Tallaght Hospital opened as an acute general 615-bed hospital in June 1998 operating on a 24/7 basis. It is the newest of the Dublin academic teaching hospitals and is aligned to the medical school at Trinity College. It employs 2,545 persons and caters for a population of approximately 500,000 – 11% of the total population of Ireland and cares for all categories of patient with any degree of seriousness or severity of ailment, adults and children.
This public, State-funded, voluntary university teaching hospital has been the subject of a very highly critical report by the Health Information and Quality Authority (HIQA) in reaction to risks to the health and welfare of patients associated with the systems of care provided in this Hospital. This was especially apparent with respect to elevated levels of clinical risk to patients who required acute admission being accommodated on the corridor adjacent to the Emergency Department. Patients awaiting transfer to an inpatient bed were warehoused, like cars on junk lot, and the investigation revealed their clinical health and welfare was not being adequately dealt with.
Tallaght Hospital was under the overall control of a 23-person board of directors in 2009 whose mandate, defined by charter, was criticised as ‘not in line with the principles of modern corporate governance’. The Board’s Code of Governance, which was adopted as recently as 2005, articulated its role as being to ‘develop and review on a regular basis the mission, vision, objectives,, functioning and strategic plan of the Board, establish, implement, and evaluate a quality management system for the regular assessment and review of patient care and manage the property and finances of the Hospital’
The investigation examined the effectiveness of the planning, accountability and oversight arrangements operated by this Board and the oversight arrangements with the Health & Safety Executive with a view to seeing how the HSE held the Hospital to account for the quality and safety of the services that it was providing. Patients experienced long waiting times to be seen by a doctor, a lack of communication and the indignity of being accommodated for long periods of time on a public access corridor.
The investigation found that between January and June 2011 that 14% of the people attending the Emergency Department left without completing their care. The waiting time in the Emergency Department for a non-admitted patient from January to August 2011 was typically 6-7 hours but some patients waited for up to 61 hours before being discharged. Unscheduled patients who attended the Emergency Department and subsequently required inpatient admission while awaiting transfer to an inpatient bed were accommodated on a trolley either within a designated area within the Emergency Department or on a public corridor while over 80% of them waited, on average, 13 hours for an inpatient bed. One patient waited 140 hours. This is Dublin – not Harare.
Patients of the Hospital experienced long delays for diagnostic tests; an ultrasound scan, for example, could take up to nine months. In June 2011, 52% of all patients were waiting over 90 days to be seen in the Out Patients Department by a specialist team. The length of patient stay at Tallaght Hospital was outside the national average of 5.9 days. No hospitals in Ireland publish hospital waiting times for inpatient waiting lists.
A fish rots from the head and this investigation found that Tallaght Hospital, with its 23-person Board, did not have the relevant diversity of knowledge, skills and competencies required to carry out the full range of oversight responsibilities necessary. The appointment process to the Board was also criticised.
Sub-committees of the Board established to manage the activities of the Hospital had no executive powers but merely advised, reported to and made recommendations to the 23-person bloated conclave of inertia and incompetence.
Concern was also expressed about financial management, financial transparency and commitment control and there were insufficient controls in place to ensure compliance with public procurement legislation.
There have been four incumbents in the chief executive role at Tallaght Hospital suggesting that it was as shabbily led as the State featherbedded Irish Red Cross. There was no clear process of delegation from the Board to the Chief Executive and supporting team in relation to the delivery and performance.
The framework for accountability and oversight relationship between Tallaght Hospital and the HSE is reflected in a Service Arrangement – but this, too, was flawed. There was no reconciliation between funds available, budgetary overspend, catchment areas, innovation and research, demand and capacity and the core business of delivering high quality safe care to patients. There was no evidence to demonstrate a clear understanding of the collective roles and responsibilities of each statutory and non-statutory hospital’s contribution to the overall delivery the HSE service plan for the catchment area Tallaght Hospital serves.
That slovenly Board tolerated a culture of patients lying on trolleys in corridors for long periods of time. A new interim board of 16 members has been appointed, nine of whom are non-executive. The Tallaght Hospital web site does not provide a biography of any of them to indicate the nature of Board tenure; the area of skill, expertise and competence that each brings to this Board nor is there anything published to indicate why the public should trust them.
Two sets of abbreviated minutes in respect of board meetings in January February are published but there is no performance indicators, no financial information, no insight into how the recommendations of the HIQA report are being responded to nor archived data in respect of prior years.
These two Board meetings last a total of five hours. No information is published as to what has ensued to enhance public confidence in this Hospital since the end of February – 100 days ago. Another case of the blind leading the bewildered without any evident engagement with the most important stakeholder, the public?
HIQA recommended that this interim board be dissolved and replaced by a new substantive board of no more than 12 members with demonstrable expertise to effectively govern Tallaght Hospital. The new board should be selected and appointed through an independent process established by the States and on the basis of having the necessary skills, experience and competencies to fulfil the role effectively. Individuals with conflicts of interest, including employees of the Hospital, should not be appointed to the Board.
A stronger performance management of board members should be introduced whereby there is an effective code of governance in place. Understandable, concise and relevant information that demonstrates that Tallaght Hospital is achieving strategic objectives and effectively managing the available resources and providing good safe care needs to be available for public inspection.
The board needs to understand their fiduciary duties as opposed to their tribal interests and the consequences of decisions and indecision.
This HIQA investigation is a commendable piece of work and the visible results of the recommendations need to become apparent very quickly.