HSE Safety and Quality Committee meeting minutes 10 May 2022

Committee Members Present

Prof Deirdre Madden (Chair), Ms Jacqui Browne, Dr Cathal O’Keeffe, Ms Yvonne Traynor, Dr Chris Luke, Ms Anne Carrigy

HSE Executive Attendance

Mr Colm Henry (CCO), Prof Orla Healy (ND Quality & Patient Safety), Mr Liam Woods (ND Acute Operations), Ms. Niamh Drew (Deputy Corporate Secretary), Ms Hannah Barnes (Secretariat)

Apologies

Mr Fergus O’ Kelly, Ms Margaret Murphy

Joined the meeting

Ms Bernie Mc Nally (NIRP Chair), Prof. Risteárd Ó Laoide, (ND NCCP) , Ms Siobhan Kelly (Program Manager) , Ms Leigh Gath (Confidential Recipient)

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 brief summary on 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.

2.1 Declarations of Interest

No conflicts of interest were declared.

2.2 Approval of Minutes

The following minutes were approved by the Committee

• 12 April 2022

The EMT Members joined the meeting at 9.35pm

NIRP Chair joined the meeting.

The Committee were briefed on a review into the interagency care and treatment of a child who died by suicide.

The purpose of the review was primarily to ascertain if any learning could be gained that would inform the treatment and care plans for young people with similar presentations going forward.

Following the conclusion of the case the NIRP have highlighted five key recommendations including Intensive support service, the development of a case worker role within each CHO AREA, case managers, Parenting Capacity assessment and the importance of clear guidance been given, sharing of learnings from this case and the development of shared interagency reviews.

The Committee agreed that a single point case manager is fundamental in such cases as well as the importance of collaboration between Tusla and the HSE.

The Committee also discussed the importance of the role of Primary Care in providing support to both patients and families in such matters. The Committee discussed the value of developing learning notices and it was agreed that Professor Healy would consider the development of a learning pathway that would set out a more specialised approach and will revert on this at the next meeting.

Professor Healy briefed the Committee on a review of the NIRP Terms of Reference (ToR) and noted that the structure will broadly remain as is currently in place. The Committee requested that consideration be given with regards to aligning the timing of other processes such as HR investigations and proposed that, while very complex, all processes should be carried out in a timely manner.

The Committee also requested that the ToR set out the how wishes of service users and family in respect of publication of NIRP reviews are considered and it was agreed that Professor Healy will revert back to the Committee having also considered implementation of the Assisted Decision Making (Capacity) Act which is due to commence in June 2022.

NIRP Chair left meeting.

The HSE Quality Profile Report which provides statistical insights into quality and patient safety data and to support understanding of variation in performance over time, was circulated to the Committee prior to the meeting for consideration. It was noted that the profile included a new indicator - Percentage of psychology patients on waiting list for treatment has now been added to the profile. Professor Healy briefed the Committee on the current data noting. The Committee had concerns relating to:

• CAMHS – Percentage of accepted referrals / re-referrals offered first appointment and seen within 12 weeks – the Committee requested that this be an agenda item for July month.
• Percentage of all attendees aged 75 years and over at ED who are discharged or admitted within 6 hours- The Committee requested that consideration is given to developing geographic mapping to provide more information on this area. The Committee also requested that this item be an agenda item at the Committees next meeting noting that representation from both Acutes and Primary Care are in attendance.
• Percentage of people waiting <18 months for first access to OPD services.

The Committee are due to hold a Quality Profile workshop on Friday 17 June 2022, where all indicators will be discussed in further detail.

The Committee reviewed the extract of the HSE Corporate Risks for Q1 2022 that had been circulated prior to the meeting.

The Committee considered the risk assessments and status updates on the controls and actions recommended to mitigate each of the risks on the Corporate Risk Register (CRR) where the Committee has oversight, namely New Pandemic outbreak of a serious / high consequence infectious disease (non Covid 19) (Risk 3), Anti- Microbial Resistance and Health Care Associated Infections (Risk 07) and Sustainability of screening services (Risk 14).

The Committee discussed the risk appetite, risk rating, the risk controls, and the critical actions recommended to manage each of the 3 risks allocated to the Committee.

The CRO noted that subject to approval at the Audit and Risk Committee two new risks are due to be added to the CRR - Assisted Decision Making and the Invasion of Ukraine and that one of these risks may be assigned to the Safety and Quality Committee.

ND Acutes provided a high-level update briefing on the implementation of the recommendations of the findings of the internal audit report on Compliance with Post-mortem practices and procedures, which were presented to the Committee in March 2022. A project group was established to ensure the recommendations from the Internal Audit report were progressed, tracked and implemented with the relevant stakeholders.

ND Acutes noted that he had a further implementation report which he would forward on to the Committee but that the focus remains on being compliant with standards. The Committee discussed the importance of having the report published and noted that a Communications plan was ready to be progressed once publication of the report was ready to proceed.

Prof. Risteárd Ó Laoide joined meeting 11.56am.

Prof. Risteárd Ó Laoide provided an update to the Committee on the Implementation of quality care: Cancer services.

He noted that the past two years have been very difficult for people living with cancer, their families and those who provide their care. While the full impact of COVID-19 on cancer care and patient outcomes is not yet quantifiable, a report by the NCCP, NHQI, NEQI, NRQI, NCRI, RCPI and other partners published in December 2021, provided some initial analyses.

This report estimated that 10-14% fewer cancers were diagnosed in 2020 compared to 2019 (pre-pandemic). However, despite the challenges of COVID-19 and the lower than expected level of resourcing for the strategy, progress has been made to implement the recommendations as highlighted.

The Committee received an update with regards to recruitment / staffing issues and proposals to improve the recruitment situation with Prof O’Laoide noting that the shortage of doctors and nurses is now a global issue. The Committee discussed the need to train more Radiologists and the development of additional posts. It was noted that the role of Radiologists has changed radically in the last 30 years and the volume and complexity of the role has increased enormously.

The Committee also discussed the role of Primary Care and the need for GP’s to have access to diagnostics. Prof O’ Laoide also briefed the Committee on how the HSE is addressing and supporting cancer patients coming to Ireland from the Ukraine.

Prof. Risteárd Ó Laoide left the meeting.

Siobhan Kelly joined the meeting.

Siobhan Kelly joined the meeting and presented an overview of the National Clinical Programme (NCP) for Ophthalmology. The Committee discussed the consequence for Children waiting for appointments and comparisons between the public and private waiting times.

The Committee were informed that CH09 has implemented a new pathway which as a result has seen the waiting list for appointments disappear. It was agreed the Committee would be provided with further information and data on this. The Committee discussed the importance of benchmarking these services comparing it to other countries.

CCO joined meeting at 13:40pm.

The CCO presented his monthly report to the Committee highlighting the following areas

• Covid 19 - He noted that the number of hospital admissions of COVID positive patients, and the number of new COVID confirmed cases in hospital continue to decrease. The Committee were also advised that to date over 3.1 million additional vaccine doses have been administered and that over 65s and the immunocompromised are now eligible for a further additional dose through the Booster programme. The Committee discussed the use of Sotrovimab in hospitals with the CCO, who said that a reduction in the number of doses of Sotrovimab being prescribed has been seen since an alert issued from TAG relating to growing evidence for the reduced efficacy of sotrovimab against the BA.2 sub-variant.
• National Screening - The CervicalCheck Programme Report 2017-March 2020 is now published providing statistical overview of the final years of Ireland’s cytology-based population screening programme, an update on the Consultant radiology recruitment plan, and CervicalCheck- Cyber-attack. The Committee noted that they had discussed the Consultant radiology recruitment plan and the challenges in this area earlier in the meeting with Prof. Risteárd Ó Laoide. The Committee asked to be kept updated on the progress of the recruitment plan.
• Public Health Consultant Recruitment and Reform – The CCO updated the Committee on the six new Public Health Areas which are aligned to the Sláintecare Regional Health Areas. The Committee noted that with effect from the 1st May 2022, these areas have replaced the former Department of Public Health structures and that five of the six Area Directors of Public Health have been appointed with the final appointment expected to be made in the coming weeks.
• Ukraine Crisis and the overall approach to the clinical work stream - The CCO said that the focus is to define the public health and clinical priorities of the refugee population and work with colleagues in Operations to meet the needs which follow. In response to Committee questions on meeting the immediate needs of the refugee population entering the country, the CCO confirmed that immediate access is being sought through GP services and noted that work is ongoing to develop supports in this area.
• DPC investigation - The CCO briefed the Committee on a DPC investigation based on a complex complaint about erasure in the national Screening Services. The Committee discussed with the CCO the importance of balancing the public health exemption with individual cases and noted that further legal opinion may be required in anticipation of the DPC’s continued engagement on this matter.

Ms Leigh Gath joined the meeting and presented the 2021 Confidential Recipient’s Annual Report to the Committee which set out the offices engagement with those who used the services during the 2021 period.

She noted that 218 concerns were raised of which 155 were formally sent to CHO areas for review. Ms Gath took the opportunity to give an example to the Committee of the work she has carried out in one case to illustrate some of the challenges experienced by service users and also to explain more about the role of her office.

The Committee emphasised the importance of the service provided by the Confidential Recipient Office and discussed further improvements which can be made regarding engagement between this office and services within the HSE. It was noted that although acute hospital concerns do not fall into the remit of the Confidential Recipient, Ms Gath had begun to meet with the ND of Acute Operations and ND Community operations on a quarterly basis to highlight concerns relating to both community operations and the acute hospitals.

The Committee expressed regret that Ms Gath will be leaving her position in September and wished her every success in the future. The Committee asked whether Ms Gath might be invited to present the HSE Board with a reflection of her experience as the Confidential Recipient over the last eight years. Ms Gath indicated she would be delighted with such an opportunity.

The meeting concluded at 15:15.