# X-Rays in Tallaght hospital



## Sunny (10 Mar 2010)

Serious how does something like this happen? I can understand workload pressures etc for a certain backlog but to allow the backlog to get to over 50,000 x-rays before it is noticed and acted upon is negligence of the highest possible order. 
Let me guess how this play out. The hospital and unions will blame funding cutbacks, the HSE will blame local management in the hospital, Mary Harney will announce that it is an issue for the HSE and has nothing to do with her as Minister Of Health, FG will call for her resignation, Brian Cowan will express full confidence in her and on and on and on and on........


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## Caveat (10 Mar 2010)

Sounds about right.  And meanwhile employees of the HSE will harrumph and insist they are hard done by and escalate their action and do even less and nobody will do anything about it...


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## Purple (10 Mar 2010)

I look at this from a process perspective; either there was a procedure in place in which case the person who didn’t follow it is to blame (and should be sacked) or there was no procedure in place in which case the person who should have put it in place should be sacked. If nobody was tasked with making sure a procedure was in place then the medical director should be sacked.

Do these places not get audited by the Irish Medicines board? If not what level of certification do they have and who is their regulatory body? Do the HSE conduct audits? 

One person is dead and another had a very delayed diagnosis which may cause them their life. The book had to stop with someone (and blaming the minister or lack of funding is just a cop-out) and that person should, at the very least, lose their job. In theory more than one person should face the music but in practice it just ‘aint gonna happen.


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## BoscoTalking (10 Mar 2010)

sack someone - come on - that just doesn't happen in HSE. 

But we just accept that standard as a nation.


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## Towger (10 Mar 2010)

pennypitstop said:


> sack someone - come on - that just doesn't happen in HSE.


 
Nope, but they will suspend them on full pay for years.


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## Howitzer (10 Mar 2010)

Someone, somewhere, didn't do their job, for a very long time.

And a number of others were complicit in faciliating this person (or persons) in not doing thier job.

Nothing to do with lack of funding or excessive workloads. Just an I can't be arsed attitude.


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## mathepac (10 Mar 2010)

Purple said:


> ... Do these places not get audited by the Irish Medicines board? ... .


IMB has no role to play in monitoring clinical practice in hospitals or in auditing diagnostic procedures.

The DOH&C is supposed to set policy and standards - they have > 560 expensive employees to do this and this number has not reduced significantly since the HSE was invented, but I'm not sure what role DOH&C is supposed to play in monitoring compliance with standards.

Various internal enquiries will probably me initiated by various self-serving self-regulating professional bodies, but don't expect anyone to be found responsible or accountable, but health services' clients will continue to suffer.

In the meantime these two outfits have some role to play in standards assessment.

[broken link removed]

http://www.hiqa.ie/


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## Purple (10 Mar 2010)

mathepac said:


> IMB has no role to play in monitoring clinical practice in hospitals or in auditing diagnostic procedures.
> 
> The DOH&C is supposed to set policy and standards - they have > 560 expensive employees to do this and this number has not reduced significantly since the HSE was invented, but I'm not sure what role DOH&C is supposed to play in monitoring compliance with standards.
> 
> ...



We're just a small business but we get audited by the NSAI (twice a year) and are subject to audits from the IMB and the US Food and Drug Administration. We also get about 5-8 customer audits a year and conduct 18 internal audits a year. 
I find it hard to believe that hospitals don't get audited by any outside body.


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## Firefly (10 Mar 2010)

Sunny said:


> Serious how does something like this happen? I can understand workload pressures etc for a certain backlog but to allow the backlog to get to over 50,000 x-rays before it is noticed and acted upon is negligence of the highest possible order.
> Let me guess how this play out. The hospital and unions will blame funding cutbacks, the HSE will blame local management in the hospital, Mary Harney will announce that it is an issue for the HSE and has nothing to do with her as Minister Of Health, FG will call for her resignation, Brian Cowan will express full confidence in her and on and on and on and on........


 
And it will be a Lesson Learned with another dust-gathering report behind it


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## annet (10 Mar 2010)

Purple said:


> We're just a small business but we get audited by the NSAI (twice a year) and are subject to audits from the IMB and the US Food and Drug Administration. We also get about 5-8 customer audits a year and conduct 18 internal audits a year.
> I find it hard to believe that hospitals don't get audited by any outside body.


 
It's called HIQA!  I cant understand how this happened.  Standard, is review and written reports of Radiology scans.  Reports are sent to consultants and in their charts.  So, there's alot more than one person culpible here!  This came to light in December - what happened between December and Now.  Cases got reviewed but why werent those caseloads advised of this.  What did Mary Harney do when she was told of this the day after Prof. Conlon was appointed.  There has been systematic failures in diagnosis from Portlaoise to Rebecca O'Malley.  Mary Harney said these kind of failures wouldnt happen with the new centres of excellence.  Obviously, that's untrue.  Risk management systems I wonder what those were.  And I wonder was the fact that patients were not advised and this was not brought into the public domain part of risk management ie. State Claims!  Oh yes, and Harney is in New Zealand.  Maybe, she's looking at that health service.


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## Caveat (10 Mar 2010)

There could well be plenty that Mary Harney did or didn't do - but she doesn't work there. 

Either someone who physically works there or who has immediate responsibility for those who work there, is to blame.

Blaming MH is like blaming John Gormley for illegal dumping.


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## truthseeker (10 Mar 2010)

I have zero faith in Tallaght hospitals procedures.

I was once referred there by my GP for an ENT appointment. Months passed and no appointment notification, when I phoned I was told there was a backlog and it would be addressed shortly. It was suggested twice that I get my GP to send another letter.
Finally, after about a year I spoke to someone who admitted to me on the phone that no one was addressing ENT referral letters and that there were shelves of them growing dusty and she personally advised I get my GP to refer me elsewhere. She said (and I quote), 'the whole system here is a mess, no one is bothering to address anything''.

More than 3 years later I received a letter from ENT stating that if I still wanted the appointment that the referral letter was about (3 years and a few months between referral letter date and appointment letter date) to phone them, otherwise they would assume I had no more need for it.

More than 3 years. I kid you not. And the only communication during that time was from ME phoning to know what was going on.

The health service is a shambles.


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## annet (10 Mar 2010)

Chronology HIQA told in APRIL 2009 and then in January HIQA was informed of the total numbers involved!


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## Purple (10 Mar 2010)

What's HIQA?


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## mathepac (10 Mar 2010)

annet said:


> ...  Cases got reviewed but why werent those caseloads advised of this. ...


Here is a big part of the problem. Clients of health service organisations are not people any more, they are merely cases or files, and health services no longer deal with people but manage caseloads.  Illnesses and conditions are treated, but not people. 

Apparently a unit's degree of "busy-ness" or importance is measured by the size of their caseload (the number of files in a cabinet) and the length of the queue awaiting the services they provide, rather than the number of individuals they are actually helping.

I was stunned recently when my grandson Jack was being admitted to modern private hospital on a consultant referral. My daughter went to park her car leaving me with Jack in reception, where we were approached by a staff-member and greeted as follows "Ah, are you the [name of the condition Jack was to be treated for]?" Jack wasn't thought of as a child or as a person, he was merely a revenue-generating condition; a cow in a dairy-herd would not be referred to in such demeaning terms.

I also attended a specialist in the recent past and I was greeted with "Are you Dr. Murphy's 11:00 o'clock appointment?" Yet again here was a client being depersonalised, dehumanised even to the point of just being a time-slot on someone's appointment's diary, with a revenue tag attached.

I naievely thought this sort of thinking had died out with the "Carry On..."  films, but apparently it persists in our modern 21st century health system and until we can change how the people working in the heath services think of their clients, their behaviour towards them will not change.


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## annet (10 Mar 2010)

Purple said:


> What's HIQA?


 
The Health Information Quality Authority which is another public quango that is suppose to be charged with regulating standards in public hospitals.  But ironically, that is minus services for persons with intellectual disabilities and our private hospitals. I am not up on whether psychiatric hospitals or social services (children) come under its remit yet but doubt it.  Private clinics for cosmetic surgery also are outside its remit AFAIK.


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## annet (10 Mar 2010)

mathepac said:


> Here is a big part of the problem. Clients of health service organisations are not people any more, they are merely cases or files, and health services no longer deal with people but manage caseloads. Illnesses and conditions are treated, but not people.
> 
> Apparently a unit's degree of "busy-ness" or importance is measured by the size of their caseload (the number of files in a cabinet) and the length of the queue awaiting the services they provide, rather than the number of individuals they are actually helping.
> 
> ...


 

You'd want to be around for ward handovers, persons were regularly not referred to by their names but identified by their conditions TURP in bed 10, or the CABG in bed 4!  I returned to Ireland in the 1990's and in one Dublin hospital they were only introducing things like primary nursing and care plans in the late 1990's....like they were new innovations in practice.... "carry on" is an understatement.


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## Shawady (10 Mar 2010)

annet said:


> Chronology HIQA told in APRIL 2009 and then in January HIQA was informed of the total numbers involved!


 
They knew of 4,000 cases in April 2009.
Doesn't sound like Mary Harney was in a rush to find out how serious it was.

"_Minister for Health Mary Harney, who is in New Zealand, said today that while she had first learnt of the issue in December last, it was only yesterday that she became aware of the scale of the problem_"


[broken link removed]


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## Complainer (10 Mar 2010)

Shawady said:


> They knew of 4,000 cases in April 2009.
> Doesn't sound like Mary Harney was in a rush to find out how serious it was.
> 
> "_Minister for Health Mary Harney, who is in New Zealand, said today that while she had first learnt of the issue in December last, it was only yesterday that she became aware of the scale of the problem_"
> ...


Did she not ask about the scale of the problem  when she was first notified?


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## Firefly (10 Mar 2010)

What other "problems" is she aware about...doesn't inspire confidence. Sounds more like a cover up operation gone wrong to me


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## D8Lady (10 Mar 2010)

Might I suggest that people use Ratemyhospital.ie [/URL]http://www.ratemyhospital.ie/[/URL]  to rat out any such incidents. 

At least it will be in public domain.


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## Sunny (10 Mar 2010)

[broken link removed]

[broken link removed]

I have to say it is staggering. There was complete systematic failure and for that, the Minister has to take responsiblity. It wasn't a simple case of x-rays not being read. There was a cover up and an inadequate repsonse by the body who report directly into her. Sorry Mary Harney but its time to go. 

From HIQA's own website:

We are an independent Authority, with broad ranging functions and powers reporting to the Minister for Health. 

We have been set up to drive quality, safety, accountability and the best use of resources in our health and social care services, whether delivered by public, voluntary or private bodies. 
We will set the standards for delivering health and social care services and we will continuously inspect to ensure that these standards are being met. 

*We will take action if there's a risk to the safety of any person using our health services.*

This is obviously not the case. They wrote letters asking for reports. Thats not taking action. 
As for the former CEO of the hospital, there should be a criminal investigation. Supposed he retired on a pension of tens of thousands of euro and could not care less.


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## johnd (10 Mar 2010)

What do people expect from public hospitals? That someone would be held accountable? That someone would be sacked? That does not happen in this state and will not happen. Just keep taking the medicine and thank the doctor nicely on your way out.


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## Purple (10 Mar 2010)

Sunny said:


> [broken link removed]
> 
> [broken link removed]
> 
> ...


The FDA (Food and Drug Administration) in the USA has the power to execute search warrants, make arrests, carry firearms and gather evidence, just like any other federal law enforcement agency. 
People have been known to vomit because of worry during FDA audits; they know that they could not just lose their job but lose their liberty as well.   

The HIQA has the power to write strongly worded letters.
This is yet another example of the states utter inability to regulate anything.


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## Green (11 Mar 2010)

mathepac said:


> The DOH&C is supposed to set policy and standards - they have > 560 expensive employees to do this and this number has not reduced significantly since the HSE was invented,


 
Not correct, there are 470 people employed in the Dept of Health and this will fall further in line McCarthy report recommendations.


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## Firefly (11 Mar 2010)

Purple said:


> I look at this from a process perspective; either there was a procedure in place in which case the person who didn’t follow it is to blame (and should be sacked) or there was no procedure in place in which case the person who should have put it in place should be sacked.


 
Correct me if I'm wrong, but doesn't a doctor request an Xray for a patient? Surely the doctor in question is ultimately the person responsible for the patient's care and should be the one following up to ensure that the Xrays were read?


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## Purple (11 Mar 2010)

From the HIQA website, under “National Standards for the prevention and control of Healthcare Associated Infections”;
_"Planning implementation
All facilities should identify a named person responsible and accountable for leading the implementation of these standards. This person should be the chief executive/general manager/lead clinician and where relevant this person should report progress to the board or management committee of the facility/service on a regular basis."_

Then, under “Monitoring” we get; 
_"There are a number of international and national audit/assessment tools(11;20;21) available that can be adapted by all health and social care services to support the process of evaluating their compliance against the National Standards. The Authority will expect to see effective internal monitoring and reporting systems for the key aspects of the National Standards proportionate to the scale and complexity of the services. This does not mean measuring everything all the time, but rather developing a portfolio of qualitative and quantitative measures to provide adequate assurance of compliance for the board, governing body or responsible clinician for the service.
Given these standards are intended to set a direction of improvement in quality and safety for patients, an important aspect of monitoring will be assessing progress against planned implementation milestones.
From publication of the National Standards, there will be a six-month adjustment period to allow all services to consider the local implications of the National Standards and develop implementation plans. During this period, the Authority will engage with the HSE and other stakeholders to discuss the nature and scope of internal monitoring processes.
Following this period, the Authority will undertake a baseline assessment exercise that will focus on the findings of the internal gap analysis, the development of plans and how priority safety areas have been addressed. This exercise will be predominantly a self-assessment process. The self-assessments will be followed up in more detail in 2010. The detailed nature of the follow-up process will be communicated to services well in advance of any visits programme. However, unannounced visits will be part of the Authority’s approach."_

So there’s lots of aspiration but despite the title, there is no standard in place.
Where’s the hospitals quality manual? 
Where are the procedures derived from the quality manual?
Where are their internal audits?
What outside party audits them? 

All of the above have been in place in small manufacturing businesses supplying medical device manufacturers since the late 1980’s. Why is it that Irish Hospitals don’t seem to have them?

An organisations quality manual should be a public document. Many companies have them available to download from their website. We give outs to our customers, our customers give their to us. It helps a customer to understand what procedures their supplier has in place and what to look for during a quality audit. It also helps a supplier understand what their customers’ expectations are.

Where can I download Tallaght Hospital’s Quality Manual?


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## Purple (11 Mar 2010)

Firefly said:


> Correct me if I'm wrong, but doesn't a doctor request an Xray for a patient? Surely the doctor in question is ultimately the person responsible for the patient's care and should be the one following up to ensure that the Xrays were read?



If a cardiologist requests x-rays it is on the understanding that they will be viewed by one of the well paid and under-worked Radiologists in the hospital in question. The same applies of a GP sends a patient to a cardiologist; they expects the cardiologist to make a diagnosis based on the results of the tests they carry out rather than just sending the test results to the Go for them to look at. That’s why there are specialties, so that people can become experts in particular areas. Reading x-rays is a specialist area.


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## Firefly (11 Mar 2010)

Purple said:


> If a cardiologist requests x-rays it is on the understanding that they will be viewed by one of the well paid and under-worked Radiologists in the hospital in question. The same applies of a GP sends a patient to a cardiologist; they expects the cardiologist to make a diagnosis based on the results of the tests they carry out rather than just sending the test results to the Go for them to look at. That’s why there are specialties, so that people can become experts in particular areas. Reading x-rays is a specialist area.


 
I agree, but from the patient's perspective, they deal with their doctor - surely it is the doctor's responsibility to ensure that the X rays are performed, read so he can provide the results to the patient?


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## Purple (12 Mar 2010)

Firefly said:


> I agree, but from the patient's perspective, they deal with their doctor - surely it is the doctor's responsibility to ensure that the X rays are performed, read so he can provide the results to the patient?



Good question, I don't know the answer but GP's don't have any special access to hospital management.

From todays [broken link removed] (In relation to GP letters);
_"Following a review, it is understood it was found an incoming letter from a GP had to pass through more than 20 separate stages before the hospital sent an appointment to the patient who had been referred. The hospital has now streamlined the process to three steps."_


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## RonanC (12 Mar 2010)

Purple said:


> If a cardiologist requests x-rays it is on the understanding that they will be viewed by one of the well paid and *under-worked Radiologists in the hospital in question*.


 
Purple, what is your problem with the public service and those who really provide it (the front line public servants)?

Tallaght Hospital should have 18 Radiologists for the volume of work it deals with. It has in reality 7 full time Radiologists dealing with more than 200,000 examinations per year. The recommended number of examinations for the staff they have is 11,000. 

Radiologists are claiming that they sent 40 letters to management highlighting the problems but nothing was done.

So Purple, please give it a rest bashing the front line public servants

Thank you.


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## Purple (12 Mar 2010)

RonanC said:


> Purple, what is your problem with the public service and those who really provide it (the front line public servants)?
> 
> Tallaght Hospital should have 18 Radiologists for the volume of work it deals with. It has in reality 7 full time Radiologists dealing with more than 200,000 examinations per year. The recommended number of examinations for the staff they have is 11,000.
> 
> ...



Most public servants do an good job, many do an excellent job (there are far more good than bad). I do have a problem with very highly paid public servants who obstruct reform, work short hours and, while being accountable to management, that management has no real sanction if they are unhappy with the quality of service their employee is providing.

If consultants were really concerned about lack of numbers then they wouldn’t look to get paid so much as they know that the more they get paid the fewer of them the state can afford to employ.

That said the real problem is a structural one where boards of hospitals are cumbersome and there is no clear lines of responsibility. I go back to my earlier point about oversight and auditing; where’s the independent regulatory body, where are the international best practice standards based processes for them to audit against and where are the sanctions (i.e. suspension, arrest and prosecution) that they can take against those found to be in breach of those standards?

By the way, most consultants make most of their money from private work.


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## Firefly (12 Mar 2010)

Purple said:


> Good question, I don't know the answer but GP's don't have any special access to hospital management.
> 
> From todays [broken link removed] (In relation to GP letters);
> _"Following a review, it is understood it was found an incoming letter from a GP had to pass through more than 20 separate stages before the hospital sent an appointment to the patient who had been referred. The hospital has now streamlined the process to three steps."_


 
I think that private GPs have been the ones banging the drums here trying to get x-rays seen. The doctor is A&E is probably less likely to bang the same drum as he is probably in closer contact to the consltant and also works for the same employer. This is just my hunch though


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## RonanC (12 Mar 2010)

Purple said:


> I go back to my earlier point about oversight and auditing; where’s the independent regulatory body, where are the international best practice standards based processes for them to audit against and where are the sanctions (i.e. suspension, arrest and prosecution) that they can take against those found to be in breach of those standards?


 


Purple said:


> By the way, most consultants make most of their money from private work.


 

I totally agree with you on both points 


Oversight agencies were created with certain functions and powers (the majority of them by our good friends in Government at the moment) but unless they are given the powers they need to fully carry out their functions they really are only as good as newspapers reporting on the story. 

I did an essay only last week on the Garda Ombudsman who invesitgated an allegation of serious breach of discipline by a senior Garda in relation to the Rossport protests and made recommendations that disciplinary action be taken but the Gardai threw it out stating that it found “no breach of discipline” 

So really what was the point of the investigation by the Garda Ombudsman, only to highlight the problem?


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## Firefly (12 Mar 2010)

If the gov had the balls they would appoint an audit committee from somewhere like France which has a good health care system to conduct quick, narrow audits of key HSE key functions and publish these findings publicly. HSE audits are close to worthless imo as they are self-protecting.


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## Mpsox (12 Mar 2010)

My wife went for an x-ray a couple of weeks back down the country, she was given her referal letter by her GP, went over to the local health centre the next day and had her  xray there and got a txt from her doctor a few days later telling her it was all clear. She was a public patient so there are parts of the country where the health service seems to be working in a far more efficient manner then Tallaght

There are a whole pile of issues around Tallaght. It was reported in the news last night for example that Tallaght was handling twice as many private patients as the recommnded norm. As for the board, you can't run anything with a board of 22 people, that becomes more about crowd control then achieving anything. It was also reported on the news that the HSE have an option to have a director on the hospital board, but never took it up


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## Purple (12 Mar 2010)

Firefly said:


> If the gov had the balls they would appoint an audit committee from somewhere like France which has a good health care system to conduct quick, narrow audits of key HSE key functions and publish these findings publicly. HSE audits are close to worthless imo as they are self-protecting.



An auditor can only audit based on the procedures that are in place. Their function is to make sure that an organisation is doing what it says it does. 

What procedures are in place?
What system are those procedures based on?
What internationally recognised standards are the systems derived from?
Where are the procedures?
Where is the management structure flow-chart that assigns responsibility?
Who is the quality manager?
Where are the internal audit records?
Do the internal audit records assign responsibility for each process (note the person being audited)?
What sanctions are in place which can be imposed on those who fail audits?
Is there a clear one-step line of command between the person who fails the audit and the person who can sanction them?
What sanctions can be taken by the auditor against a manager who fails to take corrective actions resulting from non-conformances issued during internal or external audits?

Every small company in Ireland that is ISO9001:2008 compliant can answer all of the above.
Is it too much to ask that a multi-billion euro organisation should do the same?


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## Purple (16 Mar 2010)

Interesting reading in the [broken link removed] today about standards in hospitals.


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## Firefly (16 Mar 2010)

Anyone see Mary Harney in NZ with a cast on her arm...wonder how long it took for her to get her x-ray results


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## MANTO (16 Mar 2010)

Probably not long if she went to a hospital in NZ


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## ajapale (16 Mar 2010)

Purple said:


> Every small company in Ireland that is ISO9001:2008 compliant can answer all of the above.
> Is it too much to ask that a multi-billion euro organisation should do the same?



Agreed, but such ISO9000 companies can also answer the following questions:

what is the mission / objectives of the organisation? who are our customers? what are their legitimate expectations?


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## Purple (17 Mar 2010)

ajapale said:


> Agreed, but such ISO9000 companies can also answer the following questions:
> 
> what is the mission / objectives of the organisation? who are our customers? what are their legitimate expectations?



Yes, I agree, as part of their quality statement/manual they can answer the above questions but hospitals can as well, or at least they say they can.


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## ajapale (17 Mar 2010)

I see that they are about to appoint a Quality "Czar" at Tallaght.

I dont envy the Quality "Czar" in the role.

The QC needs to put in a quality system and not just overlay (or worse still parrallel) the existing highly disfunctional admisinstration system.

When the documented management system is in place everyone has to work it (and that includes Constultants, Administrators, other Medial and Paramedical Professionals, and other roles in the organision). The system has to go accross functional departments, up and down with in functional departments and *espcecially* at the interfaces between departmentst and the interfaces with consumers and suppliers.

Attempts to resist (or subvert) the operation of the quality system have to be robustly dealt with.


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## Purple (17 Mar 2010)

ajapale said:


> I see that they are about to appoint a Quality "Czar" at Tallaght.
> 
> I dont envy the Quality "Czar" in the role.
> 
> ...


I agree, that will be the real test, and the level of outside auditing that takes place.
Where existing processes don't fit into the new system they need to be changed or else it's another P-PARS type mess.


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## ajapale (17 Mar 2010)

Purple said:


> Where existing processes don't fit into the new system they need to be changed or else it's another P-PARS type mess.



Yes, I hope that the naive expectation that a computer package could solve problems in the absence of systematic review / reform of processes is not replicated in the naive expectation that somehow the appointment of a Quality Czar can solve the problems.

Will the Quality Czar have a budget?


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## Leper (18 Mar 2010)

If you open a food shop you will need some sinks for washing of hands and utensils.  If you dont have the sinks the HSE will close you down.  

But thousands of X-Rays being ignored in Tallaght Hospital.

One law for some and another law for others!!!!!!!


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