REPUBLIKA.CO.ID, YOGYAKARTA — Rumah Sakit Pusat Angkatan Udara (RSPAU) Dr Suhardi Hardjolukito bekerjasama dengan Fakultas Kedokteran Universitas Gadjah Mada (FK UGM) dan Rumah Sakit DR Sardjito untuk menjadi rumah sakit pendidikan. Ke depan, mahasiswa-mahasiswa FK UGM akan melakukan co assistent di RSPAU.

“Kerja sama ini diharapkan dapat meningkatkan kualitas proses pelayanan kesehatan, penelitian dan pengabdian kepada masyarakat,” kata Kepala RSPAU Dr Suhardi Hardjolukito, Marsma TNI Benny H Tumbelaka di Yogyakarta, Rabu (16/10).

Lebih lanjut Benny mengatakan kerja sama ini sekaligus membuktikan kepedulian dan kontribusi RSPAU dr Hardjolukito, FK UGM, dan RSUP DR Sardjito terhadap pendidikan tenaga medis di Indonesia.

Kerja sama ini merupakan kerjasama yang kesekian kalinya, karena hasil kredensial yang telah dilakukan sudah memenuhi syarat legalitas, sumber daya manusia yang kompeten dan profesional, mutu pelayanan yang terakreditasi.

“Juga fasilitas baik medis maupun penunjang medis yang memenuhi standar yang telah ditetapkan Kementerian Kesehatan RI,” kata Benny.

Rumah sakit, kata Benny, saat ini semakin diminati masyarakat. Namun di satu sisi, kedudukan masyarakat lebih kuat dan banyak pilihan rumah sakit yang dapat melayaninya. Sehingga masyarakat akan memilih rumah sakit yang bisa memberikan pelayanan yang memuaskannya.

Untuk bisa memberikan pelayanan prima, lanjut Benny, rumah sakit tidak bisa bekerja sendiri-sendiri. Karena itu perlu kerja sama dengan rumah sakit yang lebih bagus pelayanannya.

“Hari ini kami sangat berbahagia dapat bekerja sama dengan institusi pendidikan terbaik di Indonesia dan RSUP Sardjito, rumah sakit kedua di dunia yang diberi penghargaan untuk problem solving for better hospital,” katanya menandaskan.

Bentuk kerja sama, kata Benny, tukar ilmu pengetahuan, pendidikan, pelayanan pasien, dan lain-lain. Rumah Sakit Dr S Hardjolukito merupakan salah satu rumah sakit pusat TNI yang baru saja menyandang rumah sakit pusat yang diberikan markas besar TNI, satu tahun yang lalu.

Sedang Dekan FK UGM, Teguh Aryandono mengungkapkan pelayanan terbaik di rumah sakit menjadi kunci banyaknya pasien. Kerjasama ini merupakan upaya untuk memberikan pelayanan yang prima.

Sebab, kata Teguh, tahun 2015 bakal terjadi globalisasi pelayanan kesehatan. Bila pasien tidak puas di negeri sendiri tentu mereka akan lari berobat ke luar negeri. “Kita harus bisa menjadi tuan rumah yang baik di negeri sendiri,” kata Teguh.

Sementara Direktur Medik dan Keperawatan RSUP DR Sardjito, dr Sutanto Maduseno mengatakan adanya perubahan status Rumah Sakit DR Sardjito menjadi rumah sakit tipe A, jumlah pasien rawat jalan mengalami penurunan. Para pasien banyak yang berkunjung ke rumah sakit

tipe B, seperti RSPAU dr S Hardjolukito. “Dengan demikian RSUP Sardjito bukan lagi Puskesmas besar,” ujarnya.

Agar bisa memberikan pelayanan yang baik, kata Sutanto, rumah sakit harus diakreditasi mulai dari pratama hingga paripurna. “Rumah sakit terakreditasi pari purna, bila dapat memberikan pelayanan yang manusiawi serta fokus pada pasien,” ujatnya.

Sumber: republika.co.id

(AP) — CEOs at nonprofit hospitals earned an average of $600,000 a year — and in some cases, more than $3 million — but there was no correlation between high pay and good outcomes for patients, according to a new study.

CEOs were paid more at hospitals that got high patient satisfaction scores; used more high-tech equipment, including advanced imaging machines; had more beds and were in large urban areas.

But pay wasn’t reflected in 30-day outcomes for patients with heart attacks, heart failure or pneumonia in 2008, including deaths and readmissions. Those are among publicly reported outcome measures used by the federal Centers for Medicare and Medicaid Services and others.

A Crain’s analysis published earlier this year, however, did show that quality and safety are becoming more important benchmarks in hospital CEO pay for Chicago-area hospitals.

While hospitals get big tax exemptions for providing charity care and other community benefits, the researchers in the national study said the top executives’ annual pay wasn’t tied to those measures, either.

CEO compensation varied widely, from less than $100,000 to more than $3 million, but it averaged almost $600,000 in 2009, the study found.

The results were “a little disappointing,” said study author Dr. Ashish Jha, a health policy professor at Harvard’s School of Public Health. To not hold CEOs accountable for whether patients live or die within 30 days of treatment “doesn’t quite make sense,” he said.

‘HERE’S A PLACE TO LOOK’

Jha said the study results are a message for hospital boards that decide CEO compensation: “‘If you really care about patient outcomes here’s a place to look.”

The study was published yesterday in JAMA Internal Medicine. It is based on an analysis of public records including federal tax returns for 1,877 CEOs overseeing 2,681 private nonprofit hospitals.

Most U.S. hospitals are nonprofit, and those studied comprise 98 percent of private nonprofit hospitals, the study authors said.

In an editorial in the same journal, a hospital CEO in San Francisco disputes the conclusion and said CEOs may be compensated based on many other quality measures the authors didn’t consider. Dr. Warren Browner, CEO at California Pacific Medical Center, said using death rates and readmissions as a comparison can be misleading because both may be higher at hospitals that treat a higher proportion of very sick patients.

The American Hospital Association also took issue with the study.

Compensation for nonprofit hospital leaders “is set by an impartial board of community representatives,” said association spokeswoman Elizabeth Lietz. “It appears that the study fails to fully capture the full range of responsibilities of today’s health care leaders.”

Browner, the editorial author, said hospital CEOs’ compensation typically includes a base salary plus incentive pay if the hospital meets certain targets, which may include financial performance, patient satisfaction and several other quality measures. Browner noted that patient satisfaction is subjective but easier to gauge than some other measures.

Source: chicagobusiness.com

A national study on pay for nonprofit hospital chief executives found that the presence of advanced technology played a bigger factor in higher compensation level than did quality of care, charity care or initiatives to reduce readmission rates.

The Harvard University study was released Tuesday on the Internal Medicine website of the Journal of the American Medical Association.

Researchers based their report on publicly available 2009 total compensation data for 1,877 chief executives serving at 2,681 private nonprofit hospitals. The mean compensation level was $469,096 for calendar year 2009, with a range of $106,324 to $2.1 million.

The researchers said what made their study different is that they “determined the degree to which a hospital’s performance on financial metrics, technologic metrics, quality metrics and community benefit in 2008 was associated with CEO pay in 2009.”

“Executive compensation metrics are a powerful reflection of the priorities of an institution, and likely have the ability to shape the focus of the CEO,” the researchers said in their conclusion.

“We found that CEO compensation at nonprofit U.S. hospitals varies widely and is associated with greater use of technology and higher patient satisfaction, but not with quality of care delivered, patient outcomes or community benefits.”

For example, chief executives of nonprofit hospitals with high levels of advanced technology earned on average $136,000 more than those with little advanced equipment.

“There was nearly no relationship between patient outcomes, particularly mortality and high readmission rates, and CEO compensation targets,” said Dr. Ashish Jha, the study’s main author and a professor of health policy at Harvard School of Public Health.

As a result, he questions whether nonprofit hospital CEO pay and the boards that set the compensation standards are “out of step” with efforts, such as by the Centers for Medicare and Medicaid Services, to more directly tie hospital reimbursement rates with patient outcomes.

Jha said the study did not include electronic health records as part of its technologic metrics since the transitional push away from paper records began in earnest shortly after the Obama administration began directing national health-care policy in 2009.

Jha said the researchers took on the study in part because of the influence that nonprofit hospitals’ chief executives have on “shaping the performance of their organizations through setting organizational priorities, allocating resources and hiring clinical leadership.”

Using the established metrics, the researchers determined compensation was higher for chief executives who managed more hospital beds, who ran an academic medical center (such as Wake Forest Baptist Medical Center), and the presence of higher levels of advanced technology. The average CEO of an academic medical center was paid $425,078 more than those at a non-teaching hospital.

On the flip side, chief executives were more likely to be less compensated if they had a higher proportion of poor patients and Medicare patients.

“Despite the fact that we examined nonprofit institutions whose tax-exempt status is based on their ability to demonstrate community benefit, we found no relationship between the degree of that benefit and CEO compensation,” the researchers said.

The researchers recommended that the link between CEO pay and hospital quality performances be made “more explicit.”

In a companion piece to the report on the JAMA website, Dr. Warren Browner, chief executive of California Pacific Medical Center, said most nonprofit hospitals do not reward chief executives more for technology advances, or glitz, than quality of care.

He agreed that pay for performance should apply to chief executives as much as doctors.

But he thought the researchers didn’t properly separate a chief executive’s base pay from his bonus and incentive pay. He said base pay is based mostly on a hospital’s structural attributes.

“Their conclusion that advanced technology drives CEO pay might be right,” Browner said.

“But an observational design cannot rule out alternatives, such as CEOs at fancier hospitals earn more because they are worth more, or because the members of the board compensation committees at glitzy hospitals are more accustomed to higher incomes.”

He said that hospitals that have high level of charity care demand “often struggle financially, making it less likely that their CEOs will be well compensated, even if their boards wanted to do so.”

He acknowledged that some hospital CEOs have “likely figured out how to game the system by working to align their incentive compensation with the metrics their hospital usually achieves – and trumpeting those results.”

Source: journalnow.com

PROBOLINGGO, KOMPAS.com — Panitia Khusus DPRD tentang Laporan Pertanggungjawaban (LKPJ) Wali Kota Probolinggo, Jawa Timur, melakukan inspeksi mendadak ke RSUD dr Moh Saleh, Kamis (10/10/2013) sore. Mereka meminta Direktur RSUD dr Bambang Agus Suwignyo agar menggunakan kebijakan lama terkait penanganan pasien miskin, yakni cukup mengantongi surat keterangan miskin dari lurah dan camat.

“Sebab, hal itu dikeluhkan oleh sejumlah pasien. Kesannya ada standar ganda dalam melayani pasien miskin. Bahkan ada yang komplain karena keluarga pasien didatangi pihak RSUD terkait status miskin seorang pasien,” kata pimpinan Pansus LKPJ, As’ad Anshari, didampingi anggota DRPD dari Komisi A, B, dan C.

Menanggapi keluhan tersebut, dr Agus menjelaskan bahwa kebijakan lama tersebut membuat anggaran Jamkesmas jebol. Sebab, banyak pasien mampu yang kemudian mengaku miskin dengan surat keterangan dari lurah dan kecamatan. Akibatnya, anggaran Jamkesmas RSUD sebesar Rp 2 miliar pernah jebol sehingga pemkot kalang kabut.

Karena itu, lanjut Agus, pihak RSUD membentuk tim verifikator untuk mengecek apakah pasien yang dirawat di RSUD benar-benar miskin atau hanya mengaku miskin. Setelah dicek, pihak verifikator kemudian membuat kriteria penggratisan biaya perawatan, dari 25 persen, 50 persen, hingga seratus persen.

“Yang jelas, pasien kami tangani lebih dahulu. Urusan administrasi dan verifikasi pasien kami lakukan setelah pasien tertangani. Jika tidak, pasien banyak yang mengaku miskin, padahal dia cukup kaya atau mampu,” beber dr Agus.

“Dengan kebijakan diverifikasi itu, pasien miskin ke RSUD malah mengalami penurunan. Mereka yang kaya mungkin malu setelah diverifikasi. Hingga akhir tahun ini, kami perkirakan dana yang dihabiskan mencapai Rp 1 miliar saja. Dulu kami sampai jebol lebih dari Rp 2 miliar,” lanjut dr Agus.

Dia menjelaskan, tim verifikator berasal dari pihak RSUD. Mereka bertugas mendatangi rumah pasien non-kuota untuk mengecek apakah pasien itu benar-benar miskin atau tidak.

Dalam sidak itu, Pansus LPKJ juga mengeluhkan sejumlah kejadian yang membuat pasien tidak nyaman. Misalnya petugas resepsionis yang sama sekali tidak ramah. Selain itu, ada juga keluarga pasien yang nyalinya ciut untuk membawa pasien ke RSUD, padahal dia memegang kartu Jamkesma, karena kurangnya sosialisasi Jamkesmas.

Sumber: kompas.com

Website ini akan update setiap Selasa pagi. Nantikan Informasi terbaru setiap minggunya.
Leadership menurut Standar Joint Commission Setelah dua RS berhasil meraih status terakreditasi oleh JCI, yaitu RSCM dan RSUP Sanglah, dalam waktu tidak lama lagi RS-RS pusat lainnya juga akan menyusul untuk memenuhi target pemerintah. Ada banyak standar yang perlu dipenuhi agar bisa terakreditasi, salah satunya adalah standar mengenai leadership. Di dunia nyata, ada banyak contoh kasus yang menggambarkan bahwa leaderhsip yang kuat akan dapat mendorong rumah sakit ke arah yang lebih maju, mencapai masa kejayaan dan menjadi pusat pembelajaran bagi RS-RS lainnya. Namun saat kepemimpinan berganti, tidak ada jaminan masa kejayaan tersebut tidak berakhir, meskipun pemimpin terdahulu telah menyiapkan sistem manajemen yang baik. Buku Leadership in Healthcare Organization ini merupakan pedoman untuk RS-RS dalam mencapai standar Joint Commission. Menurut buku ini, Direktur atau CEO RS bukan satu-satunya pihak yang bertanggung jawab terhadap governance di RS. Ada tiga pihak, yaitu the governing body, kelompok pejabat struktural, serta para pemimpin staf medis, kesemuanya bertanggung jawab terhadap keberlangsungan organisasi. Ketiga kelompok pemimpin ini harus berkolaborasi jika ingin tujuannya tercapai. Hal ini karena tanggung jawab para pemimpin RS bukan hanya memastikan fungsi-fungsi organisasi – khususnya fungsi keuangan untuk keberlangsungan organisasi – berjalan dengan baik. Ada tanggung jawab lain berupa penyediaan layanan kesehatan yang bermutu dan mengutamakan keselamatan pasien secara terus menerus. Inilah yang membedakan organisasi pelayanan kesehatan dengan organisasi atau lembaga usaha lainnya. Tanggung jawab yang satu (financial sustainability) dapat bertolak belakang dengan tanggung jawab yang lain (quality of care dan patient safety). Untuk itu Joint Commission mengembangkan empat kelompok standar untuk leadership, yaitu struktur, hubungan, budaya dan kinerja sistem, serta operasi. + Arsip Pengantar Minggu Lalu
	Membenahi RS juga bagian dari upaya public health		Pembentukan ikatan konsultan manajemen RS

DENPASAR, KOMPAS.com – Rumah Sakit di lima provinsi menjadi target pengawasan Badan Pengawas Tenaga Nuklir (Bapeten) dalam pemakaian alat-alat medis yang memakai teknologi radiasi.

Lima provinsi yang dimaksud adalah Jawa Timur, Jawa tengah, Jawa Barat, DKI Jakarta, dan Sumatera Utara.

“Lima provinsi itu kita target karena pemakaian alat medis dengan teknologi radiasi terus meningkat,” kata As Natio Lasman, Kepala Bapeten saat ditemui dalam konferensi pers Konferensi Internasional tentang Sumber, Efek, dan Risiko Radiasi di Denpasar, Bali, Kamis (10/10/2013).

Alat-alat medis yang memakai teknologi radiasi antara lain mesin sinar X atau rontgen dan alat diagnosis Magnetic Resonance Imaging (MRI).

Natio mengungkapkan, pengawasan perlu dilakukan untuk memastikan bahwa alat dengan teknologi radiasi punya izin, digunakan oleh pihak yang tepat, dan berfungsi baik.

Pengawasan alat tersebut penting karena radiasi yang ditimbulkan, bila melebihi ambang batas, akan merugikan pasien, seperti mengakibatkan kanker.

Sejauh ini, berdasarkan laporan, Bapeten menemukan beberapa kasus pemakaian alat dengan teknologi radiasi yang tidak berizin.

“Di Depok kita temukan ada di lima klinik,” kata Natio.

Sementara, di Aceh, Bapeten menemukan kasus dimana alat dengan teknologi radiasi dioperasikan oleh orang yang tidak kompeten.

Natio mengungkapkan, pemakaian alat dengan teknologi radiasi harus disertai izin. Bapeten berwenang mengeluarkan izin tersebut.

Pemakaian tanpa izin bisa dikenakan denda hingga lebih dari Rp 100 juta serta akan dibahas lebih lanjut apabila pemakaian secara terus- menerus terbukti mengakibatkan kematian.

Sumber: kompas.com

PT Askes menyediakan layanan baru dalam rumah sakit untuk menyongsong transformasi Askes menjadi BPJS (Badan Penyelenggara Jaminan Sosial) kesehatan. Askes menyediakan teknologi pemindai jari untuk mengecek data pasien rumah sakit.

Direktur Utama PT Askes, Fahmi Idris mengatakan pihaknya sedang dalam proses penyelesaian proses teknologi tersebut. Nantinya penerapan teknologi ini akan bersinergi dengan dinas Kependudukan dan Catatan Sipil (Dukcapil) Kementerian Dalam Negeri.

“Dukcapil itu dari catatan sipil Kementerian Dalam Negeri. Setelah masukan NIK KTP anda nanti bisa scan jempol di card reader, baru keluar data,” ucap Fahmi di Kantornya, Jakarta, Kamis (10/9).

Menurut Fahmi, pemasangan teknologi saat ini sudah berjalan di beberapa rumah sakit yang bekerjasama dengan jaringan Askes. Untuk selanjutnya perusahaan pelat merah itu masih menunggu jaringan rumah sakit lain yang telah siap menerapkan sistem ini.

“Sudah jalan, tergantung teknologi jaringan di mana jaringan internet bisa dan akan lebih lambat jika tidak ada jaringan sama sekali,” katanya.

Fahmi berharap, semua rumah sakit mempunyai jaringan internet bagus agar segera bisa dipasang teknologi card reader tersebut. “Rumah sakit kita saya lupa jumlah detailnya. Kita punya lebih artinya rumah sakit Jamkesmas dan rumah sakit pemerintah provider Askes akan dipasangi,” katanya.

Askes menargetkan akan memasang alat tersebut diseluruh kabupaten kota yang menyelenggarakan Jamkesmas dan sudah ada hubungan dengan askes. Dengan alat ini tidak akan ada penipuan kartu BPJS karena harus scan jari jempol.

Sumber: merdeka.com

SALATIGA, suaramerdeka.com – Dugaan penyelewenangan pengadaan obat di RSUD Salatiga dengan kerugian miliaran rupiah ternyata telah dilaporkan ke Polres Salatiga.

”Kasus itu saya yang melaporkan ke Polres Salatiga, sekitar sebulan yang lalu,” ujar Koordinator Gerakan Elemen Masyarakat Anti-KKN, Yohanes Baptista Maryoto, Rabu (9/10).

Ia meminta penyidik Polres Salatiga serius menangani kasus tersebut hingga tuntas, tidak misalnya menghentikan di tengah jalan.

Dikatakan, dugaan penyimpangan dalam pengadaan obat di RSUD sudah didengar sejak lama. Bahkan rumornya, hasil audit internal pun menyatakan ada kerugian sekitar Rp 4 miliar.

Hal itu ditunjang dengan hasil audit Badan Pemeriksa Keuangan untuk tahun anggaran 2012. Meskipun begitu, Maryoto menilai audit yang dilakukan BPK tampak tidak seperti biasanya.

Ia merasakan hasil audit menunjukkan keraguan-raguan auditor dalam menghitung pengadaan itu. Misalnya penggalian data yang dirasa kurang, dan sebagainya.

”Harapannya kasus ini diungkap tuntas, jangan berhenti di tengah jalan atau ditangani sepotong-potong. Ini uang rakyat, korbannya adalah rakyat, apalagi berkaitan dengan obat-obatan yang akan diberikan kepada rakyat,” ucapnya.

Sebelumnya akademisi Yakub Adi Krisanto mengungkapkan dugaan pengadaan obat yang tidak prosedural, sehingga menyebabkan obat-obatan itu kadaluarsa dan menimbulkan kerugian negara. Hal itu dapat dilakukan karena sistem pemeliharaan obat di RSUD tidak tertib.

Dikatakan, berdasarkan audit BPK, terdapat sisa persediaan obat kurang lebih hampir Rp 7 miliar di RSUD dan Dinas Kesehatan Kota Salatiga.

Sistem persediaan obat yang tidak tertib dapat diduga me­munculkan potensi penyelewengan dalam pengadaan obat. Dugaan itu telah dibantah Kabag Humas Pemkot Salatiga Adi Setiarso.

Menurutnya tidak benar terjadi praktik-praktik yang tidak prosedural dalam pengadaan obat. Justru saat ini RSUD tengah melakukan perbaikan manajemen obat.

Kapolres Salatiga Ajun Komisaris Besar Dwi Tunggal Jaladri mengungkapkan, laporan dugaan penyelewenangan di RSUD memang telah diterimanya. Saat ini polisi tengah melakukan penyelidikan dan memanggil beberapa orang untuk dimintakan keterangan.

”Kalau anggota Badan Pengawas RSUD belum ada yang dipanggil. Yang jelas laporan sudah kami terima dan saat ini masih tahap penyelidikan,” ujarnya.

Sumber: suaramerdeka.com

Hospitals are overstretched because the number of people admitted for avoidable conditions has spiralled by 48% in the last decade.

A major report today reveals that one in five of the 56 million emergency admissions in England between 2001 and 2013 were avoidable.

They included patients with dehydration, urinary tract infections, complications of diabetes, angina and ear, nose and throat infections.

Research shows better management of people’s illness in the community and in GP surgeries could prevent some of these admissions.

The Nuffield Trust study found avoidable condition admissions grew from 704,153 to over a million a year.

Researchers claimed emergency hospital admissions for avoidable conditions can “indicate suboptimal care because the individual’s health had deteriorated avoidably to the extent that hospitalisation was necessary”.

Nuffield Trust chief executive Andrew McKeon said: “Given constraints in resources for the NHS and social care in the next decade, a key concern must be the extent to which the gains made in improving quality of care over the past decade may be lost.”

Health Foundation chief executive Dr Jennifer Dixon added: “Urgent care stands out as being an area to watch, in particular the quality of care outside of hospitals and timely access to it by the public. This should be a high priority for action.”

Michael Scott, chair of the NHS Confederation’s community health services forum, said: “We know A&E departments are under more pressure than ever before so it is absolutely vital that we take every opportunity to care for patients at home or in their communities.

“If we don’t, we are needlessly putting additional pressure on A&Es.

“What patients tell us they want – and what common sense tells us – is more and better care in or near people’s homes, so they don’t need to attend A&E or be admitted to hospital in the first place.

“It is crucial that we invest in community-based services – the experts in prevention and early intervention – so that they can deliver their full potential.”

A Department of Health spokeswoman said: “We know we are facing challenging times. Our priority is to deliver better care and a more sustainable NHS.

“That is why we have set out bold and radical steps to transform the way that hospital care is delivered.

“Through more proactive primary care and better integration of health and social care, older people will be better supported in their homes and get the treatment they need in the best place for them.”

Source: mirror.co.uk

University Hospital Galway failed to provide Savita Halappanavar with “the most basic elements of patient care” and failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner, according to a report by the State’s health watchdog.

The report by the Health Information and Quality Authority into Ms Halappanavar’s death last year points to 13 “missed opportunities” which, had they been identified and acted upon by the hospital, “may potentially have resulted in a different outcome for her”.

Among the missed opportunities listed in the report are a failure to carry out the recommended four-hourly observations of her temperature, heart rate and blood pressure and a failure to follow up blood tests.

“The consultant, NCHDs and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time,” according to the report. “However, this did not happen.”

Clinical findings

It says the most senior clinical decision maker involved in the provision of care to Ms Halappanavar at any given time should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly. “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”

It says the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Ms Halappanavar did not appear to act in a timely way in response to her clinical deterioration and the report is critical of a failure to act or escalate concerns to “an appropriately qualified clinician”.

Ms Halappanavar, who was 17 weeks pregnant, died in the hospital of sepsis last October 28th following a miscarriage.

The 257-page report from Hiqa is the third report into the death of Ms Halappanavar, and follows a coroner’s inquest and an inquiry by the HSE.

In addition, the report says the clinical governance arrangements within the hospital failed to recognise that vital hospital policies were not in use, nor were arrangements in place to ensure the provision of basic patient care on St Monica’s Ward, the gynaecology ward in which Ms Halappanavar was accommodated.

The report points out that the Galway hospital developed a local Modified Obstetric Early Warning Score chart in 2009 but this was not in use on the ward three years later, in October 2012.

No formal protocol

It says there was no formal clinical escalation protocol and no emergency response team in place at the hospital and while sepsis guidelines were in place, clinical governance arrangements were “not robust enough” to ensure they were adhered to.

The report says it is critically important that the health service learns from mistakes, including Ms Halappanavar’s “tragic event”. It says there is a “disturbing resemblance” between the case of Ms Halappanavar and that of Tania McCabe and her son Zach, who died in 2007 after developing sepsis when her membranes ruptured.

Only five of the country’s 19 maternity hospitals were able to provide Hiqa with a detailed status update on the implementation of recommendations from the Tania McCabe report.

There are 34 recommendations in the report, starting with a call for their full implementation. In addition, it says the HSE and the Department of Health must as a priority review maternity services nationally.

According to Hiqa, eight maternity units do not produce any form of annual clinical report, as recommended by the 2006 Lourdes hospital inquiry.

Nationally, it warns that maternity services may, on occasion, not be as safe as they should be, or of sufficient quality.

The report says this must be addressed as a matter of urgency and it calls on the HSE and the Department of Health immediately to undertake a review of maternity services.

The authority says maternity services need to be improved in relation to managing sepsis and clinically deteriorating pregnant women, patient choice and in the provision of a suitably skilled and competent workforce to deliver safe care.

Inconsistent recording

The report reveals wide variations in clinical care across different hospitals and units. It says there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, and no centralised approach to reporting maternal morbidity and mortality.

As a result, it is impossible to assess properly the performance and quality of maternity services nationally, according to the report.

The Department of Health should develop a code of conduct for employers setting out their responsibilities on safety and performance, it says. This would clearly articulate the duties and responsibilities on them in regulating staff, including referral of professionals to regulatory bodies.

Hiqa wrote to HSE director general Tony O’Brien several times this year seeking assurances in relation to the care of clinically deteriorating obstetric patients.

Mr O’Brien responded to the authority, providing assurances on care in many hospitals, but Hiqa says it remains concerned that the assurances were not in place for every hospital providing maternity services.

Source: irishtimes.com