HSE Safety and Quality Committee meeting minutes 11 January 2022

Committee Members Present

Prof Deirdre Madden (Chair), Prof Fergus O’Kelly, Ms Jacqui Browne Dr Cathal O’Keeffe, Ms Yvonne Traynor, Dr Chris Luke, Ms Margaret Murphy

HSE Executive Attendance

Dr Colm Henry (CCO), Mr Patrick Lynch (ND Gov and Risk), Dr Orla Healy (ND Q&PS), Ms Yvonne O’Neill (ND Com Ops), Mr Jim Ryan (AND Mental Health), Mr Liam Woods (ND Acute Ops), Angela Fitzgerald (AND Acute Ops), Ms Niamh Drew, Mr Pat Galvin.

Joined the Meeting

Mr James McGrath (Item 6), Ms Sharon Hayden (Item 6), Mr Gary Kiernan (Item 2), Ms Alison Connolly (Item 2), Ms Susan Finnerty (Item 2), Dr Amir Niazi (Clinical Advisor Mental Health, Item 2), Ms Fiona Murphy (Item 5), Prof Jim Egan (Item 7), Mr John Walsh (Item 7)

Apologies

Ms Anne Carrigy,

Following a short private meeting of the Committee, D Madden took the Chair at 9.15am and welcomed members of the Committee and the Executive to the meeting.

The Chair briefly discussed correspondence that had been distributed to the Committee prior to the meeting relating to the NiRP Terms of Reference, the Patient Safety Strategy Report and Employee Assistance Programme documents, as follow ups from the last meeting and to advise the Committee on the most up to date situation with these items. The Committee were informed that the NiRP Terms of Reference scoping document has been discussed at the December Board meeting and an update is to be provided at the January Board Meeting.

Mr Gary Kiernan, Ms Alison Connolly, Ms Susan Finnerty, Yvonne O’Neill, Mr Jim Ryan and Dr Amir Niazi joined the meeting.

The Committee were brought through a presentation by Mr Kiernan and Ms Connolly. Ms Connolly spoke to a presentation about the Mental Health Commission’s background, statutory function and the findings from their 2020 report. It was noted in their findings that they identified issues with, in particular, Premises, Individual Care Planning, Restrictive Practices, Authorised Officers and Quality Improvement and felt that compliance in these areas needs to be improved. Mr Kiernan explained that the issues identified were notified to the relevant HSE management level, as part of the escalation process, but felt that there was a lack of progress to address some issues identified.

He highlighted the importance of seeing quality improvement measures as well as adherence to regulations. Recommendations include active leadership, which would be a full-time person dedicated to Mental Health Planning, the allocation of appropriate in a measurable way and that funding is tracked to ensure the resources are used to implement the strategy. The Chair and the Committee thanked the MHC representatives for their comprehensive presentation.

The ND Com Ops and AND Mental Health proceeded to update the Committee on the issues raised by the MHC. They informed the Committee that there were 4 key items that the MHC had identified; Individualised Care Planning, Premises, Authorised Officers and Restricted Practices and advised that an Individual Care Planning Training programme had been developed and rolled out over the course of 2020 - 2021.

Resources developed as part of the training are to be circulated and the training will be evaluated to look at improvements which will increase compliance. A budget of €13 million has been secured for works on Premises. Premises conditions are being reviewed with areas of priority being mapped to address the immediate needs. A comprehensive Capital Plan is being worked on in partnership with HSE Estates for the next ten years to continue the improvements with a recurring fund of €6 million obtained to invest in the safety and compliance of Mental Health Infrastructure. Additional funding has been secured under the HSE Capital Plan for 2022.

It was noted that additional staffing is required but there is a service improvement plan in place which will address current issues. The National Director advised the Committee of the significant ongoing leadership in MHS giving rise to significant increased investment and service improvement, including relative resource allocation methods and increased reporting under the new Sharing the Vision strategy on utilisation of resources. The Committee welcomed the improved compliance rates that had been achieved over the last number of years and noted that there is no quick solution to the premises issue. A discussion was held in relation to the review of the Mental Health Act to which the Committee were informed that even though it is moving at pace there is no definitive timeline and it is currently sitting with the Oireachtas.

The Committee were particularly concerned at the figures presented of children being admitted to Adult Units but did note the reduction in these incidents for the last number of years as a positive and feel that Mental Health is an area that needs to be top priority for funding and resources.

Mr Gary Kiernan, Ms Alison Connolly, Ms Susan Finnerty, Yvonne O’Neill, Mr Jim Ryan and Dr Amir Niazi left the meeting.

Gemma Moore joined the meeting.

ND QPS briefly explained to the Committee about the background to the HSE Clinical report on the Cyber Attack. She explained that a study group was established to undertake a review of the clinical impact of the Conti cyber-attack on patient safety, the mitigations staff put in place, and to capture the key learnings from front line staff affected by the attack. A broader report was published by Price Waterhouse Coopers outlining the effects on the HSE, and this additional report was produced by the QPS Division to show the effects from a clinical perspective.

ND QPS introduced Dr Gemma Moore who spoke to a presentation on this clinical report. Dr Moore outlined a study overview showing the impact on staff during the Cyber Attack, what workarounds had to be found, what worked well and what was the experience for frontline staff. The Committee were advised that as part of the study a series of focus groups were conducted with services most impacted during the cyber-attack which included radiology, pathology/labs, radiotherapy, maternity, and primary care.

The focus groups explored the impact of the loss of clinical IT systems in each area, what mitigations were implemented and the impact on staff. It became clear that the Acute sectors hardest hit due to their reliance on IT. The resilience of staff, the innovative solutions developed, the teamwork amongst staff and the leadership shown were some of the positives that were seen from the report despite the fact that staff were already feeling the stress and anxiety from Covid, working long hours, and dealing with frustrated service users. The Committee discussed the real human impacts of dealing with the Cyber Attack and staff morale was hit and the Committee noted the importance of staff wellbeing. The Committee thanked Dr Moore for the report, however they would have liked to see more data and stats.

Gemma Moore left the meeting.

ND QPS gave the Committee an overview of the Quality Profile Data. The Committee questioned the data on absenteeism as it is historical data and there is significant absenteeism currently.

The Committee were informed about the current derogation for Healthcare staff so that vital areas can be staffed appropriately and that routine services have been curtailed to maintain critical services whilst keeping it safe for all involved. ND QPS informed the Committee of a new focus group which is being established to look at this area of concern and the Committee requested that an update is provided at next month’s meeting.

ND G&R and Ms Fiona Murphy joined the meeting.

Risk Appetite Statement

The CRO gave the Committee an overview of the Risk Appetite Statement. Th

e CRO explained that it is the role of the Board to articulate the acceptable appetite risk for the HSE. The Risk Appetite Statement describes and sets parameters on the target level of risk the HSE is willing to accept to achieve its strategic objectives. The acceptance of risk should be linked to the expected benefits, improved services or service efficiencies and while there may be limitations to the use of the Risk Appetite Statement, it is intended to provide a useful guide and framework for planning the management of risk. The CRO explained the other components of the Risk Appetite Statement such as Risk Tolerance, where a risk is identified, the target level of risk is identified, and then the risk is monitored to ensure that the action plan is robust enough to ensure the target risk level can be achieved in a defined timeframe The Committee were advised that the risks reports will now also set out the risk appetite target for each risk. This will allow the S&Q Committee to more effectively monitor the Action Plan for each risk to ensure it is robust enough to mitigate the risk. One error in the Statement was identified by the Committee and the CRO undertook to amend it. The Committee thanked the CRO for his presentation his explanation of the Risk Appetite Statement.

Risk 15 - Screening Services

CE Screening Services gave the Committee an overview of Screening Services and the associated risk. The Committee were informed that even though there is no immediate patient safety issue, Screening Services risk is a long-term red risk and it will take a number of years to improve this. The CE explained to the Committee that continued legal cases create a high risk for the viability of Screening Services. As a result of these challenges there is a big impact on running the service with impacts on recruitment, high cost from legal issues and continued lack of trust in screening. Currently there are 3 main actions being reviewed to help improve outcomes, these include uninterrupted Lab Services, engagement with the public to reduce misinformation and the third is implementation of Interval Cancer Reports 2020 recommendations review and proposal of new legal framework or alternative.

The Committee felt that engagement with the public would be a good course of action as there is a lot of misinformation in the public realm about the objectives and limitations of screening. The Committee held an in-depth discussion in relation to the challenges and highlighted the importance of public education and Open Disclosure for patient safety incident. As way of an update, CE Screening Services is to revert at a future meeting when the review process has been agreed.

ND G&R and Ms Fiona Murphy left the meeting.

CCO Report

Dr Colm Henry provided a high-level overview on a number of areas, noting the following:

Currently there is a surge with the Omicron variant leading to an increase in cases with the peak expected in mid-January. The focus at the moment is on hospital activity, as absenteeism is high due to staff testing positive and/or having to isolate. He informed the Committee that currently there is an exercise being carried out to distinguish between people in hospital admitted with Covid and those who have been admitted for other conditions who have then acquired Covid.

He informed the Committee that given the threat of the Omicron variant, the HSE has been increasing capacity and updating its operational plan for the booster programme to include expanding opening hours of Vaccination Centres to 12 hours a day, seven days a week (incl. additional resources). General Practice is assisting with over 1m booster doses administered to date and the amount of participating pharmacies increasing from ca. 700 to increase to ca. 1,000 by the end of January. The Committee noted the huge impact of general practice and pharmacies throughout the pandemic.

The CCO also provided a briefing on the development of new treatments for COVID-19, which are recommended for use in defined population sub-groups where the benefits of the treatment have been shown to, or are likely to, outweigh the risk. These are new treatments, and patients who receive them will be actively monitored for effectiveness and patient safety after administration. In the majority of cases, it will be used on immunocompromised people and can be used on unvaccinated people. He proceeded to inform the Committee that the three new Covid therapy drugs have shown some promise based on clinical trials.

He noted that there is limited availability of these drugs for 2022 and therefore the importance of pre ordering is required. It was noted that as one of these is an infusion drug, there may be a preference for hospital setting for monitoring and patient safety reasons. CCO agreed to provide a report for the next meeting to update the Committee on this matter.

A briefing was also given by the CCO with regards to the impact that the pandemic is having within BreastCheck, he informed the Committee that BreastCheck will remain operational for women who have commenced their screening journey and will reduce new invitations on a cautionary basis for the next 2 weeks; reviewing the situation and adapting weekly until the surge of cases becomes more stable. All units report some reduction in staffing, but screening is being maintained during this wave.

He noted that all cancer services continue to operate, with ongoing challenges in relation to staffing absences owing to COVID-19 and related isolation. CCO updated the Committee on the latest developments relating to recognising, reporting, reviewing and learning from an Adverse Event in maternity care. A further report is to be provided at the next meeting to clarify some of the stats discussed by the Committee.

CCO advised that the Public Health Recruitment Programme is progressing. The changes will be implemented in waves as this will be a complete reform of the area. 34 priority posts will be in place by the end of June 2022, with priority focus on Health Protection and Area Consultants. The Saolta Group have advised that they have met to consider the recurring issues and themes from the range of reports and reviews relating to Letterkenny University Hospital.

The Hospital Group has agreed initial first steps to engage additional external support for the development and implementation of an appropriate change plan for the hospital.

CCO updated the Committee on the latest developments in the South Kerry CAMHS case. The Committee discussed the challenges identified such as a lack of supervision, inappropriate prescribing, and difficulties in recruiting clinicians at the time. CCO advised that a report on this matter was due to be published by Operations this month. CCO mentioned staff absence and explained that despite the derogation for staff it may become necessary to redeploy staff to resource vital service areas.

The Committee were informed of a new Safety Group that has been implemented to look at any safety issues relating to staff absence.

Mr Liam Woods, Ms Angela Fitzgerald, Prof Jim Egan and Mr John Walsh joined the meeting.

Prof Jim Egan spoke to a presentation on Organ Donation and Transplant services.

International comparison of donation and transplant rates

Prof Egan brought the Committee through comparison tables with European countries and explained that Ireland’s organ donation rate is below the international average and is insufficient to meet the numbers on waiting lists for solid organ transplant of kidney, heart, lung, liver and pancreas. In order to meet the demand on the kidney waiting list, Ireland would require 250 kidney transplants per year. Spain is the leading country for organ donation, reflective of the resource and infrastructure they have developed over 30 years. Compared to Spain, there is a significant difference in the availability of nurses and specialists in the donation and transplant area.

In Spain and other jurisdictions, donation models are developed to increase organ availability through increased age limits (up to 80 years) and development of deceased cardiac donation model. Prof Egan explained that we require a minimum of 100 donors to meet our requirements.

The Committee questioned if organ donations were to increase would we have the appropriate capacity to carry out those transplants. In response, a number of key requirements were identified including additional beds, additional theatre capacity, and additional critical care capacity.

The HSE is working with DOH on a plan to increase critical care capacity by 341 over the next 12-18 months. The Covid19 impact has shown the fragility of the donation and transplant services in Ireland, with a significant reduction in transplantation. Prof Egan indicated that support for investment in donation and transplant infrastructure is critical in tackling the escalating demand for dialysis services. Professor Egan raised the point that currently there is not dedicated capacity or ring -fencing of theatres and staff to guarantee that all transplants could be performed, even if donations were to increase.

Professor Egan asserted that ring fencing must be considered in order to maximise outputs in hospitals who also provide unscheduled acute care, in order to move towards the target of 100 donations per year and associated conversion to transplant. Enhanced theatre capacity is important in the transplant centres to allow daytime transplantation preventing risk averse decision making. Ring fencing of the service is not only about transplantation itself but also about avoidance of cancellations of scheduled urgent surgeries which occur when a transplant is prioritised for the theatre or ICU bed.

The Committee was advised that a National Review was commissioned by CCO to look at the key learning from a recent adverse event in the transplant programme. Separately, ODTI is undertaking a review of its structures to ensure that they are fit for purpose to address future transplant needs and to take account of the implications of the implementation of the Human Tissue Bill.

The Committee asked the ND Acutes to develop a 3-5 year vision for the Transplant Programme. As part of the process, the HSE will engage with the DOH to secure its support for necessary investment for the Plan. It was agreed that the HSE would update the Committee at its April meeting on progress in this matter.

The meeting concluded at 15.00.

Terms of Reference: Safety and Quality Committee