HSE Safety and Quality Committee meeting minutes 16 November 2023

Committee Members Present

Deirdre Madden (Chair), Jacqui Browne, Cathal O’Keeffe, Anne Kilgallen, Mary Culliton, Anne Carrigy, Margaret Murphy (Joined approx. 10.20), Yvonne Traynor, Fergus O’Kelly.

HSE Executive Attendance

Martina Queally (CO Community Healthcare East), Orla Healy (ND QPS), Sharon Hayden (CCO Office), Sara Maxwell (Office of the CEO), Rebecca Kennedy (Office of the Board).

Joined the meeting

Colm Henry (CCO - Item 6-7), Maria Lordan Dunphy (AND NQPS - Item 4 & 7), Gillian O’ Brien (Clinical Lead for the National Improvement Programme Wound Management - Item 4), Gemma Moore (NQPS - Item 4), Elaine Kilroe (AND Enterprise Risk Management), Róisín Egenton (Programme Manager Quality and Patient Safety Improvement - Item 7), Joseph Duggan (ND Internal Audit - Item 8), Cora McCaughan (AND Healthcare Audit - Item 8).

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

Anne Kilgallen declared her membership of the Children’s Health Ireland (CHI) Board and advised she would leave the meeting during any discussion of CHI.

2.2 Minutes

The minutes of 20th October 2023 were approved

2.3 Workplan 2024

The Committee workplan for 2024 was discussed. It was agreed that some final changes would be made and a draft would be circulated in advance of the December meeting for approval.

2.4 Matters for Noting

1. Committee Correspondence Correspondence addressed to the Committee in relation to the Owenacurra Centre and the responses to them which issued from the CEO were noted by the Committee.
2. Patient Engagement Roadmap A paper outlining the implementation of the Patient Engagement Roadmap which was requested by the Committee at its July meeting and circulated in advance of the meeting was noted.

M. Murphy joined the meeting approx. 10:20.

CCO joined the meeting.

The CCO presented his monthly report which included a Public Health update. He advised that in relation to the Winter Vaccination Programme, both the Influenza (flu) and COVID-19 vaccination, they are key enablers to maintaining and protecting our health services capacity including the availability of our staff to maintain our services throughout the busy winter season.

The Committee expressed concern in relation to the overall uptake of winter vaccines among healthcare workers (HCWs). The CCO advised that there are a number of actions now being progressed by senior leadership in relation to an urgent call to action from each area to take ownership and improve the vaccine uptake rates in their staff.

The CCO updated the Committee on the sub-optimal level of coverage in the Primary Childhood Immunisation Programme (PCIP) and the Catch-up Vaccination Programme for Refugees and International Protection Applicants (IPAs).

This creates an extant risk of outbreaks of vaccine preventable diseases (VPDs) in congregate settings for migrants, but also in the wider community, especially among vulnerable populations with higher indices of multiple deprivation (IMD).

The Committee discussed the importance of ensuring members of the relevant communities are involved and it was agreed that the CCO would provide further information on community engagement carried out in relation to these immunisation programmes.

The CCO presented an overview of the Mazars Report on New Medicines Processes which was commissioned by the Department of Health. Mazars conducted a review of the governance structures around the HSE's drug reimbursement process and the report was submitted to the Department of Health in January 2020 and subsequently made available to the HSE in May 2022, prior to being made publically available in February 2023.

The Committee discussed in particular the recommendations on Patient Involvement in the Process and asked that the CCO consider the benefit of appointing a liaison for engagement between HSE and Advocacy groups.

The CCO presented the National Doctors Training Programme Model 3 Hospital Report to the Committee which examines the challenges in the recruitment and retention of consultants in the Model 3 network and provides a set of recommendations to address these challenges. It was agreed that the CCO would keep the Committee updated on the implementation of the Report’s recommendations.

In relation to the National Women and Infants Health Programme’s Obsteric Event Support Team Programme, there was discussion in relation to the remaining hospital group that has yet to engage with the OEST programme, and the Chair will consider escalation on this. A Kilgallen left the meeting approx.

11:30 The CCO updated the Committee on the ongoing CHI Reviews, advising that the HSE and CHI oversight group continue to meet on weekly basis and the HSE Independent review is progressing under Mr Selvaduri Nayagams leadership.

The CCO advised that the terms of reference (ToR) for the review have been amended and the updated ToR had been circulated to the Committee for their information in advance of the meeting.

In relation to Organ Retention in CHI at Crumlin, the CCO advised that it is confirmed that the retention of organs does not exist at CHI Temple Street and organs at CHI Crumlin have been identified as requiring a plan for sensitive disposal.

A full review of all organs and relevant information has been completed by CHI at Crumlin where a project team is in place and there is a plan to commence communications with families later this month.

The Committee asked that an update be provided on whether the CEO has sought assurances that this is not an issue in other hospitals.

The CCO reported to the Committee on a number of the other areas set out in the report including:

• winter preparedness: Planned respiratory virus epidemiology and surveillance outputs from HPSC for the 2023/2024 winter season.
• National Screening Services
• current ED Activity at Our Lady’s Hospital Navan (OLHN)
• Childhood, Adolescent and Young Adult (CAYA) Cancers: Summary of International Comparisons of Incidence and Mortality. National Cancer Registry CAYA report 2023

CCO left the meeting and A Kilgallen re-joined the meeting

M Lordan Dunphy (AND NQPS), G O’Brien (Clinical Lead) and G Moore (NQPS) joined the meeting.

M Lordan Dunphy and G O’Brien presented a patient experience video outlining the challenges of dealing with a pressure ulcer and how this links to the Patient Safety Strategy.

The HSE Patient Safety Strategy 2019-2024 identifies a priority patient safety areas as reducing the rate of acquired pressure ulcers. In mid-2023, the National Quality and Patient Safety Directorate established a two-year programme of work to design, develop, communicate and champion a National Improvement Programme in Wound Management.

The programme seeks to enable services to optimise the quality of care and outcomes for people with, or at risk of, chronic wounds. The Committee watched the patient experience and discussed the events outlined.

The video highlighted that patients with chronic wounds must navigate a complex system that does not prioritise easy access to early, equitable and safe or evidence based wound care. G O’Brien advised that this is being recognized as an issue internationally and the programme in wound management will seek to enable services to optimise the quality of care and outcomes for people with, or at risk of, chronic wounds.

The Committee expressed their support for the programme and thanked the patient who shared their experience, M Lordan Dunphy, and G O’Brien for their time. It was agreed that plans for measurement of wound care incl. audit of impact of guidelines, training etc. would be provided to the Committee for information.

M Lordan Dunphy, G O’Brien and G Moore left the meeting.

The Committee considered the Quality Profile from the September data cycle. O Healy updated the Committee on the monthly indicators, noting that there was very little change by comparison to August indicators. It was agreed that further information on the location of individual Emergency Departments would be provided going forward.

C O’Keeffe and A Carrigy left the meeting approx. 12:50

6.1 Q2 2023 Corporate Risk Report - Safety and Quality Committee Risks

E Kilroe joined the meeting.

The AND updated the Committee on the Corporate Risk Review 2023, which was undertaken on recommendation of the 2021 Moody Risk Review, and presented to the Committee the HSE Q2 2023 Corporate Risk Register (CRR) Report.

The Committee noted that as the Corporate Risk Review is being concluded in parallel with the Q2 2023 Corporate Risk Register (CRR) Report, the Q2 report is “by exception”.

The Committee discussed the risk ratings and outlined mitigation factors presented and asked that more information on risks which have had their ratings changed to be included in the annex.

E Kilroe left the meeting.

M Lordan Dunphy and R Egenton joined the meeting.

R Egenton and M Lordan Dunphy provided an overview of the programmes of work undertaken by the National Quality and Patient Safety Directorate to address the Common Causes of Harm outlined in the HSE Patient Safety Strategy (2019-2024).

This covered a number of projects developed by the QPS team including Programme for Sepsis, Deteriorating Patient Improvement programme, Medication Safety Programme, and Improvement Programme for Wound Management.

The Committee discussed in particular work relating to the new HSE Patient Safety App. R Egenton confirmed that the app is available for the public to download currently although work is still in early stages and confirmed that they are working to make the app as accessible as possible.

The Committee thanked M Lordan Dunphy and R Egenton for the update and expressed their ongoing support for this work.

M Lordan Dunphy and R Egenton left the meeting.

8.1 Q3 2023 HCA report

ND IA and AND HCA joined the meeting.

The AND HCA presented to the Committee the HCA report for Q3 2023 which had been circulated to the Committee in advance of the meeting. The reports were comprised of the Activity report, Summary HCA Reports, Reports Issues, and an Appendix C-Report on 2021 open recommendations as requested by the Committee.

The AND HCA highlighted issues seen in certain sites including Use of Review Tools for Healthcare Associated Infections, Self-Harm and Suicide Related Ideation in Emergency Departments, and Assessment and Management of Postmenopausal Bleeding.

It was also highlighted that not all recommendations made to one voluntary hospital were accepted.

The Committee raised concern about this non-acceptance of IA recommendations as it relates to assurance, oversight and governance. The AND HCA informed the Committee that the national director Acute Operations was advised of this at the time the audit report was issued.

The Committee noted the HCA Q3 Report.

ND IA and AND HCA left the meeting.

No matters arose under this item.

The meeting ended at 15:13.

Terms of Reference: Safety and Quality Committee