HSE Safety and Quality Committee Meeting Minutes 13 December 2023

Committee Members Present

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

Apologies

Jacqui Browne

HSE Executive Attendance

Colm Henry (CCO), Martina Queally (CO Community Healthcare East), Orla Healy (ND QPS), Sharon Hayden (CCO Office), Niamh Drew (Deputy Corporate Secretary), Rebecca Kennedy (Office of the Board).

Joined the meeting: Louise Hendrick (Clinical Lead QPS Intelligence – Item 7), Lorraine Schwanberg (AND Incident Management - Item 7).

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.

The Chair welcomed executive members to the meeting.

2.1 Declarations of Interest

No declarations of interest were made.

2.2 Minutes

The minutes of 16th November 2023 were approved.

2.3 Workplan 2024

The Committee workplan for 2024 was approved subject to some final amendments.

2.4 Matters for Noting

i) Update on implementation of Emily and Brandon report recommendations

Papers providing an update on the implementation of the Emily and Brandon report recommendations as requested by the Committee and circulated in advance of the meeting were noted.

ii) Healthcare Audit Plan 2024

A paper outlining the proposed Healthcare Audit Plan 2024 which was circulated in advance of the meeting was noted and the Committee requested extra detail on the seven proposed areas of focus.

CCO joined the meeting.

The CCO presented his monthly report which included a Public Health update on Winter Viruses and vaccination uptake. The current respiratory virus epidemiology and surveillance data reports from HPSC for 2023 shows the number of COVID-19 cases as being stable, RSV activity is at very high levels and higher than previous Winter, and influenza hospitalisations have doubled. The CCO provided an update on the Winter Vaccination Programme which showed healthcare worker (HCW) vaccine uptake is at 16.2% for COVID-19 and 33.1% for influenza. The Committee expressed concern on the continuing low uptake of COVID-19 and influenza vaccines among HCWs.

In relation to the National Women and Infants Health Programme’s Obstetric Event Support Team (OEST) Programme, the CCO reported that a positive response was received from the CEO of the RCSI hospital group and there is now engagement planned with OEST Programme. It was agreed that updates on this programme will now come to the Committee quarterly.

The CCO updated the Committee on the National Screening Service in relation to the recruitment pause, Breast Check Radiologists and Radiographers shortages, and the impact of the FORSA strike. The CervicalCheck Cancer Elimination Day of action was held on the 17 November 2023. The CCO highlighted the HPV vaccination programme which has seen great improvements in the past number of years, with 80% of girls now vaccinated against HPV by age 15. The Committee discussed the follow up vaccine programme which was a once off and available to everyone not vaccinated up to age 25. The programme did not see good uptake and the Committee suggested that another attempt should be made with this programme and possibly could be rolled out using the third level colleges infrastructure. The CCO also highlighted the work completed by the NSS in relation to improving its information governance.

The CCO updated the Committee on the ongoing CHI Review, advising that the HSE CHI oversight group continue to meet with the Independent review progressing under Mr Nayagam’s leadership. The CCO outlined the objectives of the review and advised that the first phase is due to be completed by the end of January 2024. The Committee discussed whether it would be possible to include a patient representative as part of the independent review. The CCO advised that he is not in a position to appoint anyone as it is not a HSE review but he will suggest this to the reviewer and include the AND Patient Engagement in the conversation.

In relation to Organ Retention in CHI at Crumlin, the CCO advised that a project team is in place and communication has now taken place with all families. He confirmed that in respect of the Hospital Groups, the prior engagement process that was undertaken following the 2022 Internal Audit concluded that all outstanding organs retained at that time were respectfully disposed of following engagement. In respect of assurance that each hospital has reviewed the 2023 PME Guidelines, he advised that the responses infer that the Guidelines have been reviewed and that hospitals have or are aligning their practices in line with the guidance. The Committee emphasised that assurance in relation to other hospitals is still required and that the language used in the above statement is not strong enough. It was agreed that the CCO would return with stronger assurance.

The CCO updated the Committee on the ongoing National Service Plan (NSP) 2024 process advising that the team are currently working through the Letter of Determination (LoD) 2024. He highlighted that many national strategies have been paused for NSP 2024 and outlined clinical strategies which fall under the remit of the CCO which were and were not identified for funding as part of the LoD. The Committee discussed the Patient Safety Act and National Open Disclosure’s inclusion in the list of strategies which would not be funded and it was agreed that the CCO would provide more information on what exactly the impact on them would be.

The CCO gave the Committee a verbal update on the review of a serious incident resulting in the death of a teenage girl in University Hospital Limerick in December 2022.

The CCO reported to the Committee on a number of the other areas set out in the report including:

• current ED Activity at Our Lady’s Hospital Navan (OLHN)
• Beneficiaries of Temporary Protection (BOTP) - International Protection Applicants (IPA)Catch-up Vaccination Programme
• Childhood, Adolescent and Young Adult (CAYA) Cancers re Screening Programme
• drugs Shortages
• administration of IV antibiotics in nursing homes/step down hospitals

The CCO presented an overview of Clinical Governance in the HSE and funded agencies based on a paper circulated in advance of the meeting. Topics covered were Clinical Governance in Ireland; Clinical Governance HSE Centre ; Hospital Governance; Community Governance; Joint Governance for Acutes and Community; Nursing in Community Setting; Health and Social Care Professional Governance; Public Health; Primary Care; Children’s Services; CHI; Children’s Healthcare outside CHI; and the Development of a Clinical Governance Model – Next Steps for 2024. The CCO highlighted that community clinical governance is less clear than acute clinical governance and more clarity will be required for the upcoming implementation of the Health Regions.

The Committee discussed the functioning of clinical governance in voluntary agencies and requested further information on how this works. In particular, the CCO was asked to advise on how transparent this governance is, how it is managed (for example, thorough a Service Level Agreement), and how it compares to other similar health systems.

The Committee discussed the term ‘clinical governance’ and whether this use of language captures the breadth of its application. It was highlighted that this is not necessarily inclusive enough for all HCWs to see its relevance to their role. It was suggested that healthcare governance would be a more inclusive term.

The Committee noted that further discussion on Clinical Governance is scheduled for the February 2024 meeting.

The Committee considered the Quality Profile from the October data cycle. O Healy updated the Committee on the monthly indicators, noting that there was very little change by comparison to September indicators and that much of the data is now outdated due to the ongoing FORSA action.

The Committee agreed that a workshop on the Quality Profile would be held in January with the aim of agreeing how the Quality Profile will be utilised going forward.

O Healy presented the overall implementation plan with progress being reported on each commitment of the Patient Safety Strategy and the achievements and challenges for each. The Committee’s discussion focused on measures taken to achieve the ‘Measure and Learn to Improve Patient Safety’ commitment.

In relation to the Quality and Safety Signals programme (outlined below in Item 7), O Healy highlighted that the quality of the data submitted to these systems is critical. The Committee discussed the real impact of the alerts issued on this system which is a closed loop system with a nominated person (either a risk manager or QPS manager) in each one and it is cascaded through system from there until confirmation that the notification has been acted on is received. The Committee thanked O Healy for the update and were supportive of the work completed to date.

L Hendrick and L Schwanberg joined the meeting.

O Healy introduced two presentations on initiatives in progress or development with regards to patient safety surveillance and reporting systems.

L Hendrick presented to the Committee on the Quality and Safety Signals Programme which aims to enable the Irish health and Social Care Services to both monitor and reduce avoidable harm, and identify and share learning from areas of excellence. Its purpose is to provide an online system that optimises the use of available data for patient safety surveillance and quality improvement. It will do this by making it easy for stakeholders to access and interrogate data; identify signals of risk to quality and safety; detecting signals of change to allow for investigation and response; and disseminating learnings from areas of excellence to support nationwide improvement. It was highlighted that although good progress has been made in relation to this project, it has been significantly impacted by the recruitment embargo. The Committee thanked L Hendrick for the presentation and work completed on the project to date and expressed their full support for this work.

L Schwanberg and L Hendrick presented to the Committee on Data for Decision Making. They outlined the Data for Decision Making resources and tools available to boards, committees or leadership teams seeking to develop Quality agenda items. Two quality complementary agenda items were co-designed for this purpose providing a quantitative and qualitative picture of quality, namely a Quality Profile that uses statistical process control methods to present indicators across seven domains of quality; and People’s Experience of Quality where patient, service-user, family and front-line staff experiences are shared. The Safety and Quality Committee currently utilises both the Quality Profile and the People’s Experience of Quality as agenda items.

The Committee were advised that while these items do currently have a focus on acute services, they are moving to include to community data. The overall goal of these projects is more transparency of data. The Committee thanked L Hendrick and L Schwanberg for the presentation and were fully supportive of the work especially the focus on a statistical approach.

L Hendrick and L Schwanberg left the meeting AOB.

A Carrigy referred to the note which she had circulated in advance of the Committee meeting which highlighted that the HSE is the nominated agency with responsibility under the Human Trafficking Bill 2023. The Committee discussed the need to ensure that awareness of human trafficking is included in all staff training. O Healy agreed to engage with the relevant department within the HSE and to identify next steps required for the development of appropriate training.

The meeting ended at 14:50.

Terms of Reference: Safety and Quality Committee