IMPROVEMENT AND SAFETY
South Tipperary General
3rd – 6th December 2007
Table of Contents
1.0 Introduction ....................................................................................................... 3
2.0 Executive Summary .......................................................................................... 5
3.0 The Accreditation Award ................................................................................... 8
1.1 Introduction to Accreditation
Accreditation is a three-year learning and continuous quality improvement process.
Participating organisations are required to undertake self-assessment against a set
of internationally recognised standards, followed by an on-site survey. The survey
aims to validate the self-assessment and includes provision for documentation
review, interviews with Self-Assessment Teams, patients/ clients, staff and tours of
the relevant facilities.
This report details the outcome of the accreditation process for South Tipperary
General Hospital where an accreditation survey was undertaken during the week of
3rd of December 2007.
1.2 Organisation Profile
South Tipperary General Hospital is a 253 Bed hospital providing acute services for
the South Tipperary population of 82,000 people (2006 census) and bordering areas
of North Tipperary and West Waterford increasing the catchment area up to 135,000.
There are 781 staff in the organisation.
Acute hospital services in Cashel amalgamated in South Tipperary General Hospital,
Clonmel in January 2007 following a major capital development to facilitate the
transfer of A&E, General Surgery and Oncology services. There are two clinical
directorates in place, supporting the Clinicians in Management initiative. A review of
the management structure took place in 2007, resulting in the formation of the
Hospital Management Team which is chaired by the General Manager who reports to
the Network Manager.
1.3 Accreditation Objectives
The Hospital’s objectives for undergoing the accreditation process are to:
• Establish a programme of continuous quality improvement in South
Tipperary General Hospital.
• Develop a quality ethos by embedding quality into the hospital.
• Achieve external validation from which direction can be taken to improve
• Improve communication and team building between departments and
1.4 Survey Team
A Team of five Surveyors participated in the Accreditation Survey. This Team
comprised of four Surveyors from the Irish Health System and one Surveyor from the
Southern Hemisphere. The Surveyors participated in Self-Assessment team
interviews, facilities tours, met patients/ clients, staff and reviewed documentation
relating to all teams and the Organisation as a whole.
1.5 Self-Assessment Teams
The organisation established eight Self-Assessment Teams as part of the
accreditation process. These were:
Table 1.1: Self-Assessment Teams
Corporate Management Teams Care Teams
1. Leadership and Partnerships 5. Obs/Gynae and Paediatrics
2. Environmental and Facilities 6. Accident and Emergency
Management 7. General Surgical
3. Human Resource Management 8. General Medicine
4. Information Management
2.0 Executive Summary
2.1 Organisational Summary
The management and staff are to be commended on the successful amalgamation of
the Cashel and Clonmel acute hospital services and their ability to provide and
sustain the delivery of services during this period of significant change.
The Survey Team acknowledges a management team that provides leadership and
direction to its staff, which is evidenced by their support, enthusiasm and strong
commitment to both the accreditation process and the desire to drive quality
This commitment and desire to improve quality of services provided by the hospital,
is also evidenced by the hospital’s recent review of its management structure and the
subsequent establishment of a Hospital Management Team (HMT). The Survey
Team recommend that the new hospital management structure be embedded, and
the structure further reviewed with a view to defining clearer roles and
responsibilities, particularly in areas such as Environmental Services, Hygiene,
Information Management and Human Resources.
There is some evidence of strategic planning within the Hospital and this was
particularly evident within the planning process the hospital undertook prior to the
amalgamation of the two hospitals. It is recommended that the hospital work closely
with the Health Service Executive and develop a strategic plan for the hospital for the
next five years. This will provide clear direction and focus on the hospital's future.
The Hospital is at an early stage in developing a continuous quality improvement
ethos and culture. The Quality Improvement programmes have been espoused by
the hospital management and the Health Service Executive regional management
through the Multidisciplinary Quality Group. It is recommended that the quality
improvement programme be formally included in the strategic planning processes to
ensure it receives the appropriate attention and focus within the Hospital. A
comprehensive suite of organisational key performance indicators should be
developed. Ongoing evaluation, auditing and benchmarking against best practice is
There is a regional clinical ethics committee in place; it is recommended that the
hospital establish a local ethics committee/process to support staff to deal with
clinical ethical issues.
There are structures in place to identify, analyse, prioritise and eliminate or minimise
risks. However, this would need to be further developed and include a robust
feedback mechanism and training strategy for all staff to ensure a process of learning
The Survey Team acknowledges a commitment to patient/ client care within the
Hospital and the Staff’s desire to achieve excellence in the delivery of its services,
often within difficult physical circumstances. This is evidenced by the best practice
guidelines developed across the organisation, including The Cardiac Investigation
Unit, The Australian Triage System in the Emergency Department, the Minor Injuries
Unit and the introduction of the Advanced Nurse Practitioner role. The self-
assessment teams would benefit from setting clearly defined goals and objectives
with agreed performance indicator monitoring.
The level of integration between the hospital services and Primary, Community and
Continuing Care is noted. The Service User’s Representative Forum is a powerful
vehicle for including the patient/clients in the hospitals planning processes and it is
noted that the recommendations from this group are often implemented by the
hospital. It is recommended that this continues.
The on site documentation presented by the self assessment teams was clearly
indexed. However, there were gaps in the information provided. Additional
information was provided promptly as requested.
In conclusion, hospital management and staff are to be commended for their
commitment to the provision of quality patient/client care and the accreditation
process, and for the mutual respect and team spirit that exists in the hospital. The
new initiatives and quality improvement plans which have commenced should be
embedded and further progressed and formalised within the culture of the hospital.
2.2 Overall Performance
2.2.1 Areas of Excellence
• The successful amalgamation of the Cashel and Clonmel hospital services.
• The patient representative user forum is a powerful vehicle for including the
patient/clients in the overall planning process
• Implementation of hospital wide quality and risk programme
• The robust linkages with Primary, Community and Continuing Care (PCCC)
and Supporting Agencies
2.2.2 Areas for Priority Action
• A local Ethics Committee/process should be established to support staff to
deal in a formalised manner with clinical ethical issues
• Progress recruitment of the necessary number of Clinical Pharmacist’s for
• Introduce the “Baby Tagging” security system in the Maternity, Labour Ward
and the Neonatal Unit
• Ensure there is a documented process in place to assess all new
interventions which are introduced, prior to their introduction, this should
include any changes to existing interventions
3.0 The Accreditation Award
3.1 Award Decision
The decision mechanism used to translate an organisation’s criteria and risk ratings
to an accreditation award is based on a quantitative analysis of the survey results
which ensures consistency of application. The decision regarding an Accreditation
Award or Recognition Status is made by the Internal Review Committee of the Health
information and Quality Authority and advised to the Board. Based on the findings of
the Survey Team South Tipperary General Hospital is awarded:
Pre Accreditation- Level 1