Meeting details
Date of meeting
Monday 31st March 2025
Time of meeting
2pm to 4pm
Meeting format
MS Teams Meeting
Members Present
Dr Deirdre Mulholland (DM, Chair), Area Director of Public Health
Ms Jan Yates (JY), Chair CervicalCheck Quality Assurance Committee
Dr Alissa Connors (AC), Chair BreastCheck Quality Assurance Committee
Dr David Burling (DB), Chair BowelScreen Quality Assurance Committee
Mr Andleeb Zafar (AZ), Chair DiabeticRetina Screen Quality Assurance Committee
Dr Louise Campbell (LC), Irish College of General Practitioners Representative
Ms Fran Devlin, Patient and Public Partnership Representative
Ms Grace Reck, Patient and Public Partnership Representative
Mr Damien Nee, Patient and Public Partnership Representative
Apologies:
Members:
Dr Caroline Mason Mohan (CMM), Director of Public Health, NSS
Dr Jennifer Martin (JM, Deputy Chair), Director of National Health Service Improvement, Public Health
Ms Lorraine Schwanberg (LS), Assistant National Director, Incident Management, The National Quality and Patient Safety Directorate
Attendees:
Ms Hilary Coffey (HC), Programme Manager, BowelScreen, NSS
Prof Pádraic Mac Mathúna (PMcM), Clinical Director, BowelScreen, NSS
Dr Noirin Russell (NR), Clinical Director, CervicalCheck, NSS
In attendance:
Ms Colette Brett (CB), Head of Quality, Safety and Risk, NSS
Ms Helen Kavanagh (HK), Programme Manager, Diabetic RetinaScreen, NSS
Ms Grainne Gleeson (GG), Programme Manager, CervicalCheck, NSS
Ms Suzanne Lynch (SL), Programme Manager, BreastCheck, NSS
Ms Roisin Egenton (RE), General Manager, Incident Management (Open Disclosure), The National Quality and Patient Safety Directorate
Ms Niamh McNamara (McN), Quality Assurance Coordinator, BowelScreen, NSS
Ms Michelle Lynch (ML), Quality, Safety and Risk Manager, NSS
Ms Karolina Guzek (KG), Quality, Safety and Risk Executive Officer, NSS - Secretariat
Meeting minutes
1. Welcome, Introduction and Apologies
The Chair welcomed meeting attendees. Apologies for the meeting were noted.
CB welcomed two new Committee members, Patient and Public Partnership Representatives, Ms Fran Devlin and Ms Grace Reck, and introduced them to the Committee.
2. Conflicts of Interest
There were no conflicts of interest to be noted.
CB reminded members that in line with the National Screening Service (NSS) Quality Assurance Policy Framework and the committee’s Terms of Reference, the conflict of interest form must be signed by all members not employed by the National Screening Service. The Quality, Safety and Risk (QSR) Department will be liaising with the relevant members in due course regarding signing conflict of interest form
3. Minutes of Meeting 9th December 2024
Minutes of the previous meeting were reviewed and approved by the Committee. It was requested that SL, who was incorrectly listed as a member, was moved to the attendee’s section of the minutes.
Committee members requested for apologies to be separated into members and attendees going forward.
4. Cross-Programme Review
BreastCheck Programme Review Q4, 2024
- Update given by BreastCheck Quality Assurance Committee chair and acknowledged, including update on European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services (EUREF) accreditation visit.
- AC noted that recruitment of BreastCheck staff remains a concern following impact of HSE pay and numbers strategy. The Committee members were assured by the actions being taken by BreastCheck to address the issue.
- Action 68: Written confirmation of EUREF accreditation to be shared with members.
CervicalCheck Programme Review Q4, 2024
- Update given by CervicalCheck Quality Assurance Committee chair and acknowledged, including update on Internal Quality Audit and Quality Assurance activities completed in 2024.
- JY acknowledged that the age extension initiative had good uptake and was ending as agreed in February 2025.
- GG advised that an evaluation of Phase 1 of Personal Cervical Screening Reviews will be completed in 2025; these reviews were in place prior to commencement of the Patient Safety Act 2023.
- Action 69: CervicalCheck to provide an update on findings from evaluation of Phase 1 of the Personal Cervical screening Review process.
BowelScreen Programme Review Q4, 2024
- Update given by BowelScreen Quality Assurance Committee chair and acknowledged, including noting ongoing staff shortages that are impacting both endoscopy and colonoscopy capacity. The Committee members were assured by the actions being taken by BowelScreen to address the issue.
- DB informed of several initiatives implemented by the programme to increase uptake which is a focus for 2025.
DiabeticRetina Screen Programme Review Q4, 2024
- Update given by DiabeticRetina Screen Quality Assurance Committee chair and acknowledged, including increasing activity month on month.
AZ shared that the DiabeticRetina Screen Patient Reported Experience Measures (PREMs) project is under way, and looking forward to share more information when available.
5. NSS Quality, Safety and Risk (QSR) Information Report
Quality, Safety and Risk Review Q4, 2024
- Update given by CB and acknowledged, including update on 2024 projects and initiatives across the National Screening Service.
- CB informed Committee of new HSE Central Compliance Function (CCF) and new Maturity Assessment of Compliance Functions. The NSS is awaiting the finalised HSE Compliance Framework and associated documentation.
- CB noted the Controls Assurance Review Process (CARP) 2024 is now completed with 97% compliance for NSS staff and we are working on CARP recommendations and proposed actions.
Quality, Safety and Risk Dashboard Q4, 2024
- Update given by CB and acknowledged.
- Members suggested using run charts to present the data more effectively; the Quality, Safety and Risk Department will explore this proposal.
- LC noted that when General Practitioners receive misaddressed letters from NSS, they may forward them to the correct recipient without notifying NSS. LC proposed adding a note to all letters requesting that NSS be informed if the correspondence was sent to the wrong GP.
- Action 70: The proposal should be shared with relevant programmes and NSS Communications department for consideration.
NSS Corporate Risk Management
- Update given by CB and acknowledged.
- CB informed the Quality, Safety and Risk Department completed Enterprise Risk Management Policy self-audit tool and organised training for designated NSS users on utilising new HSE Risk Information System (RIS).
- The review of Risk Assessments for the NSS Risk Register is now completed, and ready for migrating to the Risk Information System (RIS) post-staff training.
- Action 71: Language used in the Risk Section of the Review Report template to be aligned with the Enterprise Risk Management Policy.
QSRM Committee name, Terms of Reference and Membership
- Following discussion and taking into consideration feedback received from the NSS Chief Executive, members agreed to rename Committee to the NSS Quality Assurance Committee, as this title more accurately represents Committees’ purpose.
- Action 72: To update the Terms of Reference and all relevant documents to reflect the Committee’s new name.
QSRM Committee 2024 End of Year Report draft
- Draft report was shared with members for consideration.
- Members commended the work of NSS Departments and Programmes and acknowledged that the report accurately reflects the Committee’s activities.
- Action 73: The Quality, Safety and Risk Department will send an email to Committee members requesting feedback, with a two-week deadline. All comments received will be reviewed. If no feedback is provided within the timeframe, the report will be considered formally approved.
6. Documents for Noting
National Screening Service Strategic Plan 2023-2027 - End of Year Report 2024 was shared with the Committee members for noting.
7. NSS Stakeholders Update
The National Screening Service stakeholders’ updates were shared with the committee members for noting.
8. Actions Update
All actions reviewed and updated on the Action Log.
9. AOB
CB informed members that the tenure of two Patient and Public Partnership Strategy Representatives (formerly known as Service Users), Mr Damien Nee and Ms Mary Hewson, has come to an end. Committee Chair and members expressed their sincere thanks for their valuable contributions, dedication, and perspective throughout their time on the Committee. The Committee wished them both all the best in future endeavours.
10: Date of next meeting
Date of next meeting – Wednesday, 4th June at 11am in person in NSS Central Office.