HSE Safety and Quality Committee meeting minutes 14 June 2022

Committee Members Present

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

HSE Executive Attendance

Dr Colm Henry (CCO), Prof Orla Healy (ND Quality & Patient Safety), Ms Niamh Drew, (Deputy Corporate Secretary), Ms Breda Moore Apologies: Prof Fergus O’ Kelly, Ms Margaret Murphy

Joined the meeting

Dr Gerry McCarthy (Consultant in Emergency Medicine, CUH), Ms Eileen Rudden ( Scheduled Care Leave from Acute Operations), Dr Mike O’Connor (NCAGL) , Ms Sandra Broderick (Community Operations), Ms Angela Tysall ( HSE Lead for Open Disclosure), Dr Gemma Moore (QPS Intelligence), Ms Alana Ryan (National Women’s Council), Mr Killian McGrane (Director, NWIHP) Dr Cliona Murphy(Clinical Director NWIHP), Ms Grace Turner (Head of Strategy, Business and Projects, NSS)

Items recorded as per agenda.

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

Minutes of Committee meeting 10 May 2022 were approved.

The EMT Members joined the meeting at 9.30am

Following discussion at the Safety and Quality Committee meeting of 10 May 2022 with regards to the recommendations of the working group on the review of the operations of the National Independent Review Panel , the Committee had requested that further consideration be given to how the wishes of service users and families were considered in respect of publication and also consideration with regards to the implementation of the Assisted Decision Making (Capacity) Act which is due to come into effect shortly.

Professor Healy presented this item to the Committee highlighting the amendments and considerations made as per the Committees request, noting that she had also discussed this in detail with NIRP Chairperson. The Committee held a discussion on how learnings can be shared, and the importance of accountability being demonstrated in open environments. The Committee requested that a further paper is developed and presented for the Committee meeting in July / September which sets out how learnings have been captured from reports such as NIRP and disseminated throughout the organisation.

Prof Healy presented the June 2022 Quality Profile which provides statistical insights into quality and patient safety data and to support understanding of variation in performance over time, which had been circulated to the Committee prior to the meeting for consideration.

Professor Healy provided an update on each of the data metric and the Committee raised questions with regards to some of the most noticeable performances.

As per the request from the Committee at its June meeting, it was noted that a presentation with regards to CAMHS Percentage of accepted referrals / re- referrals offered first appointment and seen within 12 weeks is due to be presented at the Committee’s July meeting.

A presentation and discussion on the metric regarding - Percentage of all attendees aged 75 years and over at ED who are discharged or admitted within 6 hours was provided to the Committee. The Committee were briefed on the 3-year Unscheduled Care (USC) improvement programme and the objectives for year 1. The Committee welcomed the presentation and it was agreed that they would be kept abreast of the implementation and work of the program.

The Chair welcomed Angela Tysall to the meeting to present the Open Disclosure Annual Report 2020 and reminded the Committee that the report was being presented in line with the Scally Recommendation number 32 “An Annual Report on the operation of open disclosure must be presented in public session to the full Board that is to be appointed to govern the HSE” in his report “Scoping Inquiry into the Cervical Check Screening Programme” September 2018.

A Tysall presented the report noting the objective of the National Open Disclosure Programme is to promote and support a culture of openness and transparency through compassionate and empathic communication with patients, service users, their relevant persons and staff. She explained that the annual report sets out the areas of work, the successes and challenges experienced during the 2020 period.

It was noted that despite the impact of redeployment of staff during the period March to December 2020, a number of key pieces of work were progressed by the National Open Disclosure team. The Committee welcomed the report and discussed the key developments that had been achieved to date. The Committee discussed the current program of work of the team and in particular the specific training that will be required around the proposed Patient Safety (Notifiable Patient Safety Incidents) Bill.

Alanna Ryan, Women’s Health Co Ordinator, National Women’s Council was welcomed to the Committee and provided an overview of a report on Improving Health Outcomes and Experiences of the Healthcare System for Marginalised Women. She informed the Committee that in September 2019, the Department of Health established the Women’s Health Taskforce to improve women’s health outcomes and experiences of healthcare.

The recommendations of the report included – viewing women as equal partners, champion community-based care and community development support, promote accessibility and inclusion and collaborate across government.

The Committee discussed the findings of the report and discussed the importance of tailored training on similar areas for different groups across the HSE and the approaches used. The importance of safeguarding policies and procedures for all staff was also highlighted, and the Committee suggested that further consideration should be given to mandatory training in such areas.

Dr C Murphy and Killian McGrane provided the Committee with a further update on the National Women and Infants Health Programme and the developments within Maternity, Gynaecology, Abortion Services, and the Perinatal Genetics Framework. They also briefed the Committee on the development of a Quality and Safety Framework which will be brought back to the Committee in September. The Committee discussed and welcomed work in each of the development areas but noted the recruitment challenges that are currently being faced.

The Committee received an update with regards to Corporate Risk 14 – Sustainability of Screening Services. The Committee were reminded that even though there is no immediate patient safety issue, Screening Services risk remains a long-term red risk.

The Chair provided an update to the Committee on the Patient Safety (Notifiable Patient Safety Incidents) Bill 2019 which had been discussed at the Board meeting on the 27 May and informed the Committee that it had been agreed that the Chair would write to the Minister setting out the Board’s concerns with regards to the proposed amendments to the Patient Safety Bill relating to interval cancer.

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

Covid 19 - Data up to 08 June shows an increase in confirmed cases. Other European countries are also seeing an increase in variants Ba.4 and Ba.5

Vaccination Programme - The second booster programme is progressing from its 22 April launch focussing on the vaccination of over 65s and already identified over 12s Immunocompromised with ca. 298k second Boosters administered to date. The Committee agreed that it was important to be prepared for Autumn / Winter 2023 and that all the lessons learned throughout the pandemic are not lost. The Committee raised a recent Irish Times article and sought clarification with regards to the reporting of deaths during the pandemic period and Ireland’s position compared to other countries. The CCO agreed to feedback to the Committee on this as part of the CCO report next month. Ukraine Crisis – The CCO informed the Committee that there are two workstreams supporting the HSE response to the Ukrainian Crisis.

The overall approach is to translate clinical patient care needs into strategies for safe, effective and efficient delivery of health services and to respond to requests from other workstreams/colleagues across the health system. The Committee noted the challenges with regards access to GPs for the people arriving into the country Hepatitis cases in children - The Committee were informed that there is one single tertiary referral centre for paediatric gastroenterology and hepatology, based in CHI-Crumlin.

This centre provides 24/7 support for all regional paediatric units with hepatology (liver disease) queries as well as inpatient and outpatient management of children with complex liver conditions, and those either awaiting or following liver transplantation. As there is currently no paediatric liver transplant programme on the island of Ireland, all children in need of transplant assessment are transferred abroad (primarily to one of the UK paediatric transplant centres).

The Committee queried how many affected children the HSE has capacity to care for and what the process if / when capacity is maxed out. The CCO confirmed that engagement with the UK is extremely important for this area.

Monkey Pox - The CCO provided an update on the incidence of Monkey Pox and advised that the picture is now clear as to the status of the disease.

National Cancer Screening Services – An update on National Screening was provided, and it was note that National Screening will be an agenda item for the Committees July meeting.

Obstetric Event Support Team (OEST) - The CCO provided an update on the current work of the OEST team in looking at obstetric clinical incidents occurring within the Maternity Networks. A verbal update was provided in relation to Letterkenny University Hospital.

Our Lady’s Hospital Navan - The Chair briefed the Committee on the discussion held at the Board meeting on 27 May noting that the Board confirmed its decision made on the 27 April to proceed with the planned reconfiguration of Our Lady’s Hospital Navan as there remains very serious patient safety issues which presents significant risk to some categories of patients presenting to the Emergency Department at the hospital. The transition of OLHN to a model 2 hospital ensures the delivery of more efficient and safer services for all patients regardless of their method of arrival to the hospital which is supported and endorsed by clinicians at hospital and national level.

The Committee held a lengthy discussion and noted their high level of concern remains unchanged.

The meeting concluded at 4.15pm.