HSE Safety and Quality Committee meeting minutes 18 April 2024

Safety and Quality Committee Members Present

Deirdre Madden (Chair), Anne Kilgallen, Mary Culliton, Anne Carrigy, Margaret Murphy, Yvonne Traynor, Fergus O’Kelly, Jacqui Browne, Cathal O’Keeffe (left approx.12:20).

HSE Executive Attendance

Colm Henry (CCO), Martina Queally (REO Dublin and South East), Niamh Drew (Deputy Corporate Secretary), Rebecca Kennedy (Office of the Board).

Joined the meeting

Sharon Hayden (CCO Office - Items 3-7), Sarah McLoughlin (Board Member – Item 3.2), Deirdre McNamara (Director of Strategic Programmes - Item 3.2), Aoife De Brún (Assistant Professor UCD School of Nursing, Midwifery and Health Systems – Item 4), Lorraine Schwanberg (AND QPS Incident Management – Items 4, 5 and 9), Catherine Hand (National Open Disclosure Office - Item 4), Gemma Moore (QPS Intelligence – Item 4), Angela Tysell (Lead for Open Disclosure – Item 4-5), Dara Byrne (National Clinical Lead for Simulation - Item 6), Louise Hendrick (Clinical Lead QPS Intelligence and Education – Item 7), Pamela Fagan (NIRP Chair – Item 9), Bernie NcNally (Outgoing NIRP Chair – Item 9).

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 14th March 2024 were approved.

2.3 Matters for Noting

1. Adult Safeguarding Review The Committee noted the final version of this review on which feedback had previously been provided and which had been brought to the Board on 27 March 2024. It was agreed that the Committee would review the implementation plan as soon as it is available.
2. Correspondence from ND Communications dated 10 April 2024 re Joint S&Q/P&P meeting March 2024 The above correspondence was noted by the Committee

CCO and S Hayden joined the meeting.

3.1 CCO Monthly Report

The CCO presented his report which included a briefing on the DOH 7 th National Healthcare Quality Reporting System Report 2021/2022 which provides information on a broad range of measures of health service outcomes with the purpose of providing a means of comparison against international data. The CCO outlined the various domains in the report, highlighting where Ireland does well and where there is further work needed. The Committee discussed stroke care for older people and queried whether step-down and rehab care could be more extensively utilised. The CCO advised that there is work ongoing in assessing community rehabilitation beds and he will report back to the Committee with further information once this work has been completed.

The CCO discussed the National Screening Service (NSS) Cervical Check Programme Report 2020- 2022, which shows the positive impact of the change to primary HPV cervical screening. The CCO outlined the key findings of the report which showed high numbers of women screened and young women showing high engagement with the programme. The CCO highlighted the work undertaken to compile the report during the COVID-19 pandemic. The Committee noted the resilience of staff within NSS and advised that it would be useful and important to include patient feedback as part of these reports in future. The CCO agreed to speak to the NSS about this.

The Committee noted the HSE’s first national TB Strategy: Striving to End Tuberculosis – A Strategy for Ireland 2024 – 2030 and the importance of addressing health inequities in this context. The Chair confirmed that public health and social inclusion will be a focus area for the committee meeting in May.

In relation to the HSE Commissioned Independent Review of Paediatric Orthopaedic Surgery Service at CHI, the CCO confirmed that the review is progressing, albeit with a delay, and the first phase of the review, the risk assessment, is expected in May 2024. Cases of concern are being managed by CHI in communication with the families, and a Paediatric Spinal Taskforce has now been established. The Committee advised the importance of being able to demonstrate continuity of care to the public and that surgeries are being carried out while this review is underway.

The CCO advised in relation to a Model of Care for Gender Healthcare, a Clinical Lead for the new clinical programme has been appointed to a two-year post in the HSE to develop an updated clinical model of care for gender healthcare services. The work will be informed by the best evidence on clinical care for individuals who express gender incongruence or dysphoria, and emerging and evolving international evidence, including the just published final Cass report (9th of April) will be reviewed as part of this work. The Committee will continue to receive updates on this as the work progresses.

In relation to the National Doctors Training Programme – Medical Workforce, the CCO advised that Ireland currently has too few consultant doctors by international standards. He outlined the projected total number of consultants and new hires, into the public and voluntary sectors, required to meet a target of 6000 consultants by 2030. In particular, the CCO highlighted the focus required for staffing in Model 3 hospitals. The Committee noted the CCO’s Report and requested an updated document on Consultants not on the Specialist Register for its next meeting.

3.2 Clinical Governance Operating Model for Health Regions

D McNamara and S McLoughlin joined the meeting Deirdre McNamara presented to the Committee an update on the proposed clinical governance operating model for the Health Regions, outlining the scope of the project and the methodology used in its development. The work was clinically led by Dr Pat Nash, Chief Clinical Director, Saolta Hospital Group and supported by the Strategic Programmes Office.

In relation to consultation completed, the Committee was advised that a working Group was established consisting of multidisciplinary membership from across the organisation, with representation from Directors of Nursing, Clinical Directors, HSCPs, Quality and Patient Safety Lead, Chief Officers of Community, National Clinical Leadership and GPs. The Committee questioned the lack of patient involvement in this consultation and emphasised the document seemed written under a medical lens rather than with a patient and service user focus. The Committee was advised that the current form of the model is a management structure, and its implementation will involve patient representatives, who are represented as part of the RHA implementation.

D McNamara, S McLoughlin and C O’Keeffe left the meeting

A De Brún, G Moore, A Tysall and L Schwanberg joined the meeting

Dr Aoife De Brún (UCD) presented research findings commissioned by NQPSD which are part of the wider performance and assurance programme underway since 2022. The main purpose of this research was to ascertain patient/service user experience concerning open disclosure and perceptions of what is important in shaping the patient experience of open disclosure. Additionally, the research captured the staff experience of those undertaking open disclosure although further work is needed on this aspect.

The Committee heard descriptions of poor experiences of open disclosure and how this can compound the harm that was caused by the adverse event. There were also some positive experiences where patients and service users expressed appreciation for the honest and respectful way in which they were treated and listened to. The committee discussed the need for culture change around open disclosure within the HSE. The importance of face-to-face training was highlighted as this helps build confidence of staff. The Committee was advised that it was felt that increasing levels of staff are engaged with open disclosure and that the assurance programme will examine this.

The Committee thanked Prof De Brún and the NQPS team for the work completed to date and expressed their full support for this research project.

A De Brún and G Moore left the meeting.

Angela Tysall (National Lead for Open Disclosure) presented the Open Disclosure Annual Report 2023 to the Committee. Open Disclosure is HSE Policy and a critical component in the incident management and quality improvement process as set out in the HSE Incident Management Framework 2020.

A summary of key developments during 2023 was presented, with significant improvements in mandatory training uptake, collaboration with stakeholders including patient representatives, and inclusion of open disclosure as part of undergraduate programmes for nurses, midwives, doctors and health and social care professionals highlighted. The enactment of the Patient Safety (Notifiable Incidents and Open Disclosure) Act and publication of the National Open Disclosure Framework by the DOH were highlighted as significant policy developments. It was emphasised that there is a need to ensure the Open Disclosure structure remains stable during the current transition to the Health Regions.

The Open Disclosure Annual Report 2023 was noted, and the Committee expressed its continued support for the implementation of the Open Disclosure Programme. The Committee thanked Angela for her work on open disclosure over many years as she will shortly be retiring from this post. Her approach to this important role has been one of openness, compassion and decency and the Committee wished her well for the future. The Committee stressed the importance of this role being filled without delay.

A Tysall, L Schwanberg left the meeting.

D Byrne joined the meeting.

Prof Dara Byrne presented to the Committee on the work of the new National Simulation Office (NSO) which was launched in October 2023. The role of the NSO is to provide strategic leadership in the implementation of simulation nationally. The Committee were advised that modern healthcare simulation is a valuable tool for a health care organisation and can be used to identify, mitigate, and prevent error as well as amplify good practice.

Healthcare simulation has an ability to improve performance at an individual, team, systems, and cultural level and in its patient-centred and codesign approach to problem solving. Several examples of healthcare simulation carried out in the facility at University Hospital Galway were outlined to the Committee. The Committee was advised that as new structures are developed in the Health Regions, there is potential for simulation to support the transformation of healthcare, improve patient safety, and the quality of care.

The Committee thanked Prof Byrne for the presentation and expressed full support for the development of the National Simulation Office.

D Byrne left the meeting.

L Hendrick joined the meeting.

7.1 Quality Profile February 2024

The Committee noted the Quality Profile from the February data cycle. Committee discussed several of the metrics which appear to be remaining static over time and questioned whether the most useful data is being considered each month as part of the Quality Profile. The was agreed that a workshop for the Committee to review the current KPI’s and consider how to make best use of the Quality Profile would be arranged for later in the year.

L Hendrick, CCO and S Hayden left the meeting.

This item was deferred to the May Committee meeting.

B McNally, P Fagan and L Schwanberg joined the meeting.

Bernie McNally provided an overview of the ‘Fiona’ Report to the Committee. This report outlines the NIRP review into the care provided by the HSE to a young woman known as Fiona. The Committee heard that the NIRP found that all HSE services with which Fiona came into contact tried their best to help Fiona but sadly she died at 24 years of age. The committee discussed the potential for learning from the ‘Fiona’ Report and agreed to recommend publication of the Executive Summary subject to agreement by Fiona’s family.

The Committee was also updated on the status of a review of the NIRP function undertaken by the Chair of NIRP which has now been completed. The report has been submitted to the CEO for consideration. The Committee noted that there is another NIRP Report due to be completed shortly.

The Committee thanked Ms McNally and Ms Fagan for their ongoing work and commitment to the NIRP process.

B McNally, P Fagan and L Schwanberg left the meeting.

This item was deferred to the May Committee meeting.

No matters arose under this item.

The meeting ended at 15:35.