Dr. Tracey Cooper:

With regard to a specific question raised by Deputy Byrne, we published draft standards for people with disabilities in 2009, but these standards were never formalised. We recommenced the process of refreshing them and also brought together people who had been working for us on national standards for children. We now have a brand new set of standards that are fit for purpose for 2013 and which were published in May 2013. Those are the standards against which assessments will be made.

With regard to health care associated infections, there has been much discussion regarding sanctions. I will try to clarify our functions in this regard. In the case of monitoring standards for health care services and children's services - the non-registration part of our work - we have sanctions where people do not co-operate with us. However, we do not have sanctions to enforce, which is why we publish everything and then go back to inspect again and go back on a continuum. Our function for health care concerns the HSE and service providers operating on behalf of the HSE, such as the voluntary providers with whom we are all familiar.

We are in discussions at the moment with the Department to extend our standards monitoring function to private health care facilities as well, in advance of licensing. When we get to licensing, it will be similar to our registration activities. There will be very clear sanctions that will look different because they are different environments, but it will take us and the system to another level of consequences. These are the consequences of persistent poor compliance, accepting the assessment that is conducive to the environment we are assessing. There are ongoing discussions with the Department on moving towards a licensing regime, which is a priority for the Minister. In the programme for Government and in the corporate plan there is a reference to starting a licensing process, and we hope to start it at some point in 2015. There will be consultation on that at the time. The National Standards for Safer Better Healthcare will more than likely be the standards that we use, but there will be much clearer sanctions. If we are to have accountability, there must be consequences.

We are not the only country dealing with this. It is a challenge abroad as well, but some countries have made this such a priority that the rates are published by hospitals on a monthly basis. I was speaking to a colleague last month whose hospital records the number of days since the last infection incident. Senator Burke and I have often taken the train from Kent Station in Cork, which has a sign that reads "Days since last accident". In some hospitals the wards contain signs stating "Days since last health-care-associated infection". It is in your face at ward level, because most people interact in hospitals at ward level. Then that pressure begins to build, with comparisons made among wards, theatres and clinical areas, and then we ask how the board of the institution is monitoring these numbers and how the State holds the chief executive, the board and the medical director to account in reducing those numbers.

I also agree that this is absolutely about culture, but part of that is leadership. Some countries have gone back to a modern matron system. There was a discipline under the old style because scary people would guarantee that things would be clean. With the excessively medicalised world in which we live, it is the basics that are causing the harm. Further accountability is needed and it is about the conversation that takes place among clinical teams on wards, in board rooms and across the State.

The HSE has been doing a great amount of work in providing guidance, as has the Health Protection Surveillance Centre, but from a leadership perspective, they cannot make people at local level do this. We spoke about the National Standards for Safer Better Healthcare earlier. There are health-care-associated infections other than MRSA, which we spoke about, but I would expect boards to know how clean their hospitals are. I spoke to the chairperson of a hospital recently who said that he and his colleagues did not walk around the hospital. They should get out and have a look at how things are. Some people say we cannot afford this, but we cannot afford not to. If we invest in keeping hospitals clean, we reduce the cost of the burden of disease that is happening every day. Instant sanctions should be brought in, but they should only be brought in with a licensing regime. However, instant accountability should be brought in straight away. Perhaps that is something for the committee to think about. People are really trying to improve this at national level and there is a lot going on.

Where there are persistent high rates of health-care-associated infections in a facility, sometimes that suggests that not everything else is rosy in the garden either. Such infections are termed "never" events; they should never happen. There are other patient safety events that are also "never" events, such as wrong-site surgery. There is a suite of information indicators that we need to start developing which will give us an idea of how well a hospital is performing. When we start monitoring the standards next year, we will expect increasing numbers of those patient safety outcome measures to be considered at board level and to be published. When we get to licensing, there will be a consequences regime where there is a persistent failure.

Senator Burke asked whether there were set patterns. I am not an expert in this area. I am sure there are people who can give him an answer to that, but I do not think we have noticed any particular trend. We may identify that when we compare the standards, but there are certain services - such as transplant services, oncology services and high intensity surgical services - where people are on drugs that reduce their immune system function, so if they contract an infection they are far more likely to suffer harm. Another committee member asked about preventative measures. Some hospitals screen every single person who attends. Part of the admission process is to screen the person with a nasal swab to find out if he or she is a carrier. We could be carriers in this room and we would not necessarily know it.

A question was asked about whether our reports were being used to shut down services. I agree with Deputy Ó Caoláin that there is no deliberate intent. Sometimes what is portrayed is not something that we have reported and not what we would have agreed with, but when it comes to designated centres, if a provider makes a decision to close it, that is the decision of the provider. There have been occasions on which reports have been misrepresented in the media and perhaps that has been encouraged from the wrong direction. It is a difficult matter, but we would respond if we thought it was a particularly significant issue, and we have not done so. We may get frustrated in the background, but I do not think it is a case of deliberate intent; rather, it is an increasing reflection of the challenging environment in which we find ourselves.

Deputy McLellan asked us about licensing. This is being discussed at the moment. It is not just about saying that a hospital is fine. Hospitals will have to be licensed for the type, range and scope of services that they are providing, and they will be licensed within that basket of designated activity. A community hospital that wishes to carry out neurosurgery would have to apply and demonstrate that it is capable of doing that. When we have the Safer Better Healthcare system ready, it will be timely for licensing to kick in. The Deputy also asked who was regulating a particular service, but I did not catch the name of the service.