Statement of Purpose

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1.

0 Introduction

Naas General Hospital is a 243 bedded acute public hospital serving the catchment area of
Kildare and West-Wicklow with a population of over a quarter of a million people. Our services
are designed to meet the needs of the adult (over 14 years) population in this catchment area.
The majority of our hospital activity results from unscheduled inpatient admissions through the
Emergency Department (ED). The emergency department is open 24-hours per day 7 days per
week all year round. Service users can self-present to ED or referral can be made by General
Practitioner (GP) services or within the hospital via Out Patient Department (OPD). Service
users can also access the day ward, the day hospital and the outpatients department via GP
referral.

2.0 Our Aim


Our aim is to provide a high-quality patient-centered service, which is safe, cost effective and
flexible. We hope to realize our vision with implementation of our mission statement.

Mission Statement

Together we will provide equitable and quality patient care, delivered safely by skilled and
valued staff, through the best use of available resources

3.0 Strategic Objectives

3.1 Implementation of HIQAs National Standards for Safer Better Healthcare 2012 in
conjunction with the HSEs Corporate Strategy

Naas General Hospital has developed their strategic quality objectives in line with the eight
themes of HIQAs National Standards for Safer Better Healthcare (HIQA, 2012) and to align with
the HSEs Corporate Strategy 2015-2017 (HSE, 2015).

Theme 1: Person-centered care and support


We promote kindness, consideration and respect for our patients dignity, privacy and
autonomy. We consider our service users needs when planning and delivering care in order to
improve patient experience and outcomes. We effectively listen to our service users and aspire
to meet their needs with consideration and compassion.

Theme 2: Effective-care and support


We aim to consistently deliver best achievable outcomes for our service users in the context of
our own hospital services and resources and, our provisions for accessing and co-coordinating
care for our service users within our hospital group. We deliver care based on best available
national and international evidence to achieve best outcomes for service user. We promote
professionalism and quality in our delivery of care.

Theme 3: Safe-care and support


We endeavor to deliver high quality care by embedding a culture of safety and quality
improvement into all processes and daily practices within our organisation. We continue to
monitor and assess these practices through evidence base, self assessment, clinical and non-
clinical audit, service users feedback and incident review.
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Theme 4: Health and wellbeing
We maximize our opportunity to positively influence service users and staffs health and
wellbeing. We actively promote nationally recognised health promotions and policies in order to
help achieve this goal. We refer to the HSEs paper Healthy Ireland a Framework for Improved
Health and Wellbeing 2013-2025).

Theme 5: Leadership, governance and management


We create a well-governed service to ensure sustainable delivery of high-quality safe, effective
person-centered care and support. We have clear lines of accountability at individual, team and
service levels. We support and develop leaders within our organisation and push forward the
agenda of patient safety and quality improvement. We promote effective communication and
co-operation between and within departments. We implement and promote departmental
standards to continue to achieve high quality care. We promote clinical governance through
implementation of national standards and stewardship of national strategies. We regularly
rehearse tactical response practices to ensure readiness for major event occurrence. We
encourage effective leadership through regular management and strategic group meetings.

Theme 6: Workforce
Our workforce is committed to delivering a high quality and safe service. We support our
workforce to achieve this by providing a safe working environment, and by creating a skill mix
within teams that compliments the organisation as a whole. We adhere to national mandatory
training programs. We encourage professional motivation through continuous professional
development and by promoting clinical developments. We aspire to harness the maximum
potential of staff by promoting and cultivating innovative approaches. We encourage strong
links with our academic partners and encourage internships and work placements.

Theme 7: Use of Resources


In order to best utilise our resources, we actively and regularly plan, manage and deliver our
services in order to achieve safe, high-quality care. Decisions made by those responsible for
resources are well informed and transparent. We aspire to focus our resources where they are
needed most. We encourage initiatives that link departments and stakeholders to provide a
uniform and cohesive work force, where resource management is accountable and equitable.

Theme 8: Use of Information


Quality information which is accurate, valid, reliable, timely, relevant, legible and complete
forms the basis for managing, delivering and monitoring our services. We are committed to
developing systems to ensure the collection and reporting of high quality information which will
support quality improvement of services. We adhere to national frameworks and standards for
maintenance of accurate records for legislative requirements. We promote a culture and
atmosphere of communication where service users may understand information that is relevant
to their care.

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3.2 Our Vision

Our vision is to realize a health system that has as its primary focus patient safety and quality of
care

Delivering our Vision

In order to achieve our vision we refer to The Report of the Quality and Safety Clinical
Governance Development Initiative: Sharing our Learning March 2014.

This report illustrates a framework for governance of quality and safety which was developed in
collaboration with health service providers, the framework is made up of vision, principles and
matrix of structures and processes that support clinical governance development.

The main purpose of this report is to consolidate learning and make core recommendations for
health service providers, policy makers and commissioners to inform their own specific actions
plans. Consequently, we believe that in following the principles and guides detailed below we
will achieve our vision. The report recommends the following as central to deliverance of a
quality service:

Active listening with patients and staff - understanding the experience of patients (what
matters to them) and what motivates staff is central in creating a quality culture.
Real time measurement prompts wise decisions which lead to the need for good quality
data and transparency.
Terminology matters in avoiding confusion - the term clinical governance was seen by
some as management speak- therefore, we are proposing the term quality and safety
and specifically governance for quality and safety.

We will aspire to implement these guides in order to link quality initiatives and improvements
in order to provide cohesive, consistent, continuous, high standard care within the framework
of our available resources.

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4.0 Our Services

4.1 Description of Services Provided

Naas General Hospital provides the following services


General Medicine
General Surgery
Emergency Medicine
Acute Psychiatry
These services are provided 24 hours a day 7 days a week throughout the year. The hospital
provides comprehensive medical and surgical investigation, diagnosis and treatment service for
person aged 14 years and over.

Consultant Doctors
General Medicine
Emergency Medicine
Endocrinology
Cardiology
Gastroenterology
Geriatrics/Stroke
Surgeons
Dermatology
Rheumatology
Haematology
Microbiology
Palliative Care
Oncology
Orthopaedics

Advanced Nurse Practitioners & Nurse Specialists


Minor Injuries
Cardiology
Infection Prevention & Control
Respiratory Care
Oncology Care
Palliative Care
Haemovigilance
Health Promotion
Cardiac Rehabilitation
Diabetes
Anti-Coagulation
Stroke
Tissue Viability
Resuscitation Training Officer
Rheumatology
GP Liaison

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4.2 Further Services are delivered in the following areas

Acute Medical Assessment Unit


Care of the Elderly Day Services (Day Hospital)
Clinical Engineering
Day Ward: Including Endoscopy & Colonoscopy, Paediatric Dental Service (Community
Referral)
Cardiology Diagnostics
Occupational Therapy
Pharmacy Dispensary & Team-Based Clinical Services
Physiotherapy
Pulmonary Function Laboratory
Radiology X-ray, Ultrasound, CT, MRI
Social Work
Speech and Language Therapy
Clinical Nutrition and Dietetics
Laboratory Service
Palliative Care
Phlebotomy
Out-Patient Department
Anti-Coagulation Clinic
Oncology /Haematology Day Unit
Cardiac Rehabilitation Unit
Pre-Assessment Clinic
Stroke Service
Pastoral Care
Central Sterile Services Department
Minor Injury Unit

4.3 Integration Arrangements

Naas General Hospital is of the hospitals within the Dublin Midlands Group and supports the
integration of services between hospitals within this group. A number of the consultant doctors
have joint appointments with other hospitals. Naas General Hospital links with the tertiary
referral centres outside the hospital as necessary. A number of pathways exist linking our
hospital services to community service.

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5.0 Quality & Risk Management

The Quality & Risk Department within the hospital has responsibility for risk management,
complaints management and management of compliance with National Standards. The Quality
& Risk Department operates according to HIQA National Standards for Safer Better Healthcare.
It also operates according to HSE policies around quality, risk and complaints management
including HSEs Safety Incident Investigation Policy 2014 and Your Service Your Say.

Compliments, Comments and Complaints

Complaints are managed according to the HSEs national policy Your Service Your Say which
integrates HSE guidance in meeting the legislative requirements. In keeping with the
Ombudsman recommendations, we will attempt to resolve complaints as efficiently as possible
in accordance with the complainant and to their satisfaction in an informal manner. If you wish
to proceed to formal investigation stage, your complaint will be investigated thoroughly and
you will be informed of the outcome as soon as possible. Complaints are treated in complete
confidence and will not affect your current or future treatment. Please address complaints to:

Patient Services Department,


Naas General Hospital,
Naas,
Co. Kildare.
Email: [email protected]

As well as complaints, we welcome your views on the service and care we provide. We are
delighted to hear when we are doing well, but we also need to know what we can do better. If
you would like to make any comments on our services (compliments, suggestions or feedback),
please direct to the above contact details.

National Healthcare Charter - You and Your Health Service


The National Healthcare charter is a statement of commitment by the HSE describing:
What you can expect when using health services in Ireland
What you can do to help Irish health services to deliver more effective and safe services

6.0 Policies and Procedures

Naas General Hospital is committed to the provision of safe, high quality health services,
delivered according to our standardised policies, procedures, protocols and guidelines
(PPPGs) that are based on best available evidence. This should lead to achievement of best
possible health and personal social care outcomes for patients and service users, within our
available resources.

National Clinical Guidelines are considered for use in local practice when assessing and
planning services. Risk assessments are documented when services are unable to fully
implement National Clinical Guidelines and appropriate action taken to ensure the quality and
safety of services. Arrangements are in place for training staff in appraising and developing
policies, procedures, protocols and guidelines and for identifying evidence-based best
practice.

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