Committees of the board meeting minutes

HSE Safety and Quality Committee meeting minutes 10 February 2023

A meeting of the HSE Safety and Quality Committee was held on Friday 10 February 2023 via MS Teams.

Meeting details

Committee Members Present

Prof Deirdre Madden (Chair), Prof. Fergus O’Kelly, Dr. Cathal O’Keeffe, Dr. Yvonne Traynor, Ms. Anne Carrigy, Ms. Jacqui Browne, Ms. Margaret Murphy, Dr. Anne Kilgallen, Ms. Mary Culliton

HSE Executive Attendance

Dr. Orla Healy (ND QPS), Niamh Drew (Deputy Corporate Secretary).

Joined the meeting

Item 4 Prof Risteard O’ Laoide (Acting for CCO), Sharon Hayden, General Manager, CCO Office. Item 5.1 Loretta Jenkins, GM QPS Incident Management, Geraldine Kilkelly, Quality and Patient Advisor. Item 5.3 Joe Ryan, National Director OPI. Item 6 Bernie Mc Nally, Chair of NIRP. Item 8 Joseph Duggan (ND of Internal Audit), Cora McCaughan AND Internal Audit.

Minutes reflect the order in which items were considered and are numbered in accordance with the original agenda.

1 and 2. Governance and Administration

1.1 Welcome and Introductions

  • the Chair welcomed the Committee members to the meeting
  • the Committee held a private session where the Chair provided a summary of the agenda, the relevant papers and approach to conducting the meeting, noting that the focus of the meeting would be to receive updates on key items and to suggest relevant actions as they became apparent

2. Governance and Administration

2.1 Declarations of Interest

Dr. Anne Kilgallen noted a conflict of interest with regards to Item 7 Health Care Audits.

2.2 Minutes

The Committee approved the minutes of the 20th January 2022.

2.3 Matters for Noting

An update was provided on the implementation on the Framework of Safe Nursing staffing and Skill Mix Phase 1 and 2.

3. Quality Profile

The Committee considered the Quality Profile from the December data cycle.

Discussion and clarification were sought with regards to the following areas:

CAMHS: Percentage of accepted referrals / referrals offered first appointment and seen within 12 weeks

The Committee welcomed that 92.7% of urgent CAMHS cases were responded to within three working days, which is above the 90% target, however, they sought further discussion and analysis of CH05, where it was confirmed that recruitment of a consultant remains extremely challenging.

The Committee asked that consideration be given to sharing the profile data within the CHO’s Hospital Groups as it was felt that this would allow better ownership and accountability. It was agreed that Dr. Healy would raise this at the next NPOG meeting.

Percentage of all attendees aged 75 years and over at ED who are discharged or admitted within nine hours

The Committee requested that this data be broken down further so that a clearer picture of discharges and admissions can be presented. It is envisaged that this profile will improve in the coming months.

Percentage of people waiting 18 months for first access to OPD Services

The Committee welcomed the significant progress that has been made in this area and it was agreed that the profile now needs to be changed from 18 months to 15 months. It was agreed that this will be done for the next meeting.

Percentage of hip fracture surgery carried out within 48 hours of initial assessment

The Committee noted that performance is better in some geographic areas and lessons could be learned and shared within the system.

Ambulance Turnaround Times

The Committee expressed concerns on the performance profile reported. The Chair agreed to communicate the Committee’s express concerns to the Board in the February meeting.

4. Chief Clinical Officer Report

The CCO report was taken as read. The following topics were discussed by the Committee:

Our Lady’s Hospital Navan (OLHN)

A verbal update was provided to the Committee. The Committee requested a written briefing on this matter at the March meeting.

Cariban

The Committee had requested a briefing in relation to the prescribing and accessibility of the drug Cariban which is prescribed for hyperemesis.

It was noted that approximately 1% of pregnant women develop a severe form of nausea and vomiting in pregnancy called Hyperemesis Gravidarum which is associated with dehydration, weight loss and ketonuria. The product currently available to women with this condition (Cariban) is an Exempt Medicinal Product, in that it is does not have Marketing Authorisation in Ireland. The drug has been through the approval process and funding has been granted in the 2023 budget.

The committee requested a further update at the next meeting in relation to the issue of whether GPs could prescribe this drug in accordance with clinical guidelines instead of pregnant women having to wait for a consultant appointment which may take some time.

Intravenous antibiotics

The Committee welcomed that the Office of Nursing and Midwifery Service Development are engaging with the Chair of Chief Officers and Outpatient Antibiotic Therapy Programme OPAT in order to progress work further to collectively work together on an approach to further enable and expand the delivery of IV antibiotics, in HSE funded residential facilities. The Committee requested clarification with regards Section 38/ 39’s involvement.

University Hospital Waterford

A briefing was provided to the Committee on an Open Disclosure issue that has been raised within Waterford University Hospital, Pathology Department. The Committee will be updated further on this matter as it evolves.

The Committee agreed to consider inviting to a future meeting the National Quality Improvement Programmes in Radiology, GI Endoscopy, and Histopathology lead by the Royal College of Physicians and under the governance of the National Centre for Clinical Audit, QPS HSE.

5. Patient Safety

The Committee welcomed Geraldine Kilkelly to the meeting to present her experience of several issues which arose following heart surgery. Ms Kilkelly explained that she is also a nurse employed by the HSE. The three key themes that were presented were deteriorating patients, communication with patients and families, and the long-term effect on identity and work.

The Committee commended and thanked Ms Kilkelly for sharing her personal story, which was very powerful and important, and which captured her experience through the lens of both a patient and a healthcare professional. There was discussion about ensuring that appropriate systems and programs are in place to support staff in growing a culture of safety and quality for both staff and patients.

The Committee’s discussion also highlighted the effects and importance of ensuring that good communication structures exist when interacting with patients and their families, and that good communication has positive effects on patients’ sense of dignity and well-being.

The importance of the role of the National Communications Programme in training staff in how to communicate empathetically with patients was highlighted.

Patient Engagement Road Map

A presentation was made to the Committee on the implementation of the Patient Engagement Roadmap. This was welcomed by the Committee, noting that a working group has been established with both Patient and HSE representation and a budget allocation.

It was noted that recruitment for an Assistant National Director for this program is now at shortlisting stage.

The Committee requested that regular reports be provided to show implementation progress and agreed that this will be on the Committee’s April agenda for further analysis and discussion with regards to Terms of Reference.

Further clarification was requested with regards to the range of coverage (i.e. Children, Outpatients, people with disabilities, members of the travelling community etc.). The Committee also requested further discussion with regards to training and capacity building and levels of engagement within the RHA process.

6. NIRP Report

The Committee expressed their condolences to Ms. Mc Nally on the tragic death of her niece.

The Committee was briefed on a governance review that has been requested by the HSE following a serious reportable event (SRE) in a HSE community nursing home for older people. Several key issues were identified and the NIRP made nine recommendations to the HSE which were discussed with the Committee.

A response setting out progress of implementation of the recommendations was provided by management. The Committee was shocked and saddened to learn of the events that had given rise to this governance review. It discussed in depth the key issues raised by the Chair of NIRP, particularly with regards to how training of staff is carried out and the importance of a learning culture.

It was strongly agreed that there is a need to move away from managing residential care through a clinical model, and to move towards a social model of care that emphasises the fact that this is the resident’s home rather than a nursing facility. The Committee agreed that it will request regular updates to ensure that the nine recommendations are being implemented, and that this report needs to set the agenda as a platform for change.

The Committee also discussed the publication of an executive summary including the importance of the learnings from this report being shared and implemented, as well as ensuring that the family of the individual are appropriately supported throughout such process.

The Committee requested for its next meeting a written update on the implementation of the recommendations of this report, the implementation of the recommendations in the Brandon report, and an update on safeguarding.

The report will also go to the next Board meeting.

7. Risk Management

CRR 08 “Safety Incidents leading to harm to Patients” was taken as read and will come back to the Committee at its next meeting for discussion.

8. Health Care Audit

The Chair welcomed the new ND IA and the AND IA to the meeting. The suite of reports that had circulated prior to the meeting were taken as read. It was noted that more Community, rather than Acute-based audits, had been carried out in 2022 and this was welcomed by the Committee.

The Committee requested that going forward, it would be beneficial to have both a link to the relevant clinical guidance along with a link to a copy of the full report.

The Committee conveyed that it would also be helpful for them to see what factors triggered the audit. The AND for Healthcare Audit outlined that the factors that triggered the audit are set out in audit reports and the committee agreed that it would be helpful for them to see this in the full audit reports.

These would aid and support the Committee in discussions and follow up actions. The Committee also requested updates with regards to implementation of recommendations assigned to relevant individuals who are accountable, and it was agreed that this will form part of reports going forward.

The Committee also requested that consideration be given to audits with regards to implementation of the Assisted Decision-Making Act and it was agreed that this would be considered in due course / commencement of the act.

9. State Claims Agency

The Committee was joined by a number of members of the ARC Committee for a high level presentation from the State Claims Agency on recent litigation trends.

An overview of claims by type and year was presented and discussed. The number of service user incidents per year was presented and it was noted that the percentage of major / extreme incidents and Serious Reportable Events as a percentage of total incidents remained low and steady.

The Committee discussed the fact that deficits in informed consent and other communication deficits continue to be a prominent factor in claims. It also discussed some of the reasons behind the rising costs of claims, including rising numbers of claims, rising costs of awards and rising legal costs.

It was explained that most claims arise in incidents that are moderate, major, or extreme, but that not all major and extreme incidents convert into claims. The Committee sought insight with regards to practices and comparisons with other European Countries and private providers.

It was indicated that some of this data is not readily comparable as other countries have different legal frameworks, which in some cases do not permit litigation in cases of medical negligence and provide compensation through other mechanisms. The SCA does not have access to comparable data from private providers as they do not come within its statutory remit.

There was discussion about the effectiveness of the HSE’s risk management structures and it was agreed that the organisation has very robust risk management processes and structures in place. It was advised that the State Claims Agency and the HSE are both invited to present at PAC in March to look at the cost of claims.

The Committee discussed the impact that Open Disclosure has had on claims, and it was noted that this is difficult to establish. It was indicated that the financial figures presented by SCA related to claims that had been initiated and did not include potential claims that may occur as this was difficult to predict from incident reports.

It was agreed that a further SCA presentation on catastrophic injury claims in obstetrics would be made to the Committee later in the year.

10. AOB

The Chair agreed to communicate to the Committee about a change of date for the meeting in April.


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