HSE Safety and Quality Committee meeting minutes 15 February 2024

Committee Members Present

Deirdre Madden (Chair), Anne Kilgallen (left approx. 13:00), Mary Culliton, Anne Carrigy (left approx. 12:50), Margaret Murphy, Yvonne Traynor, Fergus O’Kelly (left approx. 11:40, rejoined 13:10), Jacqui Browne.

Apologies

Cathal O’Keeffe.

HSE Executive Attendance

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

Joined the meeting

Liam Woods (ND Health Regions Programme - Items 4 and 5.2), Joe Duggan (ND Internal Audit - Item 5), Cora McCaughan (AND Healthcare Audit - Item 5).

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 Committee Minutes

The minutes of 18 th January 2024 were approved.

2.3 Committee Annual Report 2023

The Committee discussed the format of the Annual Report and suggested some changes to the layout which will be incorporated in the first draft of the 2023 Report.

2.4 Matters for Noting

1. Healthcare Audit (HCA) re Assisted Decision Making Committees The Committee noted an update from Healthcare Audit Update re Assisted Decision Making Committees.

The CCO presented his monthly report which included an update on measles. The CCO advised that the MMR vaccine uptake in Ireland is suboptimal and has declined to below 90% since early 2020. The CCO advised that falling vaccination rates are of serious concern and there is a current focus on rolling out catch up vaccines to reach certain areas/communities.

In relation to National Doctors Training and Planning - Consultant Strategy and workforce, the CCO updated the Committee on the Department of Health NCHD Taskforce report published 7th February 2024. The report recommended a target of 6,000 consultant posts by 2030 which will require 1600 - 1800 new posts per year.

The level of funding allocated will determine if this is possible as 100 new posts were funded in the 2024 NSP. The Committee discussed the number of these posts which would be in community roles, highlighting that there should not necessarily be a hospital focus.

The CCO confirmed that these posts will be in the community as well as hospital based, and also highlighted the issue of consultant staffing in model 3 hospitals - locum staff is double that in model 4s. The CCO confirmed that the HSE is seeking to expand training places for NCHDs and is working with training bodies.

It was agreed that there would be further discussion on this matter at a later meeting. The CCO provided updates from the Quality and Patient Safety Division to the Committee, outlining the process for the management of Coroner’s Recommendations.

He confirmed that the Coroner’s Core Governance Group has now been established and will be led by QPS under the governance of the CCO. The Committee noted this change in governance as positive. In relation to Patient Safety Notifications, O Healy gave an update on four notifications nationally.

In relation to the HSE CHI Independent Review, the CCO confirmed that this review is continuing to progress and the risk assessment, which is the first phase of the review, is now expected in April 2024. The Committee noted information which had been provided in relation to the National Screening Services.

Further information on Breast Check surgeons and theatre access was requested and it was agreed that the CCO would give a breakdown by unit at the next Committee meeting. Regarding Organ Retention, the CCO confirmed that following the 2022 audit, seven of the eight recommendations have been completed with one recommendation being closed out with the coroner.

The assurance requested by the Committee at previous meetings will be provided once the final recommendation has been closed.

L Woods joined the meeting and F O’Kelly left the meeting

4.1 Health Regions Update

L Woods presented to the Committee work completed to date, the key next steps and deliverables for the implementation of Health Regions. He advised that the HSE Health Regions Implementation Plan was approved by Cabinet in July 2023 and sets out a high-level roadmap and the key essential elements to operationalise Health Regions from February 2024 and includes key input / feedback from service and clinical leaders.

The Committee discussed safe transfer of care during the transition period, particularly the role of technology in enabling this. The Committee queried whether REOs will have access to all necessary service data immediately when they take up their role. L Woods advised that they will. The education of staff and culture around the change was discussed and L Woods confirmed that this is currently being considered at CEO level.

The Committee also discussed patient engagement in the Health Regions and emphasised that this should be close to REOs in the governance structure.

The Committee thanked L Woods for the update and it was agreed that further reports would be provided at later meetings as the rollout progresses.

4.2 Overall Clinical Governance in the Regions

The CCO presented an update on the clinical governance operating model in the Health Regions. A project has been underway with the aim to progress development of a clinical governance operating model for the Health Regions in line with the overall design principles and objectives of the Health Regions programme.

The work has been clinically led by Dr Pat Nash, Chief Clinical Director, Saolta Hospital Group and supported by the Strategic Programmes Office. The project commenced in December and is currently finalising outputs to share with the CCO for consideration.

The CCO advised that the proposed structure and model will need to be agreed with the CEO. The Committee highlighted that during restructuring, a focus can sometimes be on corporate governance and the Committee and Board should be suitably involved to ensure the appropriate focus on clinical governance is not lost.

The CCO acknowledged this and advised that the definition of clinical governance can arise as an issue and it will be important to clarify the governance structure here.

It was agreed that an update on the work being undertaken by Dr Pat Nash would come to the Committee when it has been approved by the CEO.

ND IA and AND HCA joined the meeting and A Carrigy left the meeting

5.2 Implementation of HCA Recommendations under new Health Regions Structure

The ND IA and L Woods updated the Committee on how the HCA function will operate in the Health Regions. The Committee was advised that new actions post March/April 2024 will be added to the new system, and the governance structure for this is still under design.

The Committee highlighted that tracking the implementation of current recommendations will be critical and past recommendations cannot be considered as legacy and not receive follow up. L Woods confirmed the new post holder will own the HCA history and all recommendations must be followed through.

L Woods left the meeting and F O’Kelly rejoined the meeting.

The Committee briefly discussed the Assisted Decision Making audit update presented for noting at the beginning of the meeting. It was highlighted that the HSE has been aware that this Act would be enacted for some time and requested that the planned audit is carried out sooner and tailored so that it is ready to happen in Q2 instead of Q4 2024.

The AND HCA presented to the Committee the HCA Report for Q4 2023 which had been circulated to the Committee in advance of the meeting. The reports were comprised of the Activity summary, Reports issued in Q4 2023, Implementation of recommendations and key report summaries.

The AND HCA highlighted key findings in certain sites including in Assessment and Management of Postmenopausal Bleeding, Nutrition Screening and use of oral Nutrition Support, Management of Transient Ischemic Attack in Acute Hospitals, Delirium and Dementia, Falls in Older Persons Services, Admission of Children to Adult Units, and Schedule 5 Policies & Procedures in Disability Services.

The Committee discussed highlighted recommendations and asked that going forward, high and medium rated recommendations which are overdue are brought to Committee’s attention. The Committee noted the HCA Q4 2023 Report. ND IA and AND HCA left the meeting

The Committee will meet with the Planning and Performance Committee on 14 March 2024 for a joint meeting on mental health.

The meeting ended at 13:40.

Terms of Reference: Safety and Quality Committee