HSE Safety and Quality Committee meeting minutes 15 September 2021

Committee Members Present

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

Apologies

Prof Fergus O’Kelly, Jennifer Martin

HSE Executive Attendance

Dr Colm Henry (CCO, Item 8), Dr Philip Crowley (ND S&R, Item 12), Mr Patrick Lynch (ND GR, Item 5,6), Joe Ryan (ND OPI, Item 4) Dr Geraldine Smith (ND IA), Anne O’Connor (COO, Item 5,7) Dr Orla Healy (Item 2, 9), Liam Woods (ND Acute Operations), Grainne Begley, Niamh Drew, Pat Galvin.

Joined the meeting

Dr Lucy Michael (Item 2), Dr Meera Sithi (Item 2), Cora McCaughan (Item 10) Brendan Lenihan (Board Member - Item 2) Robert Morton (NAS – Item 9), Dr Margaret Fitzgerald (Item 3), Gemma Moore

The following items were discussed and noted.

Minutes of the Meeting on April 20th and July 13th were approved.

No matters arose and no conflict of interest was declared.

A review of the committee’s Terms of Reference was discussed and the Chair thanked all for their comments and feedback.

After discussion the Chair advised that the revised version of the ToR would be distributed to the committee, once completed, for their review and comments.

The revised version will be sent for Board approval and will be added to the HSE Website once approved at Board level.

Committee member Jacqui Browne gave an introduction to the Social Inclusion item to be discussed and introduced Dr Lucy Michael and Dr Meera Sithi who are both involved with Syrian Refugee resettlement in Ireland through the International Organisation for Migration. Dr Lucy Michael gave an overview of the experiences of 4 refugees and the challenges they face whilst settling into a new country, integration into society and local community. The access to services, the language barrier, isolation and mental health issues were some of the biggest challenges faced. It was agreed that key workers and interpreters are available to assist refugees in other countries, but those services are extremely limited in Ireland. Dr Michael highlighted that in a lot of cases the children in the family are used as translators to support parents with understanding medical information. The Committee discussed services that would support such situations and it as agreed that Dr Michael revert back to Committee with a list of services, she would like to see made available through the HSE for the Refugees. The Committee agreed that they would then discuss this further with the possibility of Community Services being able to provide some basic health needs. It was agreed that the ARC Committee would follow up and seek data from the CFO with regards to costings and spend to date of providing interpreters.

The Chair thanked Dr Michael and Dr Sithi for their presentation and agreed to bring this to the attention of the Board at its next meeting.

It was agreed that Dr Lucy Michael would provide a further update in Q2 2022.

ND OPI referred to the report supplied to the Committee prior to the meeting which was taken as read. He explained that the Complaints team were redeployed during the pandemic but the department maintained continuity. It was noted that over the last 12 months there was a decline in the number of complaints received, most likely due to the pandemic, however there may now be an increase in complaints post Covid. ND OPI highlighted to the Committee that there must be learnings from this, and a more responsive approach and it is planned to build this into the performance management function. ND OPI agreed to look at applying the learning via training which can be applied via HSE Land and to look at the possibility of making this training mandatory.

Whilst discussing the report, the Committee commented that it would be good to see preventative measures applied from the complaints received. ND OPI advised that there was a case book relating to preventative measures that was published quarterly up to 2020 but the Committee felt there needs to be a more reactive approach. The ND OPI agreed to investigate this aspect and report back to Committee at a later meeting.

One of the complaints aspects that was felt is not being reflected in the reports is Patient Safety Incidents. ND OPI advised that this information comes in through a different channel and to revert to the Committee with further information and possible improvement measures. ND OPI explained that complaints managers are to be put in place for each CHO and for each hospital group and a report will be provided on this going forward. Chair asked for a further update in 6 months.

The ND GR gave an overview of the CRR Register and the Q2 review. He advised that the EMT have commenced its full annual review of the Corporate Risk Register. Work on the draft Risk Appetite Statement contained in the Moody Report continues. As it is a role of the Board to set the risk appetite for the organisation the final draft once considered by the EMT and the ARC will be brought to the Board for approval. Following a question from the Committee the ND GR confirmed that the more dynamic operational risks are reviewed on a monthly basis with the remaining risks reviewed as part of the quarterly review process.

The COO briefed the Committee on Risk 16 – Regulatory Non-Compliance and advised that it is being renewed as the impact of the Cyber Attack needs to be reflected in the overall risk. The lack of data for reports, due to the Cyber Attack, is causing delays. The COO explained that improved infrastructure and staff levels are needed to help minimise this risk. It was agreed the COO would report back to the committee with an update on this risk.

ND GR gave an overview of the work led by HIQA on National Standards. HIQA receive requests to develop national standards and they have implemented a prioritisation process for the development of standards for health and social care services to ensure that the standards developed are of maximum benefit to the health and social care system. A Standards Programme Advisory Group provides advice which is used in the prioritisation process. This forum supports HIQA in ensuring its work has the maximum impact in improving the experience and outcomes of people using services. HIQA are currently developing projects on standards for Home Support Services and Children’s Support Services. HIQA are also focused on supporting services to implement standards.

National Independent Review (NIRP)

COO gave an overview of the NIRP review paper for Disability Services. It was noted that currently a reform is underway which is focused on moving away from institutional models of care and service delivery to community based, person centred models of service where people with a disability can live valued and inclusive lives within our community. CHO1 Disability Services continues to progress its service improvement agenda in line with national policy and regulatory standards. The majority of Disability Services in the CHO1 area, approx. 85%, are directly provided by the HSE, which is unique compared to other CHOs where Section 38 and 39 organisations provide the majority of services.

The National Independent Review Panel recommended the establishment of a Strategic Working Group to develop a new vision for disability services in line with national policy. The Chief Officer of CHO1 has overseen the establishment of a CHO1 Strategic Working Group, which is independently chaired by a consultant with expertise in the field of disability services. A number of service reviews and recommendations have been made and whilst a lot of these have already been implemented, there is some still ongoing. HIQA has advised that there is a requirement for a detailed and time bound management improvement plan for the centres. This plan is being incorporated into the overall CHO1 service improvement programme and was submitted to HIQA. In addition, each designated centre has a specific compliance plan with identified actions to address compliance, improvement reports are being supplied to HIQA on a monthly basis and HIQA are happy with the progress to date.

Prime Time Investigates
COO commented on a Primetime review where it was suggested that the HSE was sharing information of a personal nature regarding children. Information relating to this issue was supplied by RTE, but no incidents have been identified and the COO agreed to keep the committee updated on this.

CCO presented an update on various topics including Cyber Attack, Vaccinations and Covid update. CCO advised the Committee that the effects of the Cyber Attack are receding, with many systems now fully operational, but some minor issues remain and are being worked through with the relevant service.

CCO advised that there have been nearly 7 million vaccine doses administered as of first week of September 2021. The figures are very reassuring as there is 90% vaccinated in majority of categories and cases are falling in all vaccinated groups. A booster dose is planned for the end of September for over 80’s and over 65’s.

CCO updated the committee on the Public Health Reform plan which will strengthen Public Health. A new ND of Public Health is to be appointed as well as the phased introduction of 84 new consultant posts, with over 60% of the recruitment plan for this already completed.

CCO is to provide the Committee with further details at a later date.

CCO provided an update on the estimation of lost/missed cancer diagnoses attributable to the Pandemic and Cyber Attack. A breakdown of figures was presented to the Committee of the various cancer types and the year on year percentages and CCO explained that the Covid pandemic put extra pressure on the referral, diagnostic and treatment process of patients with a cancer diagnosis. Whilst it seems unlikely that any cancer diagnoses were lost, there may have been a delay in diagnosis for some patients due to the Cyber Attack.

CCO advised a report on Gynaecological Services will be supplied for the next meeting.

CCO to report back on the timeline for the South Kerry CAMHS incident.

NDQPS gave an overview briefing on the Quality Profile. She spoke to the Patient Experience section of the report which included information relating to over 75’s and the timeframes when they present to hospital emergency departments. Due to cocooning, that particular cohort are frailer, and they are now presenting with more conditions, so in turn it is taking longer to treat their conditions and is leading to outpatient delays.

In response to the committee’s concern over some indicators on the quality profile data declining monthly, the ND Acute Operations advised that daily reports are received but the upward trend is worrying. This is as a result of growth in attendance at ED, extra admissions and delays in transfers of care due to under resourced and understaffed EDs, but he advised that action plans are being generated to address these issues. These action plans will look at where the blockages are and recommend improvement measures, one of which is integrated programmes for older persons in the community. The concern is that the volume of attendance at ED is increasing and, as a result, the wait times are increasing. The worry is this may affect patient safety as some hospitals are getting nearly three times the normal attendance. The lack of availability of GP appointments is part of the cause as people are then presenting to the ED instead. A suggested improvement is to supply more services outside of the hospital setting and have more clinical decision making in the community. ND NAS gave an overview of the National Ambulance Service and explained the challenges they are facing at the moment. ND NAS explained that Winter level numbers are already starting to present to ED and that 4 out of 5 that present are using an ambulance, which is a big demand. ND NAS updated the committee on some projects that are being trialled at the moment to reduce the demand on NAS when the service is maxed out. Diagnostic availability outside of the hospital environment and an ambulance car going to the patient were some of the project solutions proposed. The Committee was appraised on the fact that Emergency Departments are overwhelmed and that this is a worldwide ongoing issue which requires a culture change. Chair advised that a presentation on Emergency Medicine would be beneficial to the Committee.

Chair asked for a presentation on Emergency Medicine at the next meeting.

The Committee was brought through a briefing on Colonoscopy exams. A capacity review for Colonoscopy exams is showing shortfalls but this is being addressed through private sector appointments, which is adding a further 10% capacity. The Saolta group are providing additional capacity at nights and weekends in some public settings which is easing the pressure and increasing the availability of routine exams. The Cyber Attack had an effect on the effectiveness of the service as appointments could not be scheduled and results could not be read or shared. Improvement measures are in the process of being implemented, with extra capacity being utilised in the private sector and demand management is being analysed to recognise if the exam is urgent or could it be managed at a GP level to make best use of available resources.

ND IA advised the Committee on the Q2 report. ND IA advised that due to the Cyber Attack the IA team did not go to the system for the Q2 recommendations tracking update. ND IA advised the Committee that the HCA team had been redeployed as part of HSE’s Covid 19 response from March 2020 to March 2021, at which point the team returned to its substantive role in QAV. The transfer of the HCA team from QAV to Internal Audit took place with effect from 18th March 2021.

ND IA advised there were 2 Healthcare Audit reports issued in Q2 2021 and the top control measures identified were in relation to Training; Policies and Procedures; Post Incident Management Documentation; Governance; Hospital in Patient Enquiry (HIPE) coding, and National Incident Report Form (NIRF) completion. ND IA outlined that the recommendation tracking process is a selfassessment process conducted every quarter and this shows that 64% of 2019 HCA recommendations and 48% of 2020 HCA recommendations have been implemented, with the balance reported by management as being in progress or not yet started. NDIA noted that traditionally HCA had not applied any rating criteria (High/Medium/Low) to recommendations and that this is practice is now changing to be consistent with Internal Audit’s practice of rating recommendations to indicate the significance of the recommendations relative to the issues identified in the findings. ND IA advised the Committee that there were 43 audits in the 2021 plan and these are at various stages of progress.

ND IA informed the Committee that the draft audit plan for 2022 will be tabled for the Committee’s December meeting.

AND IA outlined the key findings on the two Q2 reports namely Naas General Hospital Compliance with Wound Management Guidelines and Carndonagh Community Hospital Compliance with HSEs Service Users Falls Management Guide.

ND IA presented the HCA End of Year Report for 2019.

ND IA provided the Committee with an update on implementation by management of recommendations contained in Internal Audit’s Q1-2021 key reports on NCHD Recruitment, Children First Legislation and RCSI Hospital Group Recruitment.

ND IA advised the Committee that the ARC had referred a key Q2-2021 Internal Audit report (European Working Time Directive - NCHDs - University Hospital Limerick) to the Committee for its information. ND IA outlined the report’s unsatisfactory audit opinion and audit findings to the Committee.

ND S&R spoke to the Committee on how a bid for finance works. He advised that they prepare estimates for new service developments. When the estimates are prepared, they are first submitted to the Chief Strategy Officer, before going to the Performance & Delivery Committee, then the Board before being sent to the Department of Health. The Committee asked about the bid to see were items relevant to the Committee such as Social Inclusion and NAS receiving funding. ND S&R advised that whilst they are not mentioned specifically, they would be within the bid. It was agreed that the ND S&R would revert to the Committee at a later meeting with further information relating to specific breakdown aspects of the bid to see if relevant items are included.

Date of Next Meeting: 20 October 2021.

The meeting concluded at 16.55.