Terms of Reference: Safety and Quality Committee

The role of the Safety and Quality Committee is to advise the Board on all matters relating to patient safety and quality in the health service and to provide strategic oversight of the development and implementation of National Programmes and Strategies relevant to the safety and quality agenda of the HSE, with specific reference to the Patient Safety Strategy 2019-2024.

The Committee is not responsible for any executive functions and is not vested with any executive powers. In relation to its duties and functions, it fulfils an oversight and advisory role only.

The Chair of the National Independent Review Panel will report to the Committee Chairperson.

The Committee is authorised by the Board of the Health Service Executive to use its oversight and advisory role to:

• monitor arrangements for measuring and improving patient safety and quality in the HSE
• advise the Board on the effectiveness and implementation of these measures.
• monitor arrangements for the development of a patient-centred learning culture within the HSE which aims to ensure that all patients consistently receive the safest care possible
• seek any information or explanations that it requires from any employee of the HSE, or agency totally or partially funded by the HSE
• obtain independent legal or professional advice procured in accordance with the HSE’s procurement policy
• seek the attendance of any person it considers appropriate at the Safety and Quality Committee meeting

The scope of the Committee’s authority extends to all aspects of patient safety and quality within the public health service.

The Committee’s duties are to advise the Board on patient safety and quality matters relating to its functions. More specifically, the Board requires the Committee to advise it on matters relating to:

• overseeing the development and implementation of National Programmes and Strategies relevant to the patient safety and quality agenda of the HSE, with specific reference to the Patient Safety Strategy
• report on and escalate any patient safety or quality matters it deems relevant to be brought to the attention of the Board
• advise the Board on the effectiveness or otherwise of measures being implemented to drive improvements in care through the systematic use of quality improvement methods
• advise the Board on the effectiveness of the implementation of policies and procedures in connection with communication and engagement with patients and service users specifically, but not limited to, open disclosure, informed consent, and assisted decisionmaking
• overseeing the development of a national suite of tested key patient safety and quality performance indicators and measuring and monitoring safety improvements against them
• scrutinising patient safety and quality assurance in areas such as but not limited to regulatory reports; incident reports; health care audit reports; clinical audit Reports; clinical complaints and risk
• monitoring the implementation of new patient safety practices and ensuring that appropriate systems and programmes are in place to support staff in implementing and nurturing a culture of patient safety and quality improvement
• receiving reports on the identification of risks to patient safety and overseeing development plans to anticipate and respond to such risk with the aim of creating and maintaining safe systems of care and reducing adverse events
• reviewing the effectiveness of the systems established by management to identify, assess, manage, monitor and report on risks, by receiving regular reports from the relevant National Director
• reviewing the National Service Plan and related annual work programmes of the relevant HSE Divisions as they relate to patient safety and quality, and advising the Board on the adequate resourcing and appropriate positioning of these functions within theHSE
• overseeing the implementation of good practice to ensure that lessons learnt from incidents; reviews; reports; complaints; claims; and other channels are acted upon in a timely manner underpinned by effective communication
• providing assurance that appropriate systems are in place to ensure compliance with all statutory obligations imposed on the HSE relating to patient safety and quality matters
• championing the establishment of collaborative working relationships across the health service between professions to improve patient safety and quality of care
• advising on the appropriateness, efficiency, and effectiveness of the HSE’s Healthcare Audit function by reviewing and recommending for approval the Healthcare Audit activities in the Annual Internal Audit Plan, reviewing and monitoring the adequacy of the annual Healthcare Audit programme, reviewing the findings and recommendations of Healthcare Audit and monitoring actions taken by management to resolve any issues identified.
• requesting special reports from the National Director of Internal Audit in relation to Healthcare Audit as the Committee considers appropriate or as requested by the Committee Chair, the Chair of the Board, or the CEO