentation 11
SKIN
Champions
for KidsDirector of Quality Improvement with the HSE since January 2011. Philip
Dr Philip
Crowley is National
is a doctor who
trained
in General
Practice
and&
then
worked
forTrust
five years
in Nicaragua, Central
Presenter:
Claire
Lundy,
Belfast
Health
Social
Care
(BHSCT),
America
developing
chronic
disease
care
programmes
and
working
with
grassroots
Northern Ireland and Queen’s University, Belfast, Northern Ireland community
organisations in health development. He then worked in the NHS in Newcastle upon Tyne and worked
with marginalised communities, professional groups and the health service to tackle health
Pinequalities.
r e s e n tHe
a thas
i o trained
n 1 2 in public health medicine and has worked for 6 years as Deputy Chief
Improving
the
quality
and safety
of careand
forChildren
patients
by ambulance
Medical Officer with the Department
of Health
untiltransferred
taking up his current
post. Philip
continues
to workDepartments
as a GP part-time in an inner city Dublin practice.
to
Emergency
12.30 – 13.30
LUNCH (poster viewing)
Croke Park Conference Centre
th
S E SFriday,
S I O N 37 November 2014
Plenary Chair:
Dr Philip Crowley, National Director of
Quality and Patient Safety, HSE
Dr Helen Bevan
13.30 – 14.30
National Issues Dr Helen Bevan
 The patient Perspective (Ann Bridge)
 Open Disclosure (Angela Tysall, National
Lead for Open Disclosure, HSE and Dr
John Tiernan, Executive Director,
Member Engagement Division, Medical
Protection Society)
 National Clinical Effectiveness
Committee (Dr Kathleen MacLellan,
Department of Health)
14.30 – 14.50
Ann in
Bridge
What does ‘care’Ms
mean
and for health
care? Addressing the compassion and
safety deficit
Dr Justin Brophy, Executive Clinical Director,
HSE Mental Health Services
14.50 – 15.10
Dr Justin Brophy
Panel Discussion
15.30 – 15.35
Closing Remarks
Dr Tony Holohan, Chief Medical Officer
Time:
END
Dr Philip Crowley
Presenter: Elizabeth Dillon, Emergency Department, St James’s Hospital, Dublin
Dr Tony Holohan was appointed as Chief Medical Officer in 2008. He provides expert medical and
public health advice to the Minister and the Department. He has responsibility for policy on medical
and public health matters including patient safety, quality in health care and health and wellbeing.
Dr Kathleen MacLellan is Director of Clinical Effectiveness, Department of Health. She leads the clinical
effectiveness policy function and supports the National Clinical Effectiveness Committee to promote
evidence-based healthcare through quality assured clinical effectiveness processes.
Department of Health
Dr Philip Crowley
Dr Tony Holohan
Dr Kathleen MacLellan
B
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Mr Phelim Quinn is Acting Chief Executive and Director of Regulation at the Health Information and
Quality Authority (HIQA). He was appointed Acting Chief Executive on 26 September 2014. He
joined HIQA as Director of Regulation and Chief Inspector of Social Services on 1 November 2012.
He has 30 years of experience in health and social care services in Northern Ireland, most recently in
Northern Ireland's equivalent health and social care regulatory body - the Regulation and Quality
Improvement Authority (RQIA).
Mr John Tiernan is Executive Director, Member Engagement, at the Medical Protection Society
(MPS). He also has the role of Director of Educational Services which he has held since 2007. He
qualified from Trinity College, Dublin in 1980, and worked in general dental practice before joining
MPS in 1994. He has worked as Head of Practitioner Services and subsequently Assistant Dental
Director before being appointed as Director of Educational Services for both MPS and DPL in 2007.
John was a member of the General Dental Council for 10 years– including membership of its
Education Committee, Postgraduate Education Committee and the Specialist Training Advisory
Committee. He has written and lectured extensively on the subject of communication and risk
management both in the UK and internationally.
Prof. Kieran Walshe is Professor of Health Policy and Management at Manchester Business School.
He is also associate director of the National Institute of Health Research health services and delivery
research programme, which exists to serve the research needs of managers and clinicians in the
NHS (www.netscc.ac.uk/hsdr/). He is editor of the journal Health Services Management Research
(http://hsmr.rsmjournals.com), board member of the UK Health Services Research Network and a
board member and scientific committee chair of the European Health Management Association
(www.ehma.org) . From 2003 to 2006 he directed the Centre for Public Policy and Management in
Manchester Business School, and from 2009 to 2011 he directed the University's Institute of Health
Sciences. Kieran Walshe has twenty years’ experience in health policy, health management and
health services research. He has previously worked at the University of Birmingham, the University
of California at Berkeley, and the King's Fund in London, and has a professional background in
healthcare management. He has advised a wide range of government agencies and organisations, in
the UK and internationally. He has written for a wide range of academic and professional journals.
His books include Regulating Healthcare: A Prescription for Improvement (2003); Patient Safety:
Research into Practice (2005); Healthcare Management (2006, 2011); Health Policy and
Management: A Reader (2009); and From Knowing to Doing: Connecting Knowledge and
Performance in Public Services (2010).
Department of Health
E
S
Mr Phelim Quinn
Dr Helen Bevan
Mr John Tiernan
Mr Peter Tyndall was appointed as Ombudsman on 2 December 2013. Originally from Dublin,
Peter previously served as Public Services Ombudsman for Wales. He was also Chief Executive of
the Arts Council of Wales, Head of Education and Culture for the Welsh Local Government
Association and worked in a variety of senior positions in housing and social care, most notably in
developing housing and support services for people with learning disabilities. He has an MSc in
Strategic Management from Cardiff University and is married with three daughters.
Ms Angela Tysall is Project Manager in the Office of Patient and Staff Engagement which is part of
the HSE Quality and Patient Safety Division. Her main role is that of National Lead in Open Disclosure
for the HSE. She also works as a complaints review officer for the HSE and undertakes investigations
including serious incident investigations, trust in care and dignity at work investigations. Angela has
13 years’ experience as a midwife; 2 years as a practice nurse; and 5 years as a senior sister, team
leader and acting manager of a nurse lead NHS walk-in-centre. She also has 6 years management
experience in a GP Out Of Hours service in the North West of Ireland and achieving quality assurance
accreditation for this service.
I
Mr Peter Tyndall
Ms Angela Tysall
Prof. Kieran Walshe
Dr Philip Crowley