The Dublin Midlands Hospital Group’s new five year strategic plan 2018 – 2023 focuses on five key strategic aims that will drive DMHG’s reform and development priorities. Maureen Browne reports.
Tony O’Brien, Director General of the HSE described the strategy as a ‘five-year roadmap’ for the delivery of hospital services for a population of more than 800,000 who may access care in the Group’s seven hospitals.
The Group’s five key strategic aims are to deliver excellent standards of quality and patient safety, optimise service delivery, ensure patients are treated in the right place, at the right time, by the right people, develop integrated care between Dublin Midlands Hospitals Group and its Community Primary Care Partners, foster education, academic research and innovation and strengthen co-operation and collaboration between the Dublin Midlands Hospital Group hospitals.
It has proposals on service delivery priorities in different areas.
Urgent & Emergency Care
It says prompt and optimum care for patients with serious medical and surgical conditions can only be provided where there are adequate numbers of staff with the essential skills to provide a 24/7 service.
It wants urgent and emergency care services to be redesigned to integrate between smaller and larger sites providing the optimum and safest configuration to deliver high quality emergency care.
It says it will:
- Invest in the recruitment of senior decision makers in the Urgent and Emergency Care Services.
- Formalise Trauma Networks between Tallaght Hospital, the Midland
- Regional Hospital Tullamore and St. James’s Hospital and align the development with the forthcoming National Trauma Report.
- Implement an ambulance by-pass for trauma patients at Naas
- General Hospital when appropriate.
- Expand acute floor capacity, principally in Tallaght Hospital and the Midland Regional Hospital Tullamore.
- Develop a Medical Assessment Unit (MAU) in the Midland Regional Hospital Portlaoise in line with National Clinical Care Programmes Models of Care.
- In conjunction with the Emergency Medicine Programme, develop appropriate streaming of patients for minor injury treatment.
- With the Community Healthcare Organisations (CHOs), work with General Practitioners and the Irish College of General Practitioners to provide seamless integrated care.
Acute Medicine Services
The strategic report says in excess of 80% of patients in our acute hospitals are emergency admissions following presentation at the Emergency Department. “Hospitals are under enormous strain as evidenced by the modern barometers of acute hospital care, the number and waiting times of patients on trolleys and the numbers of patients waiting for elective investigations and treatments.”
The strategy says the Group will:
- Invest in the recruitment of senior decision makers in the Acute
- Invest in improving patient flow pathways within hospitals and
- Invest in appropriate diagnostic services.
- The Group will work with the Acute Medical Programme to develop Acute Medical Assessment Units (AMAU) and Medical Assessment Units (MAU) where appropriate in its hospitals.
- The Group will develop formal linkages between its Community Healthcare Organisations (CHOs), General Practitioners and its acute hospitals to evaluate and develop best practice for Integrated Care Programmes, inclusive of integrated discharge planning.
The report says one of the major challenges facing the Acute Hospital Service is the delay experienced by patients waiting for elective inpatient and day care surgery, particularly non-cancer surgery. “There is considerable scope for treating more patients within the current system by managing the overall surgical pathway and current facilities better. “The development of skilled dedicated efficient day care surgery centres is a priority for the Group. The provision of elective inpatient surgery is much more complex. The challenge is a national/international one and the Dublin Midlands Hospital Group will work with the National Programmes, the HSE and Department of Health to improve this area of acute hospital health care.”
It says it will:
- Build its capacity to provide a model of elective surgery in line with the national model of elective surgery.
- Ensure there are protected day ward and inpatient beds for elective surgery.
- By adopting ‘local care pathways,’ it will ensure that the patient’s elective surgical journey is planned, efficient and predictable from start to finish. It will take account of the full range of hospital staff including management, doctors, nurses and allied health staff so they can make the journey as expeditious and as safe as possible, and delivered to the highest clinical standards with the best possible outcome.
- Extend some of the excellent practices already in place at some of its hospitals, encouraging initiatives that focus on pre-admission assessment clinics, extend the utilisation of day of surgery admissions,
maximise use of day care surgery, improve discharge planning, protect day ward and inpatient surgical beds and maximise operating theatre capacity and efficiency
In addition, it says it needs to:
- Extend bed capacity for both inpatient and day case surgical activity.
- Support its hospitals to meet national hospital and specialty targets for the average length of stay of surgical inpatients whether or not they have surgery and provide support for its hospitals to meet national and international standards.
The report says the establishment of clinical networks was a priority for the Group. “A clinical network can be defined as a clinical grouping which will provide collaborative advice to the Group and hospitals regarding the optimal clinical pathways/ service delivery for our patients, speciality or system based.”
It says networks will align advice with the National Clinical Programmes Models of Care and other evidence-based models, and should consider key elements such as complexity of care, skill mix and staff numbers, and essential infrastructure. “Their primary function is to improve patient access to quality care. Their creation is particularly crucial and urgent as we transition from hospital centred to Group centred service delivery. Clinical networks comprise areas of defined care across the Group hospitals and will be specialty or system based, e.g. critical care or cardiac respectively. Clinical networks will comprise representation from medical, nursing and allied health staff specific to these specialties from Group hospitals.
“The remit of the clinical networks will be to consider the scope, location and requirements for optimising services within the Dublin Midlands Hospital Group. Key areas for focus will include, but are not limited to alignment with national/international best practices and integration with the National Programmes, location of services, identification of resource, capacity requirements and allocation and future service planning.
“Recommendations from the clinical networks will be reviewed jointly by the Dublin Midlands Hospital Group and its hospitals and factored into service planning.”
It intends that the clinical networks will evolve and integrate with the relevant community care partners as they develop in the future. It will formalise and extend a number of successful projects by voluntary hospital clinical groups using a collegial approach to rationalise and coordinate specialty care across part or all of the Group, e.g. Cancer, Endocrinology, Vascular Surgery, Nephrology, Stroke and Women and Infants Services. “Their foundation has been based on clinical collaboration which is their key strength. These networks now need to have formal recognition and structure in order to upscale their advisory role in service design, planning and delivery. The clinical networks will work within existing clinical governance structures. Networks will be supported by existing human resource and financial planning models established within the Group to best meet the needs of the priorities identified.”
“Subspecialised endocrinology clinical pathways, e.g. pituitary, thyroid and adrenal, are already well established. Diabetes services are widely available and need further investment in capacity and liaison with primary care services in order to cope with the impact of the ageing population and complexity of chronic disease management.”
“There is a well-developed network between the major renal centre in Tallaght Hospital, St. James’s Hospital and the Midland Regional Hospital Tullamore. The network must develop a plan for further integration to address existing and future demographic demand.
“The Group works closely with the National Cancer Control Programme. Care pathways for the management of patients with cancer from electronic referral through diagnostic and treatment guidelines are well established in the Group and nationally. Restructuring of cancer surgery will be in line with the 2017 National 10 Year Strategy for Cancer Control.
“St. James’s Hospital is the designated cancer centre for the Dublin Midlands Hospital Group. All relevant cancer surgeries in urology and gastroenterology will be transferred to St. James’s Hospital. Some non-cancer surgery may have to be transferred from St. James’s Hospital to other Group hospitals in order to release the required resources to facilitate this transfer. St. Luke’s Radiation Oncology Network (SLRON), medical oncologists in St. James’s Hospital, Tallaght Hospital and the Midland Regional Hospital Tullamore, cancer surgeons and the relevant allied professional staff will become part of a multi-disciplinary cancer network.”
SLRON provides the entire Dublin and Midlands public radiation oncology service and the national services in sub-specialities such as Total Body Irradiation, Stereotactic Radiation, ocular brachytherapy and Paediatric radiation oncology. In partnership with the NCCP, it says it will expand capacity on the Beaumont and St James’s sites to meet the growth in cancer incidence and prevalence which is expected to almost double by 2040 as a consequence of the aging population.
“The national centre for allogeneic and autologous stem cell transplant (facilities and staff) at St. James’s Hospital will be expanded to meet growth in demand for curative cancer therapies.”
The Group says it will work closely with St. James’s Hospital, Trinity College Dublin and the NCCP to develop a capital plan for a Cancer Institute which will provide both comprehensive cancer care and research.
Women and Infants Services
“The priority for developing Women & Infants Services will be to ensure equally excellent outcomes for all women requiring obstetrical or
gynaecological care and for all infants.”
Obstetrics and Gynaecology Services
The report says it will continue developing the maternity clinical network between the Coombe Women and Infants University Hospital and the Midland Regional Hospital Portlaoise and progress the implementation of the Memorandum of Understanding between the Coombe Women and Infants University Hospital and the Group.
It will work with the National Women and Infants Programme to ensure “our patients are receiving the best care, consistent with the National Maternity Strategy, implement universal access to anomaly scans, implement the funded Maternity and Neonatal Clinical Management System in the Midland Regional Hospital Portlaoise and the Coombe Women and Infants University Hospital, develop a community midwifery Programme and expand capacity for elective gynaecological services in the Group.”
“We are working with the Children’s Hospital Group to formalise a hub and spoke model between the Midlands and the Children’s Hospital Group to care for all common paediatric medical and surgical conditions that do not require referral to the tertiary paediatric centre. We will collaborate with the National Clinical Programme for Paediatrics in implementing
relevant models of care.”
“Adult critical care provides specialised care for patients whose conditions are life threatening and require comprehensive care and monitoring.
While the critical care services across the Group work in a cooperative manner to optimise access there is still a marked deficit in critical care capacity. A major capital investment in development of critical care capacity is a top priority for the Group. We are developing a network to advise in planning the scope and location of services in alignment with the
National Programme in Critical Care.”
“Major trauma is the leading cause of death in people under 44 years of age. The National Office of Clinical Audit (NOCA) established a Major Trauma Audit which showed that in 2014 and 2015, almost a third (30%) of major trauma victims were admitted to hospitals which did
not have the resources to treat their injuries necessitating their transfer to other hospitals. In 2015 the then Minister for Health established a
Trauma Policy for Ireland Steering Group which presented its draft report “End to End Trauma Care; A Trauma System for Ireland” to the
Minister for Health in June 2017.
“The Dublin Midlands Hospital Group has held initial consultations with the major stakeholders and is in the process of developing a set of proposals for submission to highlight the strengths of a Tallaght Hospital and St James’s Hospital partnership in seeking the major trauma centre designation and the strengths of the hub and spoke models between St James’s Hospital, Midlands Regional Hospital Tullamore and Tallaght Hospital for designation as major trauma units.”
“The Group has established a review team to consider models of care for the delivery of urology cancer surgery. A urology network must advise the Group and hospitals on the distribution of services for benign conditions and must collaborate in centralising cancer services in St. James’s Hospital.
“ Increased capacity for benign urology services in the Midland Regional Hospital Portlaoise, Midland Regional Hospital Tullamore, Naas General Hospital and Tallaght Hospital are contingent on the recruitment of additional consultants and nurses. Due to specific urgent service requirements and patient needs, the Dublin Midlands Hospital Group has prioritised a short list of clinical networks which need to be established
immediately in order to identify and implement strategies for service improvement. These include diagnostics, dermatology, endoscopy, trauma and urology. As experience and confidence evolves in the rollout of clinical networks, further specialties will be engaged over time.
For these prioritised clinical networks, all hospitals will be requested to nominate network members. Members will be asked to nominate a Chair. The Dublin Midlands Hospital Group Clinical Director and CEO will work with the networks to ensure clarity regarding their role and function in their advisory capacity. The Dublin Midlands Hospital Group will ensure
that these clinical networks will have the data, support and communications they require when undertaking their activities.”
“The majority of medical diagnoses and treatment decisions are based on results of diagnostic tests. Rapid access to diagnostics, whether in hospital or in the community, enables earlier diagnosis, earlier initiation of appropriate therapy, better outcomes and shorter length of hospital stay. The recent introduction of advanced technologies in diagnostic medicine, specifically in imaging and laboratory medicine, by the HSE greatly enhances national diagnostic services. The National Integrated Medical Imaging System (NIMIS) was rolled-out starting in 2010, the clinical network should advise regarding remote reporting and shared on-call systems. They will evaluate diagnostic imaging capacity and determine requirements for timely service delivery. The National Medical Laboratory Information System (MedLIS) will be rolled-out across
“In order to focus on improving access timelines, the network is being established to provide advice on a workforce plan and the development of shared services and waiting lists across hospitals.”
“Gastrointestinal endoscopy waiting lists and times are a source of national concern. Due to the magnitude and importance of endoscopy demand a National Endoscopy Lead has been appointed, who has already carried out an analysis of the Group needs and capacity following a review of the five endoscopy sites. In collaboration with the National Endoscopy Lead, the 2018/19 focus will be on recruiting staff for the Midland Regional Hospital Portlaoise and meeting equipment requirements for St. James’s Hospital.
“The Hospital Group is prioritising the need for capital funding for Naas Hospital to expand endoscopy and day ward services. The Group is developing a five-year plan to expand facilities and staffing across all hospitals to fully address demand.”