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Quality Programme 2016


Quality improvement (QI) is the combined and unceasing efforts of everyone - healthcare professionals, patients and their families, researchers, commissioners, providers and educators - to make the changes that will lead to

● better patient outcomes

● better experience of care

● continued development and supporting of staff in delivering quality care

The development of a culture of safe and effective patient care is an evolving process and requires continuous commitment from and the involvement of all staff. The Executive Management Board (EMB) are committed to changing the focus of the quality and safety programme to bring it to the core of service delivery and have identified a number of improvements to be progressed in 2016 that will add to the measures already in place and further assist in developing a culture of safe and effective patient care.


Quality Improvement Plans (QIP’S) – National Standard for Safer Better Health Care

The Standards Implementation Team provides an important multi-professional resource that if augmented by other expertise has the potential to add value and take a leadership role in the area.

CUH have identified 48 QIP’s that will be implemented throughout the hospital during 2016. See Appendix 3 of Quality & Safety, The Change Programme 2013-2016.


2016 Service Plan

In relation to the 2016 Service Plan a number of key quality improvement actions have been identified for implementation such as;

Outpatient Quality Improvement Programme

• Implementation of the full set of Care Bundles

• Nurse Prescribing

• Theatre Productivity Programme

• Progress Endoscopy/JAG Accreditation

• Antimicrobial Stewardship Programme

• Nutrition and Hydration Programme

• Child and Adolescent Management

• Staff Training and Development

• Commissioning of new designated Paediatric Facilities. 


In the process of constructing our 2016 service plan a number of key development priorities and quality initiatives have been identified and a number of these are listed hereunder: 

Catering Service

• Audit and improve all menus in consultation with colleagues in dietetics

• Training for catering staff, including basic food nutrition, therapeutic diets, customer service, hand hygiene, food presentation, allergens, calorie posting

• Upgrade of equipment in department on a priority basis as much of the equipment is nearing the end of its life cycle

• Introduction of Allergen and Calorie Posting Policies

• Review and update all departmental policies.



Major Emergency Planning

• Submit emergency documents to the Management Team for approval in January 2016

• Circulate Severe Weather Plan in quarter one

• NCHD awareness of MEP – Distribute MEP information leaflets on induction

• Print, publish and circulate updated MEP document in the new format

• Flu plan to be circulated in quarter one

• Circulate Mass Fatalities Plan in quarter one

• Undertake monthly meetings

• Liaise with area Emergency Management Office regarding emergency planning issues

• Ongoing exercising and training for a Major Emergency.


Blood Bike South

• Meet quarterly to review and update SLA as necessary.



• Attend Consumer Affairs FOI information session on February 10th 2016

• Achieve Turnaround times to promptly address all FOI’s and Complaints logged to Services.


Smoke Free Campus

• Introduce smoke detectors and signage in areas where illicit smoking takes place

• Enhanced engagement with Line Managers in areas where non-compliance with Smoke Free Campus occurs

• Achieve BISC training targets for 2016.



• Trial mattress patches

• Replace sink splash-backs in CUMH

• Upgrade OPD Waste area

• Recover/replace chairs which are worn or damaged

• Painting schedule for CUH area as per maintenance department.


Physics Service

• Complete scientific reports for already completed project work

• Complete implementation of Head & Neck IMRT

• Upgrade computerised ECLIPSE Treatment Planning System to next software version (v13.6)

• Assist with on-going implementation of new Oncology Information System (ARIA v13.6)

• Commission new superficial therapy x-ray unit (Xstrahl 150)

• Implement MR/CT image guided brachytherapy

• Increase number of patients treated with IMRT in conjunction with other disciplines

• Develop Q-Pulse policy for training Treatment Planners

• Develop IMRT procedure for pelvic nodes.


Physiotherapy Service

• The development and roll out of an electronic referral system for inpatient referrals

• The development of a Spasticity clinic –senior in neurology gym will be working with the Consultant in Rehabilitation Medicine in setting up a clinic to reduce high tone in patients with neurological conditions

• The commencement of the minor fracture clinic in mid-February between ED /Orthopaedics in order to reduce the waiting time for patients who have be seen in theED and are waiting to be reviewed by the Orthopaedic team

• The development of an Oxygen clinic. Numerous studies have shown that many patients on home Oxygen may no longer require oxygen therapy or may require a change of prescription. It is proposed to run a clinic whereby all patients on home Oxygen will be review every 6 months and it is estimated that savings of €108,000 annually could be achieved.


Occupational Therapy Service

• Audit of ward environment’s suitability for dementia patients

• Outcome measures for all plastic and orthopaedic patients pre and post intervention, Quick DASH and PWRHE

• International Best Practice guidelines to be implemented as they are updated throughout the year.

• Development of Guidelines for the prevention and treatment of Contractures in Adults with Neurological Dysfunction.

• Development of outcomes measure with Palliative Patients

• Involvement in the National Lymphoedema Framework which is auditing Lymphoedema service in Ireland and developing National competencies.

• Development and maintenance of facilitation of Lymphoedema Support Group.

• Introduction of Fluoroscopy guided MLD into service.

• Introduction of Falls Prevention Group in Care of the Elderly Rehabilitation setting

• Implementation of Visual Scanning Treatment program

• Establishment of Cognitive Rehabilitation treatment with Care of the Elderly population

• Journal article on use of Bayley Development Screen with Premature Babies.


Housekeeping Service

• Continue to evaluate the effectiveness of the Environmental deep cleaning teams (SWOT initiative) in terms of improving hygiene standards

• Progress the amalgamation of the Environmental Audit and the Hygiene walkabout audit tool

• Prioritise staff training and development.- Basic food hygiene training , Clean pass training programme & training for Housekeeping Supervisors.


Podiatry Service

• Patient Satisfaction Survey

• Research

• Patient Information leaflets

• Caseload Management.


Speech and Language Therapy

• CUH wide essential in service education and training re Dysphagia and MCD/National Descriptors.

• Launch of the use of ISBAR tool to improve communication across the clinical teams and ourselves, across all of the sites where we provide care

• The training required and the roll out of Electronic Patient Record in CUMH plus the necessary SLT training of Neonatologists, their teams and the Neonatal Nurses in CUMH

• Mallow General Hospital:

• Development of Modified Consistency Diets which adhere to the National Descriptors and the delivery of an in service education and training programme about Dysphagia for all Ward based staff.


Cardiac and Renal Services


• Blood Borne Virus Committee developed to develop PPG’s for management of all Blood Borne Viruses

• Develop data base for monitoring and education of Hand Hygiene and PCHCAI attendances

• DOSA for Tenchoff Insection

• Introduced the VIVA machine for home dialysis.



• Undertaking 4 Nursing metrics, Medication, Pressure Ulcer prevention, Documentation and Nutrition

• PVC audits monthly

• Developed Heart Failure Care plan

• Monthly audit of EWS

• Hand Hygiene audits.

• Developed TAVI Pre and post procedure care plan

• 100 % staff have ACLS certification in CCU

• Environmental Audits.



• Reviewing and developing Clipping policy

• MDT Reviewing HCAI Policies.

• Undertaking Nursing metrics, Medication, Pressure Ulcer prevention, Documentation and Nutrition.

• Monthly EWS Audits

• Hand Hygiene Audits

• Environmental audits.


Warfarin Clinic

• Implementation of the DAWN clinical decision support software.


Nurse Practice Development

• Development of NPDU Strategy 2015-2017

• Development of page of communication on CUH website for NPDU

• Control Drug Ordering System (To prevent delays in patients receiving their analgesia)

• New Profile Document and updating in Paediatrics

• Education sessions on implementing Children’s Nursing Metrics (Test Your Care)

• Supported the introduction of Linear Labels (To improve labelling compliance & release more time to care for frontline staff)

• Review of Paediatric Care plans

• Formulation of Heart Failure Care plan

• Further roll out of “Patient’s Own Medications” system

• Synopsis of Documentation trial on 3D & 4D (To release more time to care for patients)

• Improving the current metrics system in particular the demonstration and review of results

• GA Neuro – Audit of system regarding Nursing Handover

• Development & trial of new Medication Record on 1A & GA Neuro with plan to roll out to the hospital in March 2016

• Formulation of Tropicamide protocol for eye clinic (To enable nurses to administer Tropicamide thus enhancing the patient journey)

• Nutritional Screening, Blood Glucose Monitoring, Preoperative and Falls Policy

• Psychiatric unit & 5B Student Orientation Booklets

• Review of current prescription transfer system to SIVUH

• 6 weekly rotation of 10 minute information sessions to improve metric results thus care standards

• Work on organising a forum for nurses to present their research to improve patient outcomes – “Lunch & Learn” commencing monthly from January 26th 2016

• Work on “Inaugural CUH Research Conference – Enhancing Patient Care Through Research” on 24.5.16


Emergency Department (ED)

• Major Trauma Audit

• Dartmouth Microsystems ED initiatives

• Develop ED Morbidity and Mortality

• Develop Trauma Morbidity and Mortality

• Develop CUH Resuscitations Committee

• CUH Deteriorating Patient Group

• Introduction of Entonox for minor procedures

• Ambulance Clinical Handover Policy & Procedure


Radiation Oncology

• Transperineal Prostate Biopsies – only Munster centre offering this technique in public service

• Radium 223 Xofigo – new radioisotope treatment for advanced prostate cancer initiated at CUH July 2015

• Prostate cancer clinical trials opened at CUH: PEACE-1, ENZARAD, radium223/enzalutmaide phase 2 study. CUH was the first hospital in Europe to open the ENZARAD trial

• Twice weekly consultant peer review radiotherapy treatment planning meeting

• Institution of a 3 times weekly palliative radiotherapy clinic, offering rapid access and coordinated care delivery for palliative patients

• MRI Brachytherapy Treatment Planning


Medical Oncology

• Establishment of Chemotherapy Pre-Assessment Clinic


Acute Medicine

• Establishment of TIA Clinic

Last Modified Date: 23/04/2020 14:14:48