HSE Safety and Quality Committee meeting minutes 15 June 2021

Committee Members Present

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

HSE Executive Attendance

Dr Colm Henry (CCO), Dr Orla Healy, (National Lead Patient Safety) Mr Patrick Lynch (ND Governance and Risk), Niamh Drew (Secretary), Amy Phillips.

Joined the meeting

Dr Jennifer Martin (Quality Improvement, item 3), Gráinne Cosgrove (Quality Improvement, item 3), Dr Gemma Moore (Quality Improvement, item 3), Dean Sullivan (CSO, item 4), Dr Stephanie O’Keeffe (Strategic Planning, item 4), Dr Anna Terrés, (Head of Research and Evidence, Strategic Planning, item 4), Dr Sarah McLoughlin (HSE Board Member, item 4), Collette Tully (Executive Director NOCA, item 5), Brian Creedon, (NOCA, item 5) Kenneth Mealy (NOCA, item 5), Ciara Kirke (National Lead, Patient Safety, item 6).

The Committee met in the absence of management at the start of the meeting.

D Madden took the Chair at 10.00am and welcomed members of the Executive to the meeting.

The following items were discussed and noted.

1. The Committee welcomed Jacqui Browne to her first official Safety and Quality Committee meeting.
2. The Minutes from the April meeting will be approved at next month’s meeting as they were not accessible to circulate due to the cyber attack 1.
3. The Committee discussed the copy of the NPOG Report that had been circulated by the Chair to the Committee to show members what information is presented to the Performance and Delivery Committee, The Committee discussed adding the Performance Profile Report to their agenda but felt that this was not appropriate as the Performance and Delivery Committee receive and discuss it under their remit. However, they have requested that the “Quality and Patient Safety “section of the report, is submitted to the Committee for their monthly meetings. It was agreed that the Secretariat would follow up with the relevant National Director.
4. The Chair noted that an update on the Review of the Corporate Centre would be presented by the CCO during the meeting.
5. The Chair briefed the Committee on a Press Query that she received regarding minutes of the Committee’s meeting of 16th March. The Chair agreed to write to the CCO on this matter.
6. The Committee agreed the action list is to be reviewed at the end of each meeting to update the Committee on its actions.

The CCO presented his monthly report to the Committee beginning with an update on the cyberattack and its implications. He advised this is the most significant cybercrime attack on an Irish state agency. It is understood that the attackers used the Conti ransomware, and the same group responsible is believed to have attacked the Department of Health with a similar cyberattack. He outlined a number of overarching clinical risks which are shared by all services inherent in the absence of current IT and digital systems a month ago and these risks will remain active until recovery is complete. He assured the Committee the recovery phase is already in place, scheduled care has, of necessity, now resumed in hospitals. Recovery in community services has been slower and this represents a burden on elements of the care pathway. The Committee noted the level and pace of recovery remains variable. The CCO advised the integrated clinical and operational risk subgroup of the National Crisis Management Team meets each Monday, Wednesday, and Friday to guide the operational response based on clinical priority. The CCO highlighted the significant risk within the recovery phase regarding re-entering lost data into systems and the patient safety implications that may pose.

The Committee thanked the CCO for his overview on the cyber-attack and engaged in a discussion on the impact and how it may differ between voluntary and non – voluntary hospitals. The CCO noted the impact of the attack has differed between the voluntary and non-voluntary hospitals as the voluntary hospitals had a number of independent systems. He also made reference to the State Claims Agency’s published guidance with regards to indemnity for HSE staff and highlighted the importance of communications regarding litigation. The Committee also discussed how to maintain progressive e-health initiatives going forward while staying prepared for another cyber-attack in the future and highlighted the importance of having effective backup systems and noted the effectiveness of paper trails during this attack. The Committee also acknowledged the effect this cyber-attack may have on public confidence in e-health and the need for effective communications regarding this. The Committee also raised questions on the impact of the cyber-attack on the hospital staff changeover that is due to take place during the Summer, Dr O. Healy advised the relevant systems are back up and running and would expect even further improvements to be in place by the time of the changeover and advised she will follow up on this to ensure so.

The CCO provided an update to the Committee on COVID-19 and advised that there continues to be positive outcomes for people vaccinated with reductions in mortality, outbreaks and disease prevalence amongst those vaccinated, with particular focus on the most vulnerable groups. The Committee noted the cyber-attack on the HSE has prevented the routine notification of cases, associated deaths and outbreaks of COVID-19 to CIDR. The Committee also discussed the different variants of COVID-19 and noted the importance of the vaccination programme to mitigate the risks associated with the variants of COVID-19. The Committee raised questions with the CCO on vaccine effectiveness against the Delta variant. The CCO assured the Committee both the Astra Zeneca and Pfizer vaccines are safe, effective vaccines and provide protection against serious illness from the virus. He also noted that there is reduced efficacy against the Delta variant with just one dose of both AstraZeneca or Pfizer. The Committee also noted positively the significant reduction in deaths linked to COVID-19.

The CCO continued to provide a status update on the National Screening Service and acknowledged the work from Dr Noreen Russel on her work with cervical screening. The Committee discussed the impact 2020 and 2021 have had on Screening Services and noted the KPI for cervical screening is 11.7% above the planned target in Q1. The CCO also made reference to the Expert Reference Group Interval Cancer Reports which launched in October 2020 and undertook to revert to the Committee at its July meeting in relation to steps to be taken arising out of legal advice received regarding recommendations in those reports.

The CCO made reference to the Report of the Oversight Group on the implementation of the recommendations of the Price Report, and the report by Dr Peter McKenna in relation to endometrial cancer. Both of these are currently in draft and will be circulated to the Committee for the July meeting.

The CCO also made reference to the South Kerry CAMHS incident advising a further look back is taking place and he will keep the Committee updated as required. The Committee requested a further update on the extent of engagement with patients and their families within the review.

The CCO presented an overview of the HSE Corporate Centre Review and in particular the CCO’s area. The Committee discussed aspects of the presentation such as the Healthcare Audit, the Confidential Recipient suggesting it should be included under the office of the Clinical Lead, Public Health and the importance of a Quality Patient Safety Clinical Lead. Following questions on NIMS which falls under the remit of Dr O. Healy, it was proposed that a meeting could be arranged with Dr O Healy and Dr C. O’Keeffe to discuss this area further.

Dr O. Healy presented the Quality and Patient Safety paper to the Committee that is due to go to the July Board meeting which will be one of two papers going to the Board. The Committee discussed the HSE’s governance and actions required to deliver patient safety and quality and improvement programmes and initiatives to address major causes of harm. The Committee were advised the significant increase in medication incidents from 2016 to 2020 was mainly down to increased reporting. Committee member Dr C. O’Keeffe also informed the Committee according to the State Claims Agency Medication Incidents Report, the vast majority of medication incidents by severity were negligible. The Committee acknowledged medication safety is complex and needs a co-ordinated approach and highlighted the importance of medication error initiatives.

The Committee suggested the NPOG data on Safety and Quality might be attached as an appendix to the Board Strategic Scorecard. The Committee also suggested the paper should also reflect patient safety and quality initiatives and actions in primary care and community settings and could include more detail on re incident reporting.

Dr O Healy thanked the Committee for their feedback.

Dr J Martin introduced this item and thanked the Committee for their engagement in the Quality Profile Workshop. She advised due to cyber-attack, they cannot access the feedback received from the Committee members and the Committee agreed to resend their feedback and comments. Dr Martin continued to present the agreed list of indicators for the Quality Profile following the Workshop and noted the wild card indicator will be included if / when requested by the Committee.

G. Moore updated the Committee on the Proposal for Patient and Staff Experiences on the Committee’s Agenda going forward following the Workshop. It was agreed that the patients, staff, service users and families’ experiences will be included in the agenda item that will come to the Committee bi-monthly. The Committee welcomed the structure and proposal for 2022. The Committee welcomed the opportunity to discuss the scope of the topics that will come and emphasised the importance of including a topic on mental health.

Dr J Martin presented the quality profile discussion prompts to the Committee which will support the Quality Profile. The Committee welcomed the discussion prompts and agreed to include the prompt in the Quality Profile over the coming months.

Dr G. Cosgrove presented the May 2021 Quality Profile Report as data for June was not available due to the cyber-attack. She updated the Committee on a number of areas with particular focus on testing the actions following the workshop. The Committee discussed the different indicators on the quality profile with the aid of the discussion prompt sheet circulated prior to the meeting and welcomed the approach for next month and suggested going forward, the indicator on the percentage of patients waiting <13 weeks following a referral for routine colonoscopy should have a further breakdown of the numbers in each category. The Committee welcomed this new process of working through the Quality Profile with the discussion prompt and acknowledged it will provide very engaging and positive discussions. The Committee suggested an indicator on mental health should be incorporated into the Quality Profile for 2022.

The CSO provided the Committee with a high-level introduction of the RGMS Framework noting it sets out a health service wide approach for all health research activities, to reduce risk and drive efficiencies based on best practice and extensive consultation. The development of the framework is a key deliverable from the HSE Action Plan for Health Research 2019 – 2029 and incorporates best international practice and lessons learnt in other jurisdictions. The CSO continued to introduce Dr Stephanie O’Keeffe and Dr A Terrés to the Committee. Dr A. Terrés provided a presentation to the Committee which provided an outline of the RGMS Framework, why it is needed, the key principles and functions, and progress made so far.

The Committee thanked Dr A Terrés for an informative presentation and acknowledged all of the hard work put into this Framework. The Committee raised a number of issues with Dr Terrés such as the importance of encouraging innovation, the need to scope out the Framework across both hospital and community services, and sufficient oversight. The Committee highlighted the complexity of the Research Ethics Committee Review and the importance of working alongside the academic sector.

Following queries raised some concerns about patient engagement, Dr. S.O Keefe assured the committee there were very significant levels of engagement. The Committee raised questions regarding patient representatives on the Framework Steering group and made suggestions to incorporate more inclusive language into the Framework. The Committee agreed to schedule a further meeting with Dr. A. Terrés to discuss the RGMS Framework in more detail prior to endorsing it for the Boards consideration and noting.

C. Tully presented an overview of the 5-year NOCA strategy to the Committee noting while continuing this focus is also planning for the expansion of the national audit portfolio in line with national priorities, improved digital infrastructure to support data collection, validation and reporting and a more sustainable funding model. C. Tully provided a PowerPoint presentation to the Committee which outlined the National Portfolio, uses of the NOCA data, Audit Development highlighting the feasibility studies and new audit requests and highlighted the promotion of the National Clinical Audit, NOCA values, and key enablers of the Strategy.

The Committee thanked C. Tully for an informative presentation and welcomed the 5-year Strategy. The Committee engaged in a discussion on interactions with the health technology process, working with private hospitals and highlighted the importance of a clear policy and process when sharing information. The Committee also welcomed the volume of patient response outcomes and were very supportive of the National Clinical Audit. Following questions on the extent of the work outside of acute settings, C. Tully informed the Committee they will work with Sláintecare to increase the work with patients in community settings.

The Committee also discussed the impact of the Cyber Attack on NOCA and funding deficits highlighting the importance of having a sustainable funding model. The Committee also discussed the impact of the Cyber Attack on NOCA and funding deficits, highlighting the importance of having a sustainable funding model. The Committee conveyed their full support and look forward to continued engagement with NOCA.

C Kirke briefed the Committee on the role of the National Medication Safety Programme and its objective to reduce medication related harm and improve medication safety as a priority and as set out in the Patient Safety Strategy. She informed the Committee that the HSE is a partner in an EU funded project ISIMPATHY, which is addressing polypharmacy and adherence challenges in the border counties of the country. The ISIMPATHY approach brings substantial benefit in reducing medication related harm associated with polypharmacy and adherence challenges with high risk patients and rings direct cost savings to the HSE. She presented a preliminary report to the Committee and highlighted the governance and structures of the project. Following feedback from the Committee it was agreed a patient representative would be added to the Steering Group. The Committee also discussed the harms associated with Polypharmacy, the economic analysis in the Report and welcomed the engagement with GP’s and the Nationwide rollout of this Project.

The Committee thanked C. Kirke and welcomed her back to present to the Committee when the Project is at a more advanced stage.

The ND Governance and Risk provided the CRR Q1 Report to the Committee with reference to the Risk summary and individual Risk Assessments circulated prior to the meeting. The ND Governance and Risk advised work is ongoing to move to the Q2 review in a timely fashion and there has been significant reassignment in light of the cyber-attack. He informed the Committee the ARC focused on the impact of the risks at their committee meeting and proposed to come back to the Committee once the Q2 Review has commenced. The Committee thanked the ND Governance and Risk for his update and agreed to recommence the discussion when the Q2 Review is presented.

Date of Next Meeting: 14th July 2021.

The meeting concluded at 4.05pm.