Summary of findings, recommendations and updates regarding the examination of a particular clinical department in Children’s Health Ireland (CHI)

Background

This was an internal examination commissioned by the CHI Executive. It was never intended to be made public or published to ensure that staff felt safe to participate in a confidential process, in an open manner, given the sensitivity of the issues under examination. The intended purpose was to understand issues which were understood to exist in a particular clinical department, to implement recommendations which would address any issues identified, to improve quality of patient care and to brief the Executive and Board of CHI re same. Employees participated in this Examination on a confidential basis so that long standing issues could be examined, addressed and new ways of working considered and implemented. A number of HR processes ensued and were closed out. Some of these employees no longer work with CHI. While the Examination did identify serious issues of concern (which are set out below), where possible, these were to be addressed through the appropriate internal policies and processes. The majority of the recommendations arising from this Examination have been implemented with the aim of ensuring that similar issues cannot reoccur in the future. Measures that have been adopted and are continuing also help to support a culture of respect, openness and transparency.

The purpose of this summary is to ensure that a wider audience is afforded the opportunity of an overview and understanding of the background to this examination, the process followed and findings made into a clinical department in CHI in 2021/2022 whilst balancing the needs of a confidential process.

The process followed

During meetings (2020/2021) between employees in this clinical department and members of the CHI Executive, it became evident that multiple legacy and deep-rooted issues existed that regular meetings could not address.

In early 2021, an Operational Lead was assigned to look into these issues. However, it became clear that a more robust process was required to identify the issues that needed to be addressed.

In July 2021, a formal Examination of this clinical department was initiated by the CHI Executive, with Terms of Reference agreed. The CHI Board was informed of this process.

Two senior examiners were assigned to undertake this examination, one with an operations and clinical background and the other, a senior HR manager. Staff participating in the Examination were assured of confidentiality and encouraged to be open and honest about their concerns and issues.

This Examination took four months and was conducted at the end of 2021 with the report finalised January 2022. It was divided into two phases. Phase 1 involved participant interviews (45 staff members from across CHI). Phase 2 involved looking at supporting documentation and analysis.

The initial Report of the Examination was accepted by the CHI Chief Medical Officer (CMO) and CHI Human Resources Director (HRD) in January 2022. Recommendations based on the Examination were finalised and presented to the CHI Chief Executive Officer (CEO) in March 2022 and presented to CHI Executive and Board in April 2022. The findings primarily focused on issues related to interpersonal relationships, training programmes, patient management, professional conduct and adherence to standards. The recommendations have been implemented with some ongoing.

Findings

The themes and concerns identified through this Examination fell into three distinct areas:

1. Behaviours and culture
2. Access and waiting list management
3. Leadership and governance

Findings

• Most of those interviewed described a culture within the department where change was slow, lacked governance and robust processes, and was influenced by strong and challenging personalities.
• These interpersonal difficulties among team members led to poor working relationships and a challenging working environment.
• High attrition rate among support staff due to bullying issues.
• A significant risk was identified where only one employee managed the needs of a complex tertiary speciality. This level of dependency on one individual for a critical service is not in line with best practice and created a vulnerability in this specialty.
• Inconsistencies in managing staff contracts was identified.
• Half of medical trainees described the learning environment as not conducive to learning. As a reflection of this, The training body had indicated that there would be no intake of any new trainees or Specialist Registrars (SpRs) into the programme in 2022 due to concerns about the trainee experience which was reputationally damaging for CHI.
• The report stated that a negative culture can impact service delivery, department dynamics and staff experience and has the potential to put patients at risk.

Actions

From May 2022 CHI developed a Management Intervention Action Plan to implement and track the recommendations from the Examination. Monthly meetings to review progress against an action tracker took place, with the majority (88%) of these actions now complete. The Board was kept updated at regular intervals over 2022-2023 as reflected in the Board minutes over this period.

• As an immediate priority, the clinical department required intervention to support the development of collaborative working relationships, and a safe and inclusive service for all.
• An external facilitator worked with the department to improve teamwork, culture and functioning. Teamwork has significantly improved.
• Additional staff have been recruited in accordance with the national model of paediatric care to address the risk of single-handed service.
• A review of the CHI Recruitment Policy was undertaken to ensure that recruitment is conducted in a consistent and fair fashion and in accordance with national practice.
• The training programme was reviewed and restored in 2023 with the most recent training body assessment being positive.
• Continue ongoing work with patient safety lead

Findings

• A number of issues were raised in relation to a NTPF outpatient waiting list initiative. The Examination suggested that based on the documentation review, certain NTPF-funded clinics did not adhere to NTPF standards of chronological scheduling (i.e. seeing the longest waiting patients first).
• Data suggested that some of these patients could have been seen by other departmental colleagues within the existing day to day service and potentially managed in a more proactive way.
• Patients seen in the outpatient clinic who required ongoing treatment were placed on an already long inpatient waiting list without consideration of redistribution of patients to colleagues with a shorter waiting list. The examination raised the issue as to the possibility that this could have led to any negative outcomes for patients.
• The above raised concerns relating to the prudent and beneficial management of NTPF funding and lack of oversight of access initiatives.

Actions:

• Immediate action was taken to review the inpatient waiting list.
• On examination, the patient selection for the NTPF outpatient clinic was based on the unavailability of additional diagnostic services required in the original proposed (non hospital) location for this clinic. These clinics did not take place in any consultants private clinic. Scheduling of patients to this public clinic was managed by CHI administrative staff.
• No direct payments were received by CHI staff from the NTPF. Funding for this waiting list initiative was received by CHI directly from the NTPF. Staff are only paid for additional work by CHI, over and above their contractual hours.
• A review of the relevant inpatient waiting list took place and patients were re-distributed across the department to ensure equitable access to treatment. This action was closed out in September 2022. Open disclosure was not carried out as there is no significant scientific evidence that delaying treatment will equate to patient harm in this patient cohort.
• A cross-city CHI Central Referral’s Office was established. This system manages referrals centrally to ensure equitable distribution. Efficiencies have been gained, and this process is being rolled out across all CHI specialties.
• CHI now has a robust process for NTPF funded waiting list initiatives which requires multiple internal stakeholder approvals both clinical and financial. CHI is regularly audited by the NTPF.
• As part of our internal audit programme for 2024, CHI completed an audit on management of waiting lists to maintain focus on this area. The results of this audit were reported to the Audit and Risk Committee of the Board and the results deemed CHI to currently have strong processes in relation to waiting list management.
• Capacity issues were addressed through the hiring of more personnel in certain areas and reconfiguration of access to facilities across CHI.

• There was a substantial and persistent message of concern regarding the lack of strong site leadership and good governance, along with poor operational oversight and accountability.
• There was consistent feedback that the challenging behaviours of some staff were not adequately addressed by the site leadership team. This led to a number of unresolved personal issues between employees.
• The management of a particular cohort of patients was inequitable across CHI Hospitals.

Actions:

• A review of all CHI Hospital sites leadership roles and responsibilities was commenced to provide clarity around delineation of accountability at site and executive level – this work has continued as the transformation programme has evolved in preparation for the move to the new children’s hospital.
• Morbidity and Mortality Meetings attended monthly by appropriate participants.
• Delineation of cases appropriate for general specialist team and subspecialty teams remains on-going but good progress has been made.
• The management of an identified cohort of patients in the Examination is ongoing with access to relevant specialist care as well as the development of appropriate transition pathways from paediatric to adult care.

1. Summary

CHI regularly conducts internal reviews and audits to ensure issues are identified and addressed across our services. CHI is a learning organisation and service improvements through internal reviews and clinical audits, which are an essential tool to support this, will continue to be a priority.

CHI recognises the importance of transparency and the interests of the broader public in relation to the issues identified in the report. This was an internal examination, and it is important that our staff feel safe to continue to engage in processes that ultimately lead to service improvements and better care for children and young people.

Of note the report did state “This examination however, without question has demonstrated that there is a huge cohort of committed, diligent, people centric staff across CHI willing and wanting change and reform. It is this cohort of staff with the support of strong leader’s and good governance that will mend our culture and enable positive change across CHI.”