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Features of a service meeting this standard are likely to include:

5.1.1 An identified individual whose role includes:

– having overall executive accountability, responsibility and authority for the delivery of high quality, safe and reliable services

– leading a governance system that clearly specifies, delegates and integrates corporate and clinical governance

– formally reporting on the quality and safety of the service through its relevant governance structures.

5.1.2 When a service is located on more than one site, the identified individual delegates accountability and responsibility for quality and safety of services to an identified person who is involved in the management and delivery of the service and who is at an appropriate level within the governance structure.

Features of a service meeting this standard are likely to include:

5.2.1 Integrated corporate and clinical governance arrangements, which clearly define roles, accountability and responsibilities throughout the service for assuring quality and safety. These governance arrangements are made publicly available.

5.2.2 Governance arrangements that ensure the primary focus of the service is on quality and safety outcomes for service users. These arrangements include regular review of information relating to quality and safety outcomes for service users.

5.2.3 Governance arrangements that ensure the collective interests of service users are taken into consideration when decisions are made about the planning, design and delivery of services.

5.2.4 Arrangements that ensure that the people involved in the governance of the service have the skills and competencies necessary to provide effective assurance of high quality, safe and reliable healthcare.

5.2.5 Public reporting by those governing the service on the quality and safety of care.

Features of a service meeting this standard are likely to include:

5.3.1 A statement of purpose for the service that details:

― – aims and objectives of the service including how resources are aligned to deliver these objectives

― – description of services provided

― – intended service-user population

― – models of service delivery and aligned resources necessary to deliver high quality, safe and reliable healthcare

― – location or locations of service delivery.

5.3.2 A statement of purpose which is publicly available and communicated to all stakeholders, including service users, in an accessible format.

5.3.3 Evaluation of proposed service changes to ensure the statement of purpose reflects what can be delivered safely, sustainably and within available resources.

5.3.4 Notification of, and consultation with, relevant stakeholders regarding any proposed changes to the statement of purpose that affect the function or purpose of the services. This notification is provided in a timely manner that allows stakeholders appropriate time to respond to proposed changes. Any necessary approval is sought before changes to the statement of purpose are made.

5.3.5 Governance arrangements that incorporate review and evaluation to provide assurance that services are being delivered within the scope of the statement of purpose.

Features of a service meeting this standard are likely to include:

5.4.1 Plans that set clear direction for delivering quality and safety in the short-, medium- and long-term.

5.4.2 Service objectives and plans that take account of:

̶ – national strategies, policies and standards

̶ – views of stakeholders

̶ – the needs of the population served

̶ – best available evidence

̶ – legislation

̶ – resources available

̶ – information relevant to the provision of safe services.

5.4.3 Routine representation of the collective interests of service users and consideration of these in decisions about the planning of services. Service users are kept informed of key decisions in the planning of services.

5.4.4 Monitoring the performance of the service against service objectives, benchmarking and managing and reporting on this performance through the relevant governance structures.

Features of a service meeting this standard are likely to include:

5.5.1 Management arrangements to effectively and efficiently achieve planned objectives. This includes reviewing and identifying gaps in these management arrangements and taking action to address these gaps. These management arrangements may include (but are not limited to):

– workforce management

– communication management

– information management

– risk management

– patient-safety improvement

– service design, improvement and innovation

– environment and physical infrastructure management

– financial and resource management.

5.5.2 Management arrangements, structures and mechanisms which involve all levels of the service to achieve its planned objectives for quality and safety.

5.5.3 Arrangements to manage increases or decreases in service demand that ensure the quality and safety of healthcare delivered to service users.

5.5.4 Arrangements to plan and manage service change and transition effectively including:

– identification of an accountable person responsible for leading and managing the change process

– setting clear objectives for the service change and transition

– prior assessment of service interdependencies at local, regional and national levels where relevant

– modelling of demand and capacity through estimating current and future requirements

assessment of staffing implications and determination of staffing requirements

– consideration of impact on stakeholders

– implementation of communication and engagement strategies

– development and monitoring of performance indicators relevant to change and service transition.

Features of a service meeting this standard are likely to include:

5.6.1 Active promotion and strengthening of a culture of quality and safety through the mission statement, service design, code of governance (which includes a code of conduct and management of conflict of interest), allocation of resources and training, development and evaluation processes.

5.6.2 Demonstration of a clear commitment by leaders at all levels to promote and strengthen a culture of quality and safety.

5.6.3 Facilitation of leaders at all levels in maintaining and improving the skills, knowledge and competencies to fulfil their roles and responsibilities in delivering high quality and safe care.

5.6.4 Regular review and identification of areas for improvement in the culture of the service, which incorporates feedback from service users and the workforce.

Features of a service meeting this standard are likely to include:

5.7.1 Teams and individuals who are supported and managed to effectively exercise their personal, professional and collective responsibility for the provision of high quality, safe and reliable healthcare.

5.7.2 Promotion of a culture of openness and accountability throughout the service, so that the workforce can exercise their personal, professional and collective responsibility to report in good faith any concerns that they have in relation to the safety and quality of the service. Individuals reporting these concerns are not negatively affected as a result.

5.7.3 Facilitation of members of the workforce who wish to make protected disclosures about the quality and safety of the service in line with legislative requirements.

Features of a service meeting this standard are likely to include:

5.8.1 The proactive identification, management, reduction and elimination of risks, including clinical, financial and viability risks to safeguard service users.

5.8.2 Proactive identification, documentation, monitoring and analysis of patient-safety incidents. Learning from these incidents is communicated internally and externally and used to improve the quality and safety of the service.

5.8.3 The use of information from monitoring of performance to improve the quality and safety of the service.

5.8.4 Use and dissemination of service-user feedback, compliments and complaints to promote learning throughout the service.

5.8.5 Development, implementation and continuous evaluation of programmes to actively improve the quality and safety of the services.

5.8.6 Participation in national quality and safety improvement programmes, where relevant.

5.8.7 Proactive approach to learning from findings and recommendations from national and international reviews and investigations.

5.8.8 Supporting and promoting effective communication with service users, patient support groups, external agencies and other service providers.

Features of a service meeting this standard are likely to include:

5.9.1 Formalised agreements are in place for the provision and quality of services sourced externally. The contracts of agreement include the scope of service provided, resources required and the quality assurance and governance arrangements for the quality and safety of services delivered including compliance with relevant standards.

5.9.2 Regular monitoring of the formalised arrangements in place with external recruitment agencies to assure the service they provide is compliant with relevant standards. These arrangements include the agency’s role, responsibility and area of accountability in the recruitment process.

Features of a service meeting this standard are likely to include:

5.10.1 Regular reviews of Irish and European legislation to determine what is relevant for the service.

5.10.2 A clearly documented risk assessment of any identified gap in compliance with legislation and appropriate, timely, action taken to achieve compliance to ensure the quality and safety of the services.