HSE Safety and Quality Committee Meeting Minutes 16 May 2024

Committee Members Present

Deirdre Madden (Chair), Anne Kilgallen, Mary Culliton, Anne Carrigy, Cathal O’Keeffe.

Apologies

Yvonne Traynor, Margaret Murphy, Fergus O’Kelly.

HSE Executive Attendance

Orla Healy (ND QPS), Martina Queally (REO Dublin/South East), Niamh Drew (Deputy Corporate Secretary), Rebecca Kennedy (Office of the Board).

Joined the meeting

Colm Henry (CCO – Items 6 & 7), Sharon Hayden (CCO Office – Items 6 & 7), Lorraine Schwanberg (AND QPS Incident Management – Item 4), Catherine Hogan (Patient Safety Together Lead - Item 4), Elaine Kilroe (AND Enterprise Risk – Item 5), Winifred Ryan (National Healthcare Communication Programme Lead – Item 7), Peter Gillan (National Healthcare Communication Programme Clinical Lead – Item 7).

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 Committee Minutes

The minutes of 18 April 2024 were approved.

2.3 Feedback re Implementation of the Recommendations of the McIlroy Report on Adult Safeguarding

The Committee discussed the Implementation Plan of the McIlroy Report on Adult Safeguarding which was circulated in advance of the meeting. It was agreed that timelines need to be included in the plan where possible so Committee can have oversight of progress against them. The Committee also discussed the perceived culture around safeguarding and emphasised the importance of strong professional leadership to improve this as necessary.

3.1 Quality Profile March 2024

The Committee noted the Quality Profile from the March data cycle and discussed the governance of the Quality Profile as the Health Regions are established. The Committee agreed that the indicators currently provided should give the Committee appropriate oversight of services but expressed concern that more improvement should be seen in them over time. It was agreed that the CEO would be invited to speak to the Committee on proposed governance of the Quality Profile and to outline improvement plans for the indicators which are not showing appropriate improvement.

L Schwanberg presented the Patient Safety Together (PST) Evaluation Plan which outlines the work of the PST programme during its first year. PST was launched January 2023 and is the flagship programme of NQPSD in relation to learning from incidents and other patient safety sources. The report outlines the areas of work, the successes and challenges experienced and how the programme engages with many people to embed this piece of work. The governance of the PST programme was highlighted as key to enable proper growth of the programme and allow its implementation across the Health Regions in both hospital and community care settings.

The Committee noted the report and expressed its full support for PSTs work to date.

E Kilroe presented the new Corporate Risk Register (CRR) to the Committee. In 2023, the CRO agreed with the EMT, the Audit and Risk Committee and the Board that a fundamental review of the HSE’s corporate risks and by extension the CRR would be undertaken. The review was conducted in a number of stages with workshops, briefing sessions and meetings held with EMT members, their risk teams, subject matter experts including clinicians and with Board Committees. The final version of the new CRR was approved by EMT on 13 February 2024 and considered by the ARC on 19 February.

The Committee discussed the new CRR and language changes made to some of the risks allocated to it. E Kilroe confirmed that these language changes were made to align the CRR with the HSE Emergency Management Framework. The Committee agreed that the revision has delivered a better document which will be more useful going forward. It was acknowledged that the CRR is subject to change as it is used by senior management and overseen by the Board and its committees.

The CCO presented his report which included a briefing on the National Women and Infants Health Programme (NWIHP) Annual Report 2023 which was due to be submitted to the Minister for publication as required under the National Maternity Strategy. The report highlighted the extensive work being done in the areas of maternity, gynaecology, neonatology, fertility, abortion, and sexual assault units. In response to queries from the Committee, the CCO confirmed that international reports in this area are also monitored by the NWIHP.

The CCO discussed the Organ Donation Transplant Ireland (ODTI) 3-year strategic plan for 10-year service output for Organ Donation and Transplant services nationally which has been approved by EMT. The CCO advised that the transplant rate in Ireland is below the international average and that there was an impact on the numbers of transplants carried out during the Covid pandemic for a number of reasons. The strategic plan sets out ODTI’s strategy for the next three years and specifically how it proposes to deliver on its stated remit. It also outlines the changes to ODTI’s organisational structure required to support the achievement of its strategic objectives in the coming three-year period and beyond.

In relation to the HSE Independent Review of Paediatric Orthopaedic Surgery Service at CHI, the CCO advised that phase one of the review is approaching completion in relation to the risk assessment of the relevant areas of orthopaedic surgery in CHI at Temple Street. The reviewer is at drafting stage, but the date of completion is subject to the time required for due process and fair procedures.

Separately to this review the CCO confirmed that the HSE oversight meeting continuities to meet to provide oversight and ensure that there is continuity of care plans in place for children.

The Committee noted the update provided on the National Venous Thromboembolism (VTE) Clinical Programme established in October 2022, and its objectives. The programme aims to promote patient safety & effective, efficient, equitable care through excellence in prevention, diagnosis, management & long-term care of VTE in hospitals & in the community.

The CCO advised in relation to the HPV Associated Cancers Report from the National Cancer Registry Ireland (NCRI) that overall, the stage of diagnosis for these cancers is getting earlier, reflecting the success of screening. He also confirmed that HPV vaccine rates are good but the catch-up rates still struggling. The Committee requested that data on survival rates for these cancers be provided at a future meeting.

In relation to a query from the Committee at its April meeting, the CCO outlined the number of Consultants not on the Specialist Division of the Medical Council Register and the control mechanisms in place for the appointment of these Consultants. The CCO confirmed that this protocol has now been updated to align with the establishment of the Health Regions. The Committee expressed its concern on the high number of consultants included and the slow reduction in this number over the past number of years.

W Ryan and P Gillan updated the Committee on their work with the NHCP which was established in response to the National Care Experience Programme. The NHCP aims to improve communication in practice to a professional level of competence as communication leads to positive outcomes for patients, staff and the healthcare system and that poor communication often leads to complaints and adverse outcomes.

It was highlighted that the NCHP does not receive an annual budget and there is a need to secure facilitators for the programme in each region to ensure the future of the programme. The Committee thanked W Ryan and P Gillan for their presentation and expressed full support for the NHCP.

As this was the final Safety & Quality Committee meeting under the current Chair, the Chair expressed her appreciation and gratitude to the members of the CCO’s team and the Board Office who had been extremely helpful over the last five years in the organisation of the work of the Committee; Dr Colm Henry and Dr Orla Healy for the open, respectful and professional nature of their working relationship with the Chair; and the members of the Committee for sharing so much of their time and expertise to further the safety and quality agenda of the HSE.

The meeting ended at 12:45.