HSE Safety and Quality Committee meeting minutes 14 July 2023

Committee Members Present

Deirdre Madden (Chair), Fergus O’Kelly, Jacqui Browne, Margaret Murphy, Anne Carrigy.

HSE Executive Attendance

Colm Henry (Chief Clinical Officer), Orla Healy (ND QPS), Martina Queally (Chief Officer Community Healthcare East), Niamh Drew (Deputy Corporate Secretary), June Robinson (Office of the Board), Sharon Hayden (Manager Office of the Chief Clinical Officer), James McGrath (CEO Office).

Apologies

Cathal O’Keeffe, Anne Kilgallen, Mary Culliton, Yvonne Traynor.

Joined the meeting

Bernie McNally (Chair of the National Independent Review Panel – Item 3); Damien McCallion (Chief Operations Officer – Item 6); Caoimhe Gleeson (General Manager- Human Rights and Equality Policy – Item 6), Pat Healy (National Director Clinical Programme Implementation & Professional Development – Item 5.2); Siobhán Ní Bhriain (National Clinical Director, Integrated Care – Item 5); Sarah O’Brien (Acting NCAGL Lead for Chronic Disease – Item 5.3); Juanita Guidera (Quality Improvement Facilitator Staff Engagement for Quality – Item 7); Maureen Flynn (Director of Nursing, QPS Connect Team Lead – Item 7); Kara Madden (Chair Patients for Patient Safety Ireland (PFPSI) – Item 7); Tiberius Pereira (PFPSI – Item 7); Mary Vasseghi (PFPSI – Item 7); Ashling O’Leary (PFPSI – Item 7); Bernadette O’Reilly (PFPSI – Item 7); Paul Braham (Acting Assistant National Director, Mental Health); Tony McCusker (General Manager, Community Operations, Mental Health).

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.

2.1 Declarations of Interest

No declarations of interest were made.

2.2 Minutes

The minutes of 16th June were approved.

2.3 Matters for Noting

2.3.1 Patient Engagement Roadmap

An update on the Patient Engagement Roadmap was provided for noting in the Committee pack. The Committee discussed the importance of the Roadmap from a Quality and Patient Safety perspective. The Committee agreed that the language used in the document should be more specific in terms of tangible outcomes and asked for timelines for delivery to be set out clearly.

Referencing the Enhanced Community Care model as an example, the Committee was advised that patient experience should be embedded into the Roadmap. The Committee also sought clarity on whether learnings from other countries were considered.

Bernie McNally joined the meeting at 09.50.

The Chair of the National Independent Review Panel provided highlights of the National Independent Review Panel Annual Report 2022-2023.

She advised that the NIRP has now completed four major reviews into serious reportable events where there has been a Serious Incident Management Team (SIMT) and an independent review recommended. The implementation of recommendations emanating from these reviews will ensure the improvement of HSE community health and social care services in the future. NIRP are now in the process of completing two further reviews and will report on each of these in due course.

In an update on the Brandon Report, the Committee was informed that a well-attended learning event had been held in Dublin. It was observed that a face to face event is perceived as a more ‘safe space’ to probe and have detailed conversations than the online environment. The Committee acknowledged the difficulties for people taking time out from their roles to attend such training, particularly in Dublin and suggested that a ‘roadshow’ style event may be considered in the future.

The Committee asked if NIRP is satisfied with the HSE’s response to reviews and its implementation of the recommendations. Ms McNally advised that they are generally satisfied in relation to the Brandon Report. In relation to the Emily report, it was noted that high levels of openness and transparency when communicating with the affected families and other parties is beneficial and that the HSE could benefit from a greater level of expertise in areas such as Safeguarding.

The Committee was informed that Ms McNally’s replacement has been selected and is going through the induction process

The CCO reported to the Committee on a number of the key significant areas set out in his report. These included:

• an update on MonkeyPox (MPOX);
• the National Cervical Screening Laboratory (NCSL) project;
• the Cervical Check Laboratory services tender
• BreastCheck Radiology Shortages; it was noted that the programme remains a year behind schedule owing to the pause in screening due to Covid and Covid infection control measures. BreastCheck executives continue to manage the impact of the radiology shortages and progress actions identified.
• The World Health Organization’s International Agency for Research on Cancer (IARC) and the launch of the agency’s report: Recommendations of Best Practices in Cervical Screening Programmes. The Committee commented on the importance of this report and its significance internationally.
• Radiology Diagnostics Review Imaging capacity. It was noted that public radiology service is centred almost entirely on public hospital radiology departments which is challenging. To support a greater understanding of the current system challenges, the CCO commissioned the Expansion of Cross Sectional Imaging Capacity in the Acute Hospital Sector – The next five years (the Sheehy report). The CCO and COO are commissioning work to address the challenges identified and are developing the Terms of Reference (TOR) to move this forward. The CCO agreed to provide an update on next steps and share the Terms of Reference once agreed.
• National Womens and Infants Health Programme (NWIHP) - OEST programme, the CCO advised that there were 3 reported events to the OEST programme in June and noted that the CEO has asked the National Director of Acute Operations to engage directly with the CEO of the hospital group to engage with the OEST programme.
• The CCO provided an update on Sodium Valproate, an oral medication licensed for use in Ireland since 1975 for epilepsy and other conditions and provided an update on “Anti-Microbial Resistance and Infection Control (AMRIC) – Carbapenemase-producing Enterobacterales (CPE).
• The CCO advised that the HSE OLHN operational group is meeting to progress the key issues that are required in advance of full reconfiguration.
• As requested by the Committee at its June meeting an update on Genetics and Genomics was provided, as well as an update on the “Urgent and Emergency Care – people over 75 years and older” Quality Profile metric.

Grainne Cosgrove, Pat Healy, Siobhán Ní Bhriain and Sarah O’Brien joined the meeting at 12.00.

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

Using April data, P Healy, S Ní Bhriain an S O’Brien provided a recruitment update for the Enhanced Community Care Programme and also an update on the Programme from the following perspectives: Integrated Programme for Older People (ICPOP), Integrated Care Programme for Chronic Disease (ICPCD) and Community Healthcare Network (CHN).

The COO and C Gleeson joined the meeting

Corporate Risk Register 018 - Assisted Decision-Making Capacity Legislative Changes was discussed. The COO focused on the commencement of the Assisted Decision-Making (Capacity)(Amendment) Act 2022 in April 2023 and its evolving impact on both service users and their families and HSE services.

The Committee emphasised the need to ensure the patient remains at the centre of this implementation and does not become lost in the system as the required adjustments are made. The ND Integrated Care confirmed that this is a key concern and education is ongoing system wide to help staff adjust.

The Committee thanked the COO and C Gleeson for the presentation and commended the work undertaken to date to implement this legislation.

The COO and C Gleeson left the meeting.

M Flynn, J Guidera, K Madden, T Pereira, M Vasseghi, A O’Leary, and Bernadette O’Reilly joined the meeting.

M Flynn introduced representatives from Patients for Patient Safety Ireland (PFPSI) to the Committee. She advised that PFPSI has transitioned to liaise with the HSE through the National Quality and Patient Safety Directorate (QPS) from the 1st July 2023 to further enable and focus on the delivery of the commitments of the Patient Safety Strategy.

T Pereira presented to the Committee on the work of PFPSI which is a small, voluntary, independent organisation. He advised that PFPSI was initially formed to enable patients to tell their story of their experiences in the health service. Since the WHO programme recognition, the group has become more ambitious and has a remit to engage and become more proactive, working in collaboration with health care workers and policy makers. He advised that PFPSI have established good working relationships with government departments and other patient safety advocacy groups.

The aim of PFPSI is to empower patients in relation to all of their interaction with the health service. The area which they have been focused on recently is education on health literacy, particularly in relation to medication. B O’Reilly highlighted the ‘Know, Check, Ask’ information campaign which encourages patients to become more familiar with their medication, as well as iSIMPATHY (implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years) which is an EU funded project undertaken in collaboration with Scotland and Northern Ireland to the Committee.

The Committee thanked the PFPSI representatives for attending the meeting and expressed strong support for the work they have undertaken.

M Flynn, J Guidera, K Madden, T Pereira, M Vasseghi, A O’Leary, and Bernadette O’Reilly left the meeting.

P Braham and T McCusker joined the meeting.

The Committee was updated on the Mental Health Commission’s (MHC) Annual Report 2022 which was published on 9 June 2023. In line with established practice, Community Operations – Mental Health has developed a detailed action plan in response to MHC findings which is due to be submitted on 31 July 2023.

In the 2022 report the MHC noted that there had been a steady and increasing trend in compliance over the last number of years and while the overall compliance rate (88.4%) was marginally lower than the previous year, there are positive indicators when pandemic-related factors are accounted for. However, the MHC expressed concern about low levels of compliance with four key regulations, namely premises, individual care planning, risk management and staffing.

The Committee considered a draft HSE Action Plan which is due to be submitted at the end of the month and addresses areas of concern. The Committee discussed ligature management and the applicable risk management process and was advised that a new risk matrix is currently being developed with input from international mental health fora.

The Committee queried the process proposed to address shortcomings identified in certain properties and was advised that the MHC continue to seek a multiannual costed and funded plan for development of premises however this is extremely challenging The wider response to the action plan to improve services and overall compliance is dependent on the level and reconfiguration of existing resources and new development funding. This requires significant HR engagement on productivity and enhanced recruitment and retention.

The Committee thanked P Braham and T Mc Cusker for the presentation and was supportive of the proposed action plan.

P Braham and T Mc Cusker left the meeting.

No matters arose under this item.

The meeting ended at 14:50.