Ms Tracey Cooper:

On behalf of the Health Information and Quality Authority, HIQA, I thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss with it our programme of work. I am joined by Mr. Phelim Quinn, our director of regulation, and Mr. Marty Whelan, our head of communications and stakeholder engagement. We very much welcome the opportunity to appear again before the committee and engage with members. I appreciate there are a number of members whom we have not met before and we look forward to working with all of them, as always.

The authority was established just over six years ago and we are very conscious of our responsibilities to the Government, the Oireachtas and the public. We look forward to hearing the committee’s views both today and in the coming years. HIQA was established as an independent authority reporting to the Minister for Health and, latterly, the Minister for Children and Youth Affairs, with a wide range of regulatory and non-regulatory functions, most of which are set out in the Health Act 2007. All of our functions contribute towards driving continuous improvement in the safety and quality of care and support for people using our services.

While many of the members may be familiar with our work, I would like to describe briefly the functions of the authority and then to focus on a number of topical issues, including the commencement of the regulation of residential services for adults and children with disabilities, the patient safety issue of health care-associated infections and what we plan to achieve in the coming years with our next corporate plan. If there are other specific areas of our work that members would like to discuss, we will be happy to take questions following this presentation.

The role of the authority is to promote safety and quality in the provision of health and social services for the benefit of the health and welfare of the public. This means that the authority has responsibility for setting quality and safety standards in services, with the exception of mental health services, and also regulating health and social care services for adults and children. This includes the registration and inspection of designated residential care services for older and dependent people such as nursing homes. The authority is also responsible for inspecting children’s services and health care services. As we will touch on, in a couple of weeks we will be pleased to begin the regulation of residential services for adults and children with a disability. We are responsible for promoting the better use of resources. This is important for us. We do so through undertaking health technology assessments to evaluate the cost and clinical effectiveness of new and existing drugs, devices and services, in order to inform and guide decision-making on how and in what we invest and, perhaps, disinvest as a health service. We also set standards for inter-operability for health information systems and provide and inform health information advice and policy. We also have responsibility for supporting providers and staff in bringing about improvements in the safety and quality of services. Members will see from our corporate plan that this has been an important and increasing focus for us in the past year - we have had feedback from people with whom we have been working - and we achieve this through the setting of standards, providing customised guidance and helping to build capacity and capability in the workforce through delivering quality and patient safety initiatives to support them.

As a learning organisation, we also have a duty to ensure we learn from similar organisations and health care challenges in other jurisdictions in order to ensure that, both individually and collectively in the health system, we do not replicate issues of concern that have already been identified elsewhere. A particular example with which members may be familiar is the circumstances that have resulted in two public inquiries being undertaken into significant quality and safety failings that took place at the Mid Staffordshire NHS Foundation Trust in England. The reports of these inquiries identified significant issues at hospital, regional and national level and included the response of the health care regulators over time. Such learning includes ensuring robust systems are in place for us to risk-assess information effectively at local and national level, the need for robust collaborative approaches with other regulators and, more and most important, the need to ensure our assessment and monitoring activities have a clear and unambiguous focus on what is most important, namely, the quality and safety of care as experienced by patients and other service users.

In my presentation I wish to focus on one of our newest functions, namely, the regulation of residential services for children and adults with a disability. We will commence this new function, if regulations permit, on 1 October. I wish to share with the committee details of how we will be undertaking this extremely important activity. The context is that there are approximately 9,800 people with a disability who live in residential care services. These services are provided in approximately 1,700 residential services that are run by 88 service providers across the country. The service providers include the State, through the Health Service Executive, and private and voluntary providers.

Almost five years ago I addressed the committee on the development of standards in this area and outlined the importance of having standards that focused on promoting good, safe practice and also safeguarding the rights of both adults and children with disabilities. HIQA and I extend our sincere gratitude and appreciation to current and former members of the committee and many others for their ongoing support and encouragement in bringing us to the important point we are at today. It is important that we are now in a position to begin this vital work. This will be a landmark moment for people with a disability living in Ireland and their family members. It is the first time that residential services for people with a disability will be subject to independent scrutiny by a regulator in this country.

From now on, people who use disability services and-or their families will know what they should expect from residential services and service providers will know what is expected of them in delivering a person-centred, high-quality and safe service. We published the national standards for residential services for children and adults with disabilities in May 2013 and they will be used as a framework to drive continuous improvements in these services. I will refer to them as the national standards from now on. We in the authority are passionate in believing that children and adults using residential services have the right to be safe, to receive good care and support and to have access to the services they need to enable them to live a fulfilling life in as independent a way as possible. The national standards will apply to all residential services provided to children and adults with a disability regardless of whether the service is operated by public, private or voluntary agencies. Following the publication of the regulations by the Government, all services providing these services will have to be registered with HIQA and will be assessed against the requirements in the Health Act 2007, the underpinning regulations and the standards to which I have referred.

The standards focus on the outcomes to be achieved for the adults and children receiving services. The standards are grouped under eight key themes and cover a number of areas including respecting peoples' autonomy, privacy and dignity and promoting individuals' rights. They are also aimed at ensuring the facilitation of choice, which was a very loud theme we heard from people with disabilities when we were developing them, and safeguarding and protecting people from abuse. They require that people who live in residential services should enjoy a good quality of life and live in a place that feels like their home. It is vital that all services are of a consistently high quality, regardless of which provider is running them.

In advance of this function, we have initiated quite an extensive process of engagement with providers and advocacy groups to provide support. For providers, we have held a series of information sessions and focused engagements. Following commencement, we will also organise a number of focused meetings with providers on such topics as preparing for inspection, responding to reports, action plans and submitting notifications. Importantly, the purpose of regulation is about supporting continuous improvement in the quality and safety of services and we will support providers to this end. However, services must be safe for people. Failure to comply with the Act, the regulations and-or the standards is an offence and persistent failure to comply reflects on the fitness of the provider and other key senior managers to provide such services for vulnerable people. As with our inspection of residential services for older people, with which members may be familiar, if we are not satisfied that the provider is sufficiently addressing non-compliances then further action will be considered. These actions are set out in the Act and may include refusal to register, prosecution, the placing of additional conditions and, in situations where there is significant risk to the life, health or welfare of residents, immediate cancellation of the centre's registration. Repeated non-compliance may also impact on the continued registration of the centre. We very much look forward to beginning this important function and much preparation has gone into this in advance. Most importantly, we look forward to making a difference to people with a disability living in residential care across the country and providing assurance to their family members and the public.

In respect of the authority's function to help improve patient safety, I would like to focus on the prevention and control of health care associated infections, which is a significant priority for us and the health system. Health care associated infections represent the most frequent adverse event during health care delivery and no institution or country can claim to have fully solved the problem yet. Based on data from a number of countries, it can be estimated that each year, hundreds of millions of patients around the world are affected by health care associated infections. These are avoidable infections. Every day, these infections result in prolonged hospital stays, long-term disability, increased resistance of micro-organisms or bugs to antimicrobial drugs such as antibiotics, high costs for patients and their families including unnecessary deaths and massive additional costs for health systems, which are particularly important given our economic climate. For example, in high-income countries, of which we are one, approximately 30% - one third - of patients in intensive care units are affected by at least one health care associated infection during their stay. It is also important to note that these infections are not exclusive to hospitals. They can be prominent in every health and social care facility including community hospitals, nursing homes, ambulances and the homes in which people are being cared for. In addition to the significant patient safety issues and unnecessary harm that may arise with these infections, the annual financial losses due to these avoidable infections are also significant. The World Health Organization reports an estimate of annual costs due to these infections at approximately €7 billion in Europe, reflecting 16 million extra days of hospital stay and 37,000 attributable deaths that are avoidable, and about $6.5 billion in the US.

Ireland has made continued progress in reducing health care associated infection rates over the last number of years and, like many countries, more needs to be done. For example, the health protection surveillance centre in the HSE has reported that the number of reported cases of methicillin-resistant staphylococcus aureus, which is a particular type of staphylococcal infection resistant to particular antibiotics that we know as MRSA, in the bloodstream has decreased steadily over the last six years from 592 in 2006 to 242 in 2012, representing a reduction of 59%. Although the overall trend in the proportion of MRSA observed in Ireland is decreasing, it is still relatively high, albeit similar to the UK and southern European countries. In 2011, Ireland ranked tenth out of 28 countries reporting MRSA figures throughout Europe.

Many infection prevention and control measures, including hand hygiene, do not require monetary investment. This is about leadership, behavioural change and staff taking responsibility and being held accountable for what is a simple, modern-day duty of care. It is also about the empowerment of patients, their families and the public to take personal responsibility for safeguarding themselves and to be comfortable in actively seeking assurance from staff that they have cleaned their hands. This must be a priority for the leadership of any health system and health and social care facility. In 2013, it is inexcusable for this fundamental and avoidable patient safety and costly issue not to be considered as a priority by every member of staff working in a health or social care facility, every chief executive, every board and every health system.

Over the last number of months, the committee may have noticed that the authority has published the results of a number of inspections. We have inspected 36 hospitals against the national standards for the prevention and control of health care associated infections. The last inspection was last week. A total of 28 of these were unannounced and eight were announced inspections. Given that hand hygiene is recognised internationally as the single most important preventive measure in the transmission of health care associated infections in health care services, the primary focus of these inspections was on the standards in respect of hand hygiene and environmental hygiene. It is important to note that these findings only represent a single point in time. The main findings of these inspections were that overall, 1,045 opportunities to perform hand hygiene were assessed. A total of 67% of opportunities were taken, 72% of which were compliant with best practice. However, one in three patients receiving those health services did not have the appropriate hand hygiene prevention precautions undertaken by those caring for them. This demonstrates that one third of all hand hygiene opportunities did not take place, which obviously increases the risk for those patients. Of the six hospitals that have had more than one monitoring assessment, it is fair to note that there have been demonstrable improvements in the hand hygiene culture. Other general areas identified for improvement included: waste and laundry management practices; the securing of "clean" utility rooms that were not contaminated; access to needles, syringes and medication; and the securing of "dirty" utility rooms. In 2013, these aspects of preventing and controlling health care associated infections should be embedded into the culture of all health and social care facilities. This patient safety area will continue to be a priority for the authority and will become increasingly so when we begin a licensing system which will represent more accountability for health care facilities. We will expect avoidable and unnecessary harm to patients to be substantially reduced at that time.

We have been in existence now for over six years. We are absolutely committed to discharging the responsibilities bestowed on us by the Oireachtas in the most person-centred, robust, professional, objective and independent manner. In so doing, our focus is, and always will be, on driving high-quality and safe care for people using our services. With this in mind, and following a public consultation process, we have developed a new corporate plan with a time frame from 2013 to 2015. I will summarise the approach to our plan. It is obviously influenced by our vision, mission and values and includes a strategy map on one page where people can clearly identify what we are here to do.

It articulates the direction the Health Information and Quality Authority, HIQA, will take in that three-year period and the outcomes we wish to achieve through our work to add value and have a maximum impact during what are challenging times for the country and our system.

The expansion programme for the allocation of new functions to the authority envisaged in the Government’s health reform plan and by other policy decisions is significant for us and the health system. HIQA will be regulating previously unregulated areas such as services for people with disabilities that I have just covered. It is also envisaged that we will take on further additional functions that include a substantive monitoring programme of health care facilities against the National Standards for Safer Better Healthcarethat we published last year. We will take on the supervisory authority for research ethics, the competent authority function for medical ionising radiation protection and, in a new development, the registration of children’s special care units. We will also move towards the development of a licensing system for health care facilities. During this period and given the challenging times in which we find ourselves, an increasing focus for us will also be on informing decision-making through the provision of advice on the assessment of new and existing technologies and health information systems and management, while also supporting people to improve through providing quality and safety development opportunities.

To address these challenges, we will ensure any new function is properly planned for, is as cost-effective as possible and that there are adequate systems and resources in place to support it. We will also work to ensure such functions are undertaken in a well managed way that takes account of the impact of increasing regulation on the people whom we regulate. Consequently, our new corporate plan will commit us to working with our stakeholders in a collaborative and constructive manner. In some instances we will develop what we call memoranda of understanding which are formal collaborative commitments with key stakeholders, including other regulators, to ensure clarity regarding our respective roles and responsibilities, that information is exchanged to ensure patient safety issues do not drop through the gap and that the overall burden that regulatory activity places on service providers is reduced, wherever possible. I am delighted to announce to the joint committee that the plan was recently approved by the Minister for Health and laid before the Oireachtas yesterday. I understand HIQA has furnished members with copies this morning and will publish the plan this afternoon on our website.

This is a difficult time for providing and maintaining good quality and safe health and social services. However, there are also opportunities in these times to ensure services are as efficient and effective as possible, with an uncompromising focus on safety. The impact of economic and fiscal constraints is significant and obviously continues to be a challenge and concern. Therefore, it will be more essential than ever that what we do and how we do it will have a maximum impact on people receiving services and that our focus is real, relevant and appropriate. In this climate the focus for those providing services and for us in regulating services will be about safety, that is, getting services safe and keeping them safe.

I thank the joint committee for giving me the opportunity to make this presentation and its time. I look forward to working closely with members in achieving our shared purpose.