Our Commitment to Quality

 

Our Quality & Safety Culture

An independent assessment of the Safety Culture within Nua Healthcare Services in November 2021 concluded that:

“Nua was assessed as having a range of strengths […] with the overall level of risk associated with Nua’s operations as 'Low' with a corresponding safety culture which, although currently assessed as being at the top end of 'Proactive', is on the cusp of becoming Generative.”

“Nua personnel were readily able to demonstrate and discuss how they manage risks at all stages and across all areas of their business. Importantly, they demonstrated how the risks to Service Users and Residents are carefully balanced with the risks to Nua personnel.”

Furthermore, the assessment found that:

• There was a strong approach to quality and safety within Nua Healthcare Services “with a capacity to establish an overall generative culture” across the organisation. Note: ‘Generative’ culture is the highest level of culture maturity an organisation can have based on assessment.
• Leaders and Managers demonstrate “a thorough understanding of the specific risks” faced by the organisation “and an embedded knowledge of the integrated, comprehensive, and robust controls required to manage and mitigate the risks”.
• Team members at all levels throughout the organisation “work well individually and collectively, demonstrating a high degree of mutual trust and a willingness to engage in opportunities to improve”.

• Both the Board and the Executive & Senior Management Team members are “fully engaged with Quality and Safety matters”.

Leadership, Governance and Management

We believe robust governance structures and processes underpinned by knowledge and communication at Nua Healthcare foster good outcomes.

Notwithstanding legislative and best practice business process requirements, Nua’s approach to Leadership, Governance and Management has always been of simplistic process design and good two-way communication throughout the organisational structure.

Our policies and standardised ways of working facilitate the effective collection, analysis and communication of Quality, Safety, Operational and Clinical KPI’s from team member to team member, at predetermined daily, weekly and monthly intervals.

Our teams are clear on 'What', 'Why' and 'When' they do each job-specific task, and each team member is supported through an empowered line management structure that utilises a 'Plan', 'Do', 'Check' Act' approach towards problem-solving and thereafter, communicate any serious matters through the appropriate forums right up to Board of Director level.

 

 

Our Quality & Safety Performance

Compliance with National Standards and associated Acts and Regulation is paramount to Nua Healthcare. We understand the importance of adherence to the same in pursuing excellence in service delivery. Therefore, we emphasise the design, implementation, and audit of our ways of working and, as necessary, the timely fulfilment of corrective action plans and sharing of knowledge across our service.

Regular audits are carried out to assess, evaluate, and improve the provision of services in a systematic way, in order to achieve better outcomes for the people who avail of our services.

Nua’s commitment to quality and safety includes a dedicated quality and safety team that fulfil, as standard, eleven (11) audits per service every six (6) months as part of a regulatory schedule.

Further out of schedule audits and quality and safety ‘support visits’ are either triggered by policy, negative performances against quality and safety key performance indicators (KPIs), issues or concerns raised at weekly Senior Management Governance Meetings, internal escalations, or in the event of an adverse incident.

Internal Auditors are suitably qualified, trained, and experienced subject-matter experts in their relevant fields, who have an in-depth working knowledge of Nua's systems and ways of working.

As standard, we fulfil:

• Six-monthly audits in Residential Intellectual Disability Services.
• Quarterly audits in Mental Health Approved Centres.
• Six-monthly audits in Mental Health Community Residences.
• Six-monthly audits in Supported Living (wraparound services).
• Annual audits in Supported Living (non-wraparound services).
• Safety Officer audits, focused primarily on Occupational Health & Safety / Incident & Accident Prevention / Risk.
• Reduction / Mitigation audits, completed as part of an annual schedule across all service areas.
• New Admission audits in both Intellectual Disability and Mental Health Services, in line with the relevant regulatory requirements.
• Residents' Finance audits, completed as part of an annual schedule across all service areas.
• Specific risk-based audits (i.e., Ligature, Arson), completed as part of an annual schedule across all service areas.
• Others as required i.e., Quality & Safety Improvement Initiatives (QA Zooms) audits post-implementation, to ensure the agreed target compliance level has been achieved.

We use online quality auditing and planning software to:

• Set and communicate clear quality and safety policy.
• Monitor compliance.
• Generate corrective action plans.
• Report on performance.

We communicate through the following forums/by the following means:

• As required using a risk-based escalation process outlined in our Quality & Safety Policy.
  • Serious quality and safety concerns are escalated through line management as and when they occur and reported upon in more detail at weekly Senior Management Governance Meetings.
• Post audit communications to the relevant personnel as part of the Auditing Process.
• Weekly reporting from Quality & Safety Department to Operations.
• Quality & Safety is a primary focal point of the weekly Senior Management Governance Meeting.
• Reporting/Representation, as required, in line with standing agenda's to the:
  • Fortnightly Quality and Safety Committee Meeting.
  • Quarterly Safety Committee Meeting.
  • Both good and bad service-wide performance is presented at monthly Clinical Governance Committee Meetings prior to summary report being provided by the Chair of the Clinical Governance Committee to the Board of Directors.
• Quality & Safety is a standing agenda item at all individual team meeting's across all areas of the service.
• The Quality & Safety Department operates an ‘Open-Door’ policy and there is open communication/cooperation with all departments/areas.

The following data demonstrates Nua's commitment to quality. Individual service reports can be freely obtained at all times through the HIQA or MHC websites.

 

HIQA Audit Results

MHC Audit Results