Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome from the Health Information and Quality Authority Ms Tracey Cooper, chief executive, Mr. Phelim Quinn, director of regulation, and Mr. Marty Whelan, head of communications and stakeholder engagement. They will present to us an update on the authority's work programme. This is part of our yearly meeting with the authority which provides a very valuable service. We look to it for guidance, information and communication. It has become a very important part of the health care stakeholder agenda and arena. We look up to it and aspire to seeing the standards it sets being met across all parts of the health system.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give to the joint committee. If they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair and parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I invite Ms Cooper to make her opening remarks.

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.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Cooper for her excellent presentation. It is a time of challenge. One point that jumped out at me from Dr. Cooper's remarks and HIQA's report last week was the importance of challenging those in leadership positions, particularly in hospitals, to continue to prevent the spread of infection. It is staggering that those in leadership positions do not and are not as proactive. I thank HIQA for its new corporate plan entitled, Safer Better Care, of which members have received a copy. For the information of members, as part of the joint committee's work programme, it will host a meeting with HIQA's new chairperson, Mr. Brian McEnery, on 31 October. Perhaps we might incorporate discussion of the plan as part of that meeting. We can discuss this later.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome Dr. Cooper and note that the corporate plan presented today is ambitious to say the least. I wish HIQA well in rolling it out in the coming months and years.

I wish to raise a couple of issues with Dr. Cooper, particularly in respect of residential services for people with disabilities, for which HIQA's inspection function is now coming on stream. Dr. Cooper states that in the State approximately 9,800 people with disabilities live in residential care in voluntary, private or State institutions and mentions an important word when she notes that often such places are their homes. In the context of inspections, obviously the priority will be to ensure such residential care is safe and in an environment that is conducive to providing for a good quality of life for such people with disabilities. Critically, however, there must be an understanding that often these are extremely vulnerable people and that such locations are also their homes. In the context of discussions with stakeholders, how much discussion did HIQA have with organisations representing people with disabilities or with people with disabilities as to what they needed or considered to be their priorities in the delivery of safe care?

While this does not pertain specifically to HIQA, my concern is that sometimes, when arbitrary decisions are made in the context of regulations, it can be very blunt and damaging to people who may experience a huge upheaval within a short space of time. In the context of such inspections, have there been preliminary discussions with the various providers as to what is expected, as opposed to this blunt instrument being applied when HIQA starts the inspection process? This primarily is for the residents themselves, not for the providers. I hope Dr. Cooper can elaborate on this point to an extent because it is critical. While this is not a criticism but merely an observation, in the case of residential care for older people, there were closures that had huge traumatic effects on the individuals themselves, as well as their families, and I do not wish to see this happening on a frequent basis in this context. However, I accept that it is most important to have safe facilities for people with disabilities. Nevertheless, flexibility and understanding are also critically important, as well as the realisation that if there is a need for closures or if orders are served on various organisations, the people at the heart of it should be those who are informed first and should be the first priority with regard to reallocation or an assessment of their needs and requirements, rather than making the decision and then being obliged to address their concerns.

Dr. Cooper has mentioned that obviously HIQA's vision is to provide safety for patients using health services in general. I note, for example, that the special delivery unit often arrives in hospitals and advises hospital management on how it may be more efficient in streamlining the movement of patients through hospitals. Is HIQA consulted in advance in this regard? Alternatively, if decisions are made on how a hospital should improve its services from emergency departments right through the hospital on to the other side, is HIQA involved in such discussions and are its views sought?

Dr. Cooper mentioned memoranda of understanding with stakeholders. In this context, is there a view that HIQA has a critically important role to play in advance of plans being finalised, as opposed to plans being implemented only to find thereafter that they are in breach of HIQA standards? To what extent does HIQA have discussions with hospital management, the special delivery unit and others?

While I apologise for going on a little-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Two minutes remain to the Deputy.

Billy Kelleher (Cork North Central, Fianna Fail)
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I thank the Chair. In respect of evaluating the clinical and cost effectiveness of health technologies, including drugs, and providing advice arising from the evaluation for the Minister for Health, where does that leave the National Centre for Pharmacoeconomics, the organisation that advises in this regard? Is there duplication? Is this complementary or is one subservient to the other? Alternatively, are both entities advising the Minister who will then make the final decision? Members have had this discussion previously about recommendations being made and the Minister acting on them, as opposed to the Minister having a position whereby he can decide-----

Jerry Buttimer (Cork South Central, Fine Gael)
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That may be another day's work.

Billy Kelleher (Cork North Central, Fianna Fail)
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This is part of the statutory functions of the Health Information and Quality Authority. It actually states this on page 34 of its corporate plan.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is another day's work.

Billy Kelleher (Cork North Central, Fianna Fail)
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Yes, but it is important to have clarity in this regard because this issue is raised frequently in the context of new advances in medical technologies and medicines pertaining to cancer care and treatments. Where is HIQA in the overall scheme? For example, does it also advise the Irish Medicines Board because of the new generic substitution and other areas for which the Oireachtas or the Government has legislated recently? These are the key observations in the context of the corporate plan.

This discussion has taken place previously and I compliment HIQA on outlining and highlighting the inspection results in the various hospitals and health providers in respect of basic cleanliness, with which this country has been struggling for a number of years. MRSA has been prevalent in hospitals for a number of years.

While the incidence has been reduced dramatically, I have a concern that if front-line service providers or staff are under significant pressure - this is not a criticism but an observation - these infections can recur. Nurses may be in charge of a large number of patients and junior doctors are working very long hours and under pressure to deal with the day's workload. Do individual staff understand the importance of hygiene? Is it sufficiently promoted by hospital management or during staff training?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join in the welcome to Dr. Tracey Cooper and her colleagues. I also join in welcoming the advent of the inspection regime for residential services for people with a disability. In this context, I wish it to be clear that in this discussion there is no distinction between physical and intellectual disabilities, nor between State, voluntary and private providers.

I am taken aback by the scale of what is being undertaken by HIQA, given everything else for which it has responsibility, never mind its very ambitious plan up to 2015. HIQA is responsible for overseeing 9,800 people in residential care, 1,700 residential services in various locations and entities and 88 service providers across the State. What is the position on staffing as regards its capacity to take on this further responsibility? Is it possible to provide an indication if staffing levels have been increased in order to cope with this additional workload? I note that Dr. Cooper describes it as a landmark moment. I agree. HIQA is now in a position to begin this vital work. However, allied to the question of staffing and looking at some 1,700 entities, is this a Golden Gate Bridge situation or worse, that by the time the work is completed it will be time to start all over again in order to cover the whole gamut of the challenge? I ask Dr. Cooper to give the committee an understanding of how she believes HIQA is geared for the task.

Dr. Cooper referred to instances of failure to comply with the Act, standards and regulations. Such a failure is an offence, about which there is no question, and a repeat will result in consequences which can include immediate cancellation of a centre's registration, which would be a very serious matter. In the current under-resourcing of the health service public facilities suffer greatest as they have the least wriggle room in which to compensate for any loss of a funding stream. There is a risk that repeated failure to achieve 100% compliance could have very serious consequences. I have previously expressed to HIQA my concerns, as have other voices, that while HIQA's reports are hugely welcome and nobody questions its purpose and intent, sometimes these reports have been used or misused by the HSE and the Department of Health to give effect to other agendas such as a reduction in services and even closure. This is not desirable. I have a great fear that under-resourcing could result in situations that would have very detrimental impacts and consequences, certainly not what HIQA would have intended. I ask Dr. Cooper to comment further.

Referring to infections associated with health care, HCAI, Dr. Cooper has described as inexcusable that this fundamental and avoidable patient safety issue would not to be considered a priority by every member of staff, management and the respective health providers. It is time for us to go way beyond the word "inexcusable". As a society, we need to ratchet up our attitude, to make it absolutely clear to all concerned that this is not just inexcusable but rather criminal neglect. I will describe it as bluntly and baldly as such. It is way past inexcusable. If the message comes from this meeting that we will not tolerate anything less than 100% compliance, it will be a good starting point. I hope HIQA will take the same view.

The statistics Dr. Cooper has provided show one third non-compliance. I am not for one moment suggesting it only involves those who are front-line providers, but they certainly have the first responsibility. As members of society visiting families or friends, we have a shared responsibility to ensure the highest standards of hand hygiene. It is described in Dr. Cooper's remarks as "internationally recognised as the single most important preventative measure against HCAI." We need to be very clear that there is an absolute responsibility on everyone. Excuses can no longer be made. Can Dr. Cooper demonstrate what she refers to as demonstrable improvements in subsequent inspections? She has indicated the facts about first inspections. Have second inspections found demonstrable improvements?

On this particular matter, Dr. Cooper has stated that when HIQA begins the licensing system, it will expect avoidable and unnecessary harm to patients to be substantially reduced. I return to the point that it is no longer sufficient to declare that it will be substantially reduced; harm must be eliminated. We need to address this issue in that vein because anything else demonstrates laxity or a degree of tolerance. What penalties are imposed when 100% compliance is not adhered to? In noting non-compliance, can HIQA inspectors identify and expose those who are failing to comply? HIQA's reports deal with hospitals, but it is down to individuals. The figure of 33% represents 33% of staff who are responsible. Can we move this onto a new level and start to identify people and repeat offenders? That is how to begin to make an impact to eliminate this very serious threat to our health.

Jillian van Turnhout (Independent)
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I echo the welcome to our guests. I look forward to a discussion of the corporate plan at a future date.

The new inspection process will begin with inspections of residential services for children and adults with disabilities. I have a supplementary question following from Deputy Ó Caoláin's question. Does HIQA envisage a timeline for the inspection of all 1,700 centres? These inspections cannot happen soon enough. Given the staffing issues involved, what is the time period envisaged? When will it be possible to state with certainty that every service for children and adults with disabilities is provided in a good environment? I have a concern about the proposed strike action and whether HIQA has been advised of contingency plans to maintain the quality of care provided.

I wish to focus my remarks on health care associated infections. I was very troubled by the information included in the HIQA report and by Dr. Cooper's remarks, including her reference to the Mid-Staffordshire Trust inquiry. I read that document in advance of the meeting. Robert Francis, QC, who chaired the inquiry observed a culture where managers saw the glass as half-full when, in fact, it was half-empty, that it was the culture what did it.

I thought that was a really good summation, one we could apply to ourselves. At the Mid-Staffordshire Trust inquiry it was stated a system reset was required, that there was a need for better warning signals, greater accountability of senior managers and for staff, if not open and honest about mistakes made, to be open to criminal prosecution. In the Netherlands, about which I know a little, an incident at the Maasstad Ziekenhuis hospital in Rotterdam resulted in the resignation of the chairman of its board and disciplinary action against professionals, including microbiologists. We have seen instances in other countries where sanctions and accountability apply. That brings me to the situation in Ireland.

Following publication of a report, the response from one hospital was that we needed hand hygiene champions, by which I was flabbergasted. I am involved in work in the area of children's rights. One might employ a hand hygiene champion in a kindergarten to encourage children to wash their hands. However, in this instance we are talking about medical professionals who understand the potentially fatal consequences of not washing their hands. Are we really suggesting the answer in this instance is to appoint champions? Given the potential fatal consequences, who is accountable in hospital settings? I have not thus far been able to get an answer to that question.

When a report is produced, who is accountable? Are the warning signals, which it has been suggested in the case of the Mid-Staffordshire Trust need to be in place, given here such that a person working in a hospital who believes it is not acting appropriately can seek to change that culture? Are there consequences for health professionals for failure to comply? We know that without clear accountability and responsibility, culture will not change. We all have good intentions in life, but we need to know there will be consequences if we do not meet our responsibilities.

My father is in a nursing home where staff habitually change their gloves and aprons. I had not realised how much they did so until I read the report. Perhaps the delegates will answer my question about who is accountable? Who should we as a committee be inviting to attend meetings on foot of reports? As far as I am concerned, everybody but nobody is accountable.

Dr. Tracey Cooper:

I will ask Mr. Quinn to respond first to members questions on disability, following which I will answer the questions on health care and associated protections.

Mr. Phelim Quinn:

I will first outline our planning in relation to this programme. One of the questions was how well we were staffed to tackle this challenging issue in terms of regulation. We acknowledge it is extremely challenging. The number of designated centres with which we will be required to deal will increase by 200% in the course of the next three years. As a result of this, we have engaged in rigorous planning in terms of how we will approach this task in workforce and methodology terms. We have obtained agreement and sanction to fill a significant number of posts for the authority in terms of this new function. We are in the process of recruiting approximately 41 additional staff to deal specifically with the regulation of residential services for adults and children with disabilities. We have also looked at our current staff complement, including our management capacity and support services and are seeking to ensure much of the efficiency within our current capacity can stretch to the disability regulation function.

Jerry Buttimer (Cork South Central, Fine Gael)
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Have the additional 41 staff been recruited and trained?

Mr. Phelim Quinn:

No. A significant number of the inspectors have been recruited and will be in place at the end of October or mid-November at the earliest. We are recruiting additional staff and are confident that we have planned well for this. There has been some slippage, but we have looked at how we will deal with this in terms of contingency planning.

We have also, as part of this new function, looked at issues around support for our staff in discharging their functions. On Monday of next week we will launch a new methodological approach to our inspection process, called the authority monitoring approach. This will enable a consistent approach by all of our inspectors across all of the services we will be regulating. This will apply to health and social care services for adult and children.

Next Monday we will also launch a new ICT system which will help us to be more efficient in how we assimilate information and produce reports. This is about the modernisation of our approach to regulation.

Deputy Kelleher referred to residential centres as residents' homes. We acknowledge that this is the case, given that many are residing therein on a long-term basis. In this regard, our approach to regulation will be person-centred and rights-based. We are speaking, in terms of these being older persons' services and disability services, about some of the most vulnerable people in our society. That we are regulating these services acknowledges the vulnerability and protection issues involved. I draw members' attention to the fact that one of our core corporate objectives is to safeguard the rights of individuals using our services. I also draw their attention to our strong focus on improvement. While in the past there have been many headlines on the closure of and sanctions placed on homes for older and dependent persons, in this instance we need to take a balanced approach and look at what we can do by way of regulatory intervention to help improve services before they reach the end point of closure. Our focus in the course of the next few years will be on improvement, always bearing in mind that we can apply sanctions.

I hope I have responded to all of members' questions.

Dr. Tracey Cooper:

I would like to comment further on disability services. Deputy Kelleher asked about our stakeholder engagement when we were developing our approach. It is important for us to set standards which are, first and foremost, about the people receiving the services. The success of outcomes must be seen through their eyes. When developing the standards, we engaged in an extensive process with people receiving services, including adults and children with physical and intellectual disabilities. Deputy Ó Caoláin is correct that this applies equally to groups of people and providers. We also engaged with groups of parents of adult children with disabilities and the parents of children with disabilities. Of most concern to parents of adult children with disabilities is that they might die before their adult children. We spent a great deal of time getting people's views. We had an advisory group of providers, voluntary representative bodies and people who received and used the services. They were all involved up to the final stage and we hope we have rounded off by demonstrating that it is very much about the person. Other sets of standards with which members may be familiar, including in respect of older persons, are of a different style because the successful outcomes are different. I hope we have engaged fully, which is fundamental to us.

Senator van Turnhout has asked how long we take to inspect all services. The sector for people with disabilities has a different demographic than the long-term care sector.

It is a different provider basis as well. When we start the function, hopefully in October, there is a three-year timeline in the health Act by which time every centre must be either registered or not, as the case may be. We obviously cannot hit the ground running and go to all of those centres. For clarity, there are 1,700 places or facilities but they will convert to approximately 1,300 designated centres. There could be a campus with a number of places for single people. Obviously, we will not go everywhere in the first day.

We have a very robust process to assess risk. People send in concerns to us that are unsolicited. We also require mandatory information that comes to us on an ad hocnotification, if there is an allegation of abuse, for example, or periodically, where we seek certain information all the time. We also have engagement with colleagues and providers in the system. We have met with providers on many occasions to get people's gauge. We will start to synthesise the intelligence that we have to focus on a risk-based approach. If we have more concerns about a centre we are more likely to go there more frequently and sooner than if we have less concerns about a centre. All of that must kick in. Obviously, we would like to be a position over the coming months to get to as many centres as possible, particularly the ones where we have concerns. We will publish all of those reports.

I believe I have answered all the questions.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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There is one more. How does HIQA balance its role and responsibilities with the possibility of publicly-funded centres having quite serious reductions in budget provision and the consequences of that? In presenting its reports HIQA is trying to ensure the best standards are applied, but we have evidence that this has not always been how its reports have been used.

Dr. Tracey Cooper:

It is a difficult challenge. This is not, and cannot be, about black and white decision making, regulations, standards and compliance, because we simply are not in that world. I spoke at the end of the presentation about the focus on safety. I use a phrase, "Get it safe, keep it safe and then we will build quality." Certainly, in the first number of visits and inspections we conduct we accept that it is extremely challenging every day to keep the number of staff and keep the right skills of those staff in services. Of course, we must take into account the challenges that are being faced. In addition, however, these services are being provided 24/7 to very vulnerable people. We have never prescribed in any of our standards that X number of staff must be provided for Y facility to do Z.

What we would expect on a continual basis is that every provider will assess the climate, challenges and the workforce they have available to them against the needs of the people for whom they are providing the service. The first thing we would expect every provider in these services to do is say, "These are the type of people we have living with us and these are their needs. That means we must provide X number of staff to cover them appropriately and these are the skills the staff will need." People who have more needs will need staff who are, perhaps, trained to a slightly different level from others. The first interest for us is that we would want sufficient numbers of suitably qualified staff. In challenging times we find that if providers lose permanent staff, it is difficult to replace them. The question then is how that is being contingency managed, how they manage the risks for residents and provide as safe a service as they can and then, obviously, there are the quality aspects. That is done in a number of ways. Some people have agency arrangements and some are more able to recruit than others. However, given those challenges, our focus must be on finding out how those providers are managing the services and the risk of those services. Some people might say that they must be careful about the type of people they accept for a time because they do not have sufficient staff any more to deal with people with particularly special needs.

First, we must be pragmatic, realistic and relevant to the environment, but we must also be the custodian of vulnerable people. We closed a nursing home a number of months ago for a variety of reasons. This place had high risk, high acuity and very dependent people. It had challenges in its staffing and was providing these services 24/7, but it had no qualified nurse on duty for a chunk of the day and then the providers lied to us and said they did. It is really difficult. Ours is not a puritanical agency, we just want to know what people are doing to manage. There are different ways to do it and I am not saying it will be easy. We will have to get our approaches right - Phelim Quinn mentioned consistency which is really important for us - so the judgment of our inspectors takes those issues into account. However, we must balance that with ensuring the services are safe.

Jerry Buttimer (Cork South Central, Fine Gael)
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Given that it is now a new departure for HIQA and that these will be the homes of many people who are vulnerable, in achieving that consistency will HIQA be communicative and co-operative with the provider who might not have the wherewithal to achieve the standards HIQA seeks? Vulnerable people will be affected. For argument's sake, if facility X is closed, HIQA might end up discommoding a large or small number of people who have nowhere else to go.

Dr. Tracey Cooper:

I mentioned in the presentation that our increasing priority for the last year has been supporting improvement. Instead of us getting at people all the time, people are asking us to help them get better. We have reorganised HIQA and we have a directorate, led by Marie Kehoe-O'Sullivan who is our director of safety and quality improvement, to provide support. We have already had extensive meetings with all of the disability service providers. We have asked them what guidance they need to help them implement the standards. We have very good relationships with them at present and hopefully that will continue. They have identified a number of areas, such as risk management, medication management, action planning and improvement tools. We are now in the process of providing guidance to them.

We provide training and support in conjunction with an organisation called the Institute for Healthcare Improvement, which provides online quality training. We have offered a place to each of the 88 service providers to put some of their staff through quality improvement. We would prefer them to get better before we reach a point of having to enforce. It was much less so with elder persons when we started, but hopefully it will be much more supportive than it was.

I will respond on some of the other matters before discussing health care associated infections. Deputy Kelleher asked about the special delivery unit. We have engaged with that unit since it was started. While I am not aware of the exact conversations that happen in every hospital, I would be very comfortable that the approach of the SDU around service redesign, efficiency and effectiveness is absolutely consistent with what we would recommend. There are best practice approaches surrounding process mapping and ensuring that the patient journey is optimised. I would not have concerns about that at all.

The Deputy asked about the National Centre for Pharmacoeconomics. The director of that centre happens to be a former board member of HIQA. We work very closely and well with it. We work collaboratively on certain approaches. Its focus is very much on health technology assessment for drugs and the reimbursement for drugs. We do not duplicate each other, but work in a complementary fashion. Our focus to date has been more on looking at procedures and things such as vaccine programmes for cervical cancer and cancer screening programmes. There is plenty of room for both of us and the centre is involved closely with our scientific advisory groups. Both jobs need to be done, and it works very well.

I will turn now to health care associated infections. Phelim Quinn might wish to add his comments. The reason we included health care associated infections in today's presentation is that we feel as strongly about it as every member of the committee has articulated. I do some work outside of Ireland wearing another hat. Many countries are really struggling with this issue.

The issue is related to the behaviour and habits of humans and the bad rituals rather than good rituals that are put in place.

I wish to make a strong pitch today by stating the following. First, the infections are avoidable. Second, when someone contracts a health care associated infection there may be minimal harm or a person could die. Third, we cannot afford infections given that they are an avoidable acquired injury or harm caused by being in a health or social care facility, not just hospitals.

The committee saw my presentation that showed the redundant costs incurred for treating people. Notwithstanding the harm caused, the problem is not easy to deal with. To be fair, a huge amount of work has been done in the system and guidelines have been produced which are helpful aspects. However, I agree that the matter is about accountability. In my presentation I used the words "simply unacceptable" but changed them to "inexcusable". I wish to inform Deputy Ó Caoláin that it is both unacceptable and inexcusable. We have dealt with the matter for a while and there have been changes and some improvements. The first national publication that comprised all hospitals was in 2008 which is five years ago and the second was in 2009. We have also faced other challenges. People have asked us to carry out more inspections. After Mr. Phelim Quinn joined us at the end of last year we started conducting unannounced inspections. However, we would not expect to see such poor compliance in 2013.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it caused by a cultural shift backwards, complacency or do people no longer care?

Jillian van Turnhout (Independent)
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There is a lack of accountability.

Dr. Tracey Cooper:

There are lots of issues and some of the committee members have articulated them. There is no deliberate intent not to do it. I would say that there has not been sufficient leadership to ensure that hand hygiene is done.

Recently one member of the team had a discussion with a junior doctor fresh out of medical school who said that they were taught hand hygiene once in medical school in third year. There is something about how we institutionalise such hygiene. We must ensure that all health and social care professionals are educated and told what is expected of them in the workplace. Hand hygiene needs to be embedded as a normal part of work.

Last week someone made the comment that people are too busy to practice hand hygiene. That is not an excuse but hygiene could be made easier. Some sinks are five bays away, there is not a sink in every bay and sinks or cleansing gel may be inaccessible. It could be more in the space for people to use hygiene in their basic approach. The evidence is very clear and I quoted the World Health Organization. Hand hygiene has become one of its priorities and its guidance has been broadcast across the world. It clearly stated the five moments for hand hygiene that are opportunities that will reduce infections. I have made the point that hand hygiene is the single most important measure to prevent the transmission of infection.

We have noted that the second standard that we examined was environmental hygiene. We know that the risks of transmission of infection are significantly reduced by a clean and decontaminated environment and equipment. We do not necessarily mean that one should buy lots of new stuff. We are just saying to keep it clean and human behaviour is at the heart of that. A number of factors are involved. We need to ramp up accountability. Everybody is accountable for their own hand hygiene but some people are more accountable for making sure that all of their workforce do so. If I were a hospital chief executive I would want to know that such practice was strongly embedded in business. It is a normal part of business in 2013.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Dowds has indicated that he wishes to comment because he must leave to attend another meeting.

Robert Dowds (Dublin Mid West, Labour)
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I thank the Chairman for allowing me to comment now. Senator van Turnhout has stolen my thunder. Can I press the delegation on sanctions? In terms of people washing their hands and so on, there must be sanctions, whether naming and shaming or whatever, if they do not take the advice on cleanliness. A warning should be issued in the first instance but there must be a step-by-step sanction system. We are very bad at applying sanctions in Ireland in the area of health, the banking sector and all kinds of areas. Has Dr. Cooper the authority to insist that such sanction is implemented? I ask her to elaborate on the matter.

I am glad that HIQA will be responsible for the inspection of places where people with disability live because they are so vulnerable. I do not know whether the following is within its remit. I have had a lot of dealings with people with disability and know that the activities provided are often inappropriate. Does HIQA play a role in such provision? If so, can it ensure that the disabled facilities examined provide a sufficient amount of suitable activities? There is a real problem with activities.

Jerry Buttimer (Cork South Central, Fine Gael)
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I shall take two other speakers now and the delegation can bank all of the questions. Members have patiently waited to contribute. I call Deputy Catherine Byrne and Senator Colm Burke.

Robert Dowds (Dublin Mid West, Labour)
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I ask the delegation to supply the answers to the Chairman.

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. The Deputy can also read the transcript.

Robert Dowds (Dublin Mid West, Labour)
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Yes.

Catherine Byrne (Dublin South Central, Fine Gael)
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Dr. Cooper's contributions are always thought provoking. My mother died after she contracted MRSA having spent just a week in a hospital but I did not think that hand hygiene could be the only thing that led to her demise. She went into the hospital on a Friday, we took her out of it the following Friday and she died at home two weeks later. She was eaten alive at home just two weeks later. In much distress we wrote to the hospital but we never received an acknowledgement of our letter.

I grew up in an area that had five hospitals run by religious orders and I often think how clean those places were. One evening I witnessed a cleaner wiping the floor with a cloth who then decided to wipe a locker beside a patient. Hygiene is the personal responsibility of everybody who works in a hospital and I do not regard it as someone else's job to tell a person to wash his or her hands. People must take personal responsibility for doing so. When children are being reared at home we insist that they wash their hands on a daily basis, particularly after using the bathroom. I want everyone to reflect on the issue.

I have read the report and have a few questions on the regulations governing residential services for children and adults with disabilities. What proportion of the HIQA budget is set aside for the new function? How many new staff will it employ? It will take some time for the first round of inspections to take place. How will HIQA approach the first inspections? How will it prioritise service providers? Is there a system for doing so?

I commend HIQA on engaging with service providers and other groups in advance of the implementation of the new service. What were the main issues to arise from that engagement? Did service providers tell HIQA the ways to provide good services?

My next question is on residential care for older people. The document entitled the National Quality Standards of Residential Care Settings for Older People in Ireland was published in 2009. How often are quality standards published? Are they still fit for purpose given that the document is four years old? Does HIQA plan to update the document?

Colm Burke (Fine Gael)
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I thank Dr. Cooper and her colleagues for the presentation which stated that 242 cases of MRSA have been identified. Is there a set pattern in terms of the type of hospital or institution where it arose? Does the prevalence of MRSA depend on the number of patients in a unit? Does it depend on the type of medical care being provided, for example, elderly care, maternity care or psychiatric care?

Is there any set pattern in terms of a higher incidence and can we identify how a more aggressive approach can be taken to dealing with the issue and making sure it does not arise?

The issue of low morale in hospitals has been raised with me by people from a number of different medical facilities in the last six months. In some facilities, morale is very low and there is no team approach to the operation of such facilities. Conflict is arising between management and medical staff, between management and nursing staff and between nursing staff and others on the front line. Has HIQA found, during the course of its inspections, that there is a higher degree of non-compliance in facilities where morale is low? Is that apparent from any aspect of the inspections? It is a worrying trend. In the context of what Deputy Dowds raised, I do not agree with the witch hunt approach because I do not think it works. The solution lies in fostering a team effort in all of the medical facilities. Is there a follow-up process by HIQA in terms of how to implement a team effort in the context of reducing the level of non-compliance?

Ciara Conway (Waterford, Labour)
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Last week I sat in the kitchen of a woman whose husband died from an MRSA infection. I knew this meeting was coming up so I made a point of meeting her and talking to her about her experience. The main point she stressed to me was the importance of sanctions. Currently, the name of the hospital is published on a website and that is about it. What else happens? A number of reports have been published in recent weeks on various hospitals, including one in my own home city of Waterford. That hospital did not get a good report in terms of hand hygiene. What is happening there and what is the follow-up process? How can I assure the people of Waterford that if they go into the accident and emergency department of their local hospital, they will be safe? People are telling me that they are afraid to go into hospital because they might end up more sick. That is a real indictment of our hospital services. When people are sick, we want them to go to hospital and to get better.

I agree with Senator Burke that this should not be about conducting a witch hunt. We want to solve the problem. We want to find solutions and to create an environment in which people get better. The question was posed whether we should engage with educators and students on this. Enormous resources are expended by the State on the education of the medical, nursing and auxiliary staff who work in our hospitals. What level of emphasis is placed on hygiene in the training and education of staff? I do not want to refer to any particular hospital, but if one is in the vicinity of medical care centres anywhere in Ireland, one will invariably see people walk out in scrubs. How is that acceptable?

The witnesses spoke about empowering families to question medics and to challenge care givers, but that is a very difficult thing for vulnerable families to do as they sit at the bedside of a sick family member. They just want their loved one to get better and should not have to ask staff if they have washed their hands or changed their uniform when they went out for lunch. Families should not have to ask such questions. These things should just happen. Management has an enormous responsibility in terms of taking a leadership role and breaking the culture of non-compliance. It is not good enough to see staff walking around in scrubs outside clinical environments. That should be made crystal clear to staff and medical students alike.

My brother is studying medicine and will be going off on placement shortly. He is currently looking for short sleeved shirts because he knows he cannot wear long sleeved shirts at work. Already he is starting to think about getting himself ready, but when he goes into a hospital for his placement, he will probably be greeted by senior medical staff walking about in scrubs. That is just not good enough. This is very basic stuff.

I wish HIQA well in its role in the inspection of facilities for older people and children with disabilities, in its role in assessing hospital hygiene standards, as well as in its role in social work departments. However, I wish to know more about the qualifications of the inspectors. Everyone here is aware of the recent very damning report on child care facilities and crèches. We know that such facilities are often inspected by public health nurses, who place great emphasis on the clinical environment but not on the practice. I need some reassurance about the qualifications of the inspectors. Are they sufficiently qualified and experienced to be able to assess properly social work departments, hygiene standards as well as facilities for those with disabilities? These are three very different roles requiring different competencies.

Jerry Buttimer (Cork South Central, Fine Gael)
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There are three speakers remaining and I would like to take them all together, if that is acceptable to everyone.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I have one question for HIQA about resources, which is raised in the final page of the authority's submission. We are all aware of the environment in which the health service is operating. Hospitals and health care facilities have lost up to 25% of their budgets in recent years as well as hundreds of members of staff. As Deputy Ó Caoláin has said, some of the reports by HIQA, which are excellent, may have been used in the past for a different purpose by the HSE or the Department of Health. To what extent, if at all, does HIQA address the whole question of resources and the availability of numbers and categories of staff? This is a key question because when one hears about HIQA reports, one hears about what the authority has found in particular hospitals or health care facilities, but there is no commentary on the level of resources available, whether such resources are adequate, whether staffing levels are adequate or whether the categories of staff available are adequate. I ask the witnesses to address that issue.

Regina Doherty (Meath East, Fine Gael)
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I thank HIQA for its presentation this morning. The corporate plan is amazingly impressive and I wish the authority the best of luck with that. I seek answers to two questions and a comment on something Deputy Ó Caoláin said earlier. First, has HIQA issued the national standards that will apply to the residential care services? If so, will the witnesses describe them briefly to us? Second, on the hand washing scandal, while I am not discounting the emotional and loss of life aspects, can the witnesses tell us if they know the financial cost to the Exchequer arising from the fact that medical professionals are not doing something so basic and fundamental, something which we teach our one and two year old children to do?

Finally, I wish to deal with something which I believe was a bit unfair. I ask the witnesses to comment on Deputy Ó Caoláin's assertion that he is aware that the HSE misuses HIQA reports. He said that he believes that the HSE deliberately under-resources facilities so that they will not meet HIQA standards. Does HIQA agree with that?

Sandra McLellan (Cork East, Sinn Fein)
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I welcome HIQA here today and I thank the authority for its reports. HIQA has come to occupy a prominent place in public awareness of the hospital system in the context of hygiene and safety. At the time of HIQA's establishment there was enormous public concern about the spread of the MRSA superbug which seemed to be spiralling out of control in our hospital system. It is worth emphasising that aside from the additional costs associated with combating infections, people's peace of mind is very important when they are utilising our health care facilities.

It is positive that the rate of infection has decreased from 592 in 2006 to 242 in 2012, a 57% reduction. Will HIQA outline its plans to reduce the number of infections even further? Is it a realistic aspiration to reduce it below the European average over the coming years? Does HIQA believe that target will be realised?

I appreciate HIQA has a substantial workload. In the past month or so, it published reports on four community hospitals in my constituency - Youghal, Cobh, Midleton and Fermoy - and these varied in recommendations and outcomes. We have seen many HIQA evaluations indicating many hospitals are not safe. What are the consequences for hospitals identified as failing to comply with standards and how does HIQA intend to ensure they comply?

In regard to future developments, the corporate plan is transparent and encouraging. I hope this continues. I note HIQA will take on additional functions and will move towards the development and implementation of a licensing system for health care facilities. Will it provide us with further detail on the proposed system? Is it envisaged that direct provision accommodation centres will at some point fall within the remit of HIQA? I have raised concerns about these centres on a number of occasions as they are not subject to independent oversight by HIQA, the ombudsman or the new child and family agency. Does HIQA foresee a role for itself in that area?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I wish to comment before the witnesses respond. I welcome Deputy Doherty's contribution, but I do not believe I used the word "deliberate" with regard to under-resourcing. However, she raised a very interesting point - a moot point I could not discount.

Dr. Tracey Cooper:

There are some common themes among the issues raised and perhaps Mr. Quinn would like to address the issues in regard to disability.

Mr. Phelim Quinn:

The additional budget we have received for this area is €3 million per annum. I have already outlined the fact that we have 41 new staff for the disability area, including direct and indirect staff involved in inspections. In regard to the first inspections to be carried out, we will engage with service providers. Due to the fact the profile of service providers is very different for disability services, we hope a number of service providers will come forward or volunteer to be first for inspection and registration. There is significant anxiety among providers in regard to registration and we need to be able to demonstrate to providers that the process for them will not be overly onerous.

One of the other anxieties that has been expressed through engagement with service providers and some of the special interest groups concerns the ability of HIQA as regulator to acknowledge the range and diversity of service models in the area of residential services for children and adults with disability. Reference was made earlier to the way we will deal with them. We must acknowledge there are large congregated settings and that there are also very small residential units. We will apply the standards within the various contexts where we do the inspections. The key issue for us in terms of consistency is to ensure we apply ourselves using the authority monitoring approach.

I would like to pick up on the issue raised by Deputy Conway regarding the inspection of social care services and services provided by social workers. Since coming to HIQA, I have acknowledged that we need to make a better match regarding the skills, qualifications and experience of some of our inspection staff for the services we are inspecting. Therefore, in the most recent round of recruitment for children's services, we have had specific job specifications for social workers with child care experience and inspector managers with social work management and child care experience. We have had similar specifications with regard to those being recruited for services for adults and children with a disability. We have looked specifically for people from a health and social care background with explicit experience within the disability sector. I believe there is a credibility issue we need to ensure we continue to address. On the prevention and control of health care acquired infection, we recently recruited a cohort of people with specific infection control backgrounds. These recruitment programmes demonstrate we are trying to build a credible inspection process.

I want to try to address some of the issues raised earlier by Senator van Turnhout regarding the inquiry chaired by Robert Francis QC and how it links to some of the questions raised regarding infection control within hospitals. One of the key issues is culture. I believe the introduction of announced inspections tackles the issue of culture. In the case of inspections, what we are trying to do is to look at the governance and leadership systems within our hospitals and at how they connect to front-line staff. We also need to look at what employer accountability exists and at the relationship between that and employee accountability. We believe practitioners need to be held to account in this way. There also needs to be continuous liaison and communication between us and professional regulators. One of the other key findings from the Francis report - on the back of the medical staff scandal - was the inability at times to demonstrate a good, flexible and constructive relationship between the system regulator and the professional regulators. We need to have a dialogue about how we hold registered professionals to account for what may be assessed as neglectful care.

In the course of the last quarter of this year and throughout the next three years, we will publish a three year assurance programme. This will consist of targeted, thematic and service reviews across a range of services and themes within our hospitals. This will allow us, using the framework of the national standards for safer, better health care, to provide a board to ward assessment of specific issues. One example of this will be an assessment of our ambulance service - board to service delivery. Following the completion of an ongoing consultation service, we will also look at a range of services in the same way.

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.

Sandra McLellan (Cork East, Sinn Fein)
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Direct provision.

Dr. Tracey Cooper:

The HSE has an oversight function, as does the Child and Family Agency, which involves knowing the numbers and trying to help provide services for asylum seekers. However, I do not know the regulatory-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Who monitors the conditions in which the people live?

Dr. Tracey Cooper:

You need to clarify that with the HSE.

Jillian van Turnhout (Independent)
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The Department of Justice and Equality and the HSE. I have done quite a lot of work in the area, but the answers I have received from the Government to date are not appropriate.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is a different issue and we will come back to it later.

Dr. Tracey Cooper:

All of the standards about which we have talked, particularly those for people with disabilities and their health care standards, have a large section dealing with workforce resources.

In response to the question about ensuring that there are enough staff to carry out a job, given the current reality, if the staff numbers, and the skills of those staff, are such that there are not enough to provide a service then certain services should not be provided in that situation. When we start monitoring how a hospital, for example, manages its workforce it is not just a matter of knowing how many people there are on a shift basis but also of ensuring that health care professionals are working to the highest level they can rather than saying "Doctors always do that". Emergency nurse practitioners are trained up with all the clinical governance and are doing more advanced work than they have done previously which helps in providing the workforce.

As far as budgetary resources are concerned we are not there to comment on how much the budget provider has but we want to know that it is using the money appropriately for the population of patients and is making decisions about curtailing or optimising services based on risk, type of patient, waiting lists, rather than making arbitrary cuts. In the current climate we are not going to comment on the resources but we do want to know that they are being used in an informed way.

Regina Doherty (Meath East, Fine Gael)
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I asked the question and Dr. Cooper may not be able to answer it, about the financial cost to the State.

Dr. Tracey Cooper:

I do not know for Ireland. Someone may know. I urge people to look at the WHO website which has quite a lot of useful public-friendly information. The members have seen the extrapolated European figures that I put into the presentation. The WHO would say that because not every state has the data capture systems it may be a slightly lower estimate than the real one. I do not know what it is for Ireland. Across Europe it is hundreds of millions of euro. In proportion to our country it would be a significant sum of money.

Colm Burke (Fine Gael)
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In respect of morale, does Dr. Cooper find a higher incidence of non-compliance?

Mr. Phelim Quinn:

In the acute hospital sector there is anecdotal evidence from some of our inspectors that staff would discuss issues of morale with them at the point of inspection. I do not believe that there is any specific or set pattern. Some staff on the ground sometimes welcome the prevention and control of health care acquired infections because they may have tried over a period to effect certain changes which have not happened but after the inspection they can see changes happening as a result of the recommendations made. We do not have evidence of a specific pattern or impact of lowered staff morale.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I do not propose to put words in Dr. Cooper’s mouth but for repeat offenders, despite everything that management might attempt to apply, can individuals within the hospital team responsible for what is nothing short of criminal neglect, be identified? HIQA is noting their failures and is giving a blanket response, 33% failure, etc. I hope this will improve significantly, as Dr. Cooper suggested it would, with repeat inspections. There will perhaps be a hard core of repeat offenders and at some point rather than damning all we should identify those who persistently refuse to adhere to the highest standards.

To Dr. Cooper’s knowledge, does it happen at any of our facilities, hospital or other, that people presenting for admission are asked to sign waivers in respect of instances of HCAIs occurring? Is there any evidence of that or has it even been suggested?

Dr. Tracey Cooper:

I will answer the second question first. I certainly have not come across any. I was surprised at the question. We have not had experience of any waivers, not even a suggestion or whisper of them, which is good.

I agree absolutely that people should be held accountable for persistent poor compliance. I have a problem with people who say their target for hand hygiene is 80%. In my view that equates with people deciding actively not to clean their hands for one in five patients. That is the reality. This goes back to what I said about team level. There are different levels of accountability. Somebody said, and I agree, that everybody is accountable and everybody has responsibility for doing it right. That does not mean that when people persist in poor compliance everybody ignores them. I would like to know that at team level, at ward level, consultants and senior nurses are setting examples.

Someone responded to a report last week by saying that doctors are really busy. I do not care if someone is a doctor, a porter, a pharmacist or a nurse. It makes no odds. Everybody is responsible. In answer to the Deputy’s question, the leadership at facilities must address people who are reportedly non-compliant. If a ward has had a persistent number of health care associated infections I want to know who the repeat people are and how to support them because this involves remedial action and training. If there are persistent problems it should be part of a disciplinary process for a hospital if a member of staff persists in offending. There is an opportunity and we persist in raising awareness to persuade people to do something different tomorrow when they go to work and have their colleagues challenge them.

Deputy Conway felt uncomfortable about empowering patients but patients can tell who has not washed their hands when coming towards them. I have been in that position. If I was sitting in an emergency department with my child and I was watching a nurse, pharmacist or doctor going back and forth in a clinical environment to patients without washing their hands I would not let that person touch my child.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is fine for Dr. Cooper who is empowered to do that but a mother in a waiting room or someone in a public bed is not going to be able to do that. I have been in that situation.

Dr. Tracey Cooper:

Please do not get me wrong, I am not saying that people should do this and we let every medic-----

Jerry Buttimer (Cork South Central, Fine Gael)
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People should do it. Dr. Cooper is right.

Dr. Tracey Cooper:

From our perspective, the clinicians are the ones with the responsibility but there is also the question of the power of the patient. I had this conversation with our staff recently and they said exactly the same thing to me, it is not easy. What do we do in society to give people help, to make it okay to challenge because we are not there yet? The responsibility is solely the clinician’s.

A couple of years ago I stood in a hospital, not in this country, looking into a four bed bay where there was someone with TB, someone on chemotherapy, someone who had cellulitis and I cannot remember what the other person had. It was visiting time, 2 p.m. in the afternoon, and these people had been on the ward for a few days so the visitors had got to know them. All the families that were visiting were shaking one another’s hands, saying hello to the patient in the next bed. One could have tagged the transmission of infection. Nobody was doing anything about it. We can do something about education but the primary responsibility lies with health and social care professionals.

Jerry Buttimer (Cork South Central, Fine Gael)
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When one walks into Cork University Hospital the public address system roars at one and there are a lot of hand disinfectant dispensers.

Dr. Tracey Cooper:

That is great.

Jerry Buttimer (Cork South Central, Fine Gael)
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If that can be done at the front door in such a visible manner, why can it not be replicated in different parts of the hospital?

Dr. Tracey Cooper:

As I left a ward at 2 a.m. one morning - not in this country - a voice asked me had I washed my hands. I looked around and realised it was an automatic voice machine beside the dispenser. I went into the toilet area and a voice notice said: "You are in a dirty area. Have you washed your hands?" These were all sensor-triggered voice alarms. There was no one in the room. I was embarrassed and I washed my hands. There are innovative methods for addressing this issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Cooper, Mr. Quinn and Mr. Whelan. I compliment and pay tribute to Marty Whelan who does a lot of quiet work in the dissemination of information. It is quite usual to receive an e-mail or a phone call from Marty at a very early hour of the morning. I thank all HIQA staff for their professionalism. I wish the new chairman the very best and we will see him in October. I thank the former chairman and wish him well.