Meeting details
Date of meeting
Wednesday 12th June 2024
Time of meeting
11am to 1pm
Meeting format
Central Office, National Screening Service, Dublin 1 / MS Teams Meeting
Members Present
Dr Deirdre Mulholland (DM, Chair), Mr Damian Nee (DN), Dr Caroline Mason Mohan (CMM), Dr Alissa Connors (AC), Dr Jennifer Martin (JM), Dr David Burling (DB), Mr Andleeb Zafar (AZ), Ms Jan Yates (JY), Dr Laura Cullen (LC), Ms Samantha Hughes (SH)
Apologies
Ms Helen Kavanagh (HK), Dr Noirin Russell (NR), Ms Lorraine Schwanberg (LS), Ms Mary Hewson (MH), Ms Margaret Brennan (MB)
In attendance
Ms Colette Brett (CB), Hilary Coffey (HC), Ms Suzanne Lynch (SL), Dr David Keegan (DK), Prof Padraig MacMathuna (PMcM), Ms Grainne Gleeson (GG), Ms Niamh McNamara (NMcN), Mr Declan O’Reilly (DoR), Ms Michelle Lynch (ML), Dr Alan Smith (AS), Ms Karolina Guzek (minutes)
Meeting minutes
1. Welcome, Introduction and Apologies
The Chair welcomed meeting attendees and asked for introductions. Apologies for the meeting were noted.
2. Conflicts of Interest
There were no conflicts of interest to be noted.
3. Minutes of Meeting 11th March 2024
Minutes of the previous meeting were reviewed and approved by the Committee.
In reference to the “Improving Equity in Screening” presentation given in Q1 2024, DB noted the low uptake numbers for BowelScreen. HC assured the Committee that, as an action from the last BowelScreen Quality Assurance (QA) Committee meeting, the programme management and Public Health are preparing a report on the research and initiatives that BowelScreen/NSS have undertaken over the years to understand and take action to improve uptake.
BowelScreen Clinical Director emphasised that the trends identified by the programme are acknowledged as internationally recognised issues and are being managed appropriately. The Committee discussed the importance of equity work across the NSS and the prioritisation of same and requested for NSS Public Health Department to engage with the programmes on equity projects to establish the priorities.
Action 59: Update from BowelScreen QA committee on uptake numbers at next meeting.
4. Presentation: Patient Reported Experience Measures (PREMs)
Presentation on Patient Reported Experience Measures (PREMs) was given by Consultant in Public Health Medicine, Dr Alan Smith. The project is at the early stages under the governance of the PREMs Oversight Group with a phased roll out across NSS screening programmes.
AS emphasised that gathered information is anonymised participant’s feedback only and it is currently used at local level to create Quality Improvement Plans by two partaking programmes, BreastCheck and BowelScreen. JM highlighted the potential risk of complaint logged by client being missed; SL and AS reassured the Committee that there is oversight of the results by programme management. Information and signposting are included at the start for all PREMs participants regarding the pathway for making complaints. AS informed that data gathered is fed back to the relevant programme operational teams and Quality Assurance Committees and PREMs Oversight Group. QSRM Committee Chair stated it would be very useful to know how the information from PREMs impacts on programmes. High-level updates on the PREMs project to be presented to QSRM
Action 60: PREMs project team to review the risk regarding potential complaint not being identified within PREMs process.
Presentation slides will be shared with the Committee members for information.
5. Cross-Programme Review
BreastCheck Programme Review Q1, 2024
- Report reviewed, acknowledged, and noted AIRE, the new BreastCheck database, successfully went live.
CervicalCheck Programme Review Q1, 2024
- Report reviewed, acknowledged and noted it was a busy and successful quarter with significant and important actions being completed.
BowelScreen Programme Review Q1, 2024
- Report reviewed, acknowledged and noted the current endoscopy capacity challenges and ongoing engagement with service providers to mitigate the impact on participants. Uptake for the programme was discussed and is for further review by BowelScreen Quality Assurance committee.
DiabeticRetina Screen Programme Review Q1, 2024
- Report reviewed, acknowledged and noted all key milestones on the single provider mobilisation project were met.
Committee members noted that the risk regarding the recruitment pause was included as a high risk across all 4 of the programmes’ risk registers and the moratorium is impacting on day-to-day capacity of the programmes. All present members agreed to the drafting of a letter highlighting the issue and supporting derogation based on priorities should be provided to NSS Chief Executive for HSE Chief Clinical Officer.
Action 61: QSR Department to liaise with relevant programmes and departments and draft a letter of support on behalf of the Committee on the current recruitment pause and the derogation of priority posts.
Quarterly Programme Review Template was reviewed, and members requested for changes to be made to the information presented to the Committee, to include changes in risk rating over time, relevant mitigations, and, when included, for Quality Assurance Action Plan / Quality Improvement to list of projects with status only.
Action 62: QSR Department to amend Cross Programme Review Template as per Committees comments.
6. NSS Quality, Safety and Risk (QSR) Information Report
QSRM Committee Annual Report 2023 draft
- Second draft of QSRM Committee Annual Report 2023 was circulated to the members for feedback ahead of meeting; all comments were considered and incorporated, where appropriate. Members were encouraged to submit additional comments to QSR Department if they have any.
- Action 63: Committee’s Chair will liaise with QSR Department to finalise the Report before submitted to NSS Chief Executive.
NSS Quality, Safety and Risk Review Q1, 2024
- 2024, Q1 report presented and acknowledged.
- CB gave an update on Patient Safety Act.
CB informed the Committee that the QSR Department is currently working on two new dashboards – documents status and recommendations from reviews; both dashboard templates will be presented to Corporate Management Team initially for approval in Q3 2024. Quality, Safety and Risk Dashboard Report Q1, 2024
- 2024, Q1 Dashboard reviewed and acknowledged.
- JM’s feedback regarding dashboard presentation was acknowledged and will be included in the report going forward.
NSS Corporate Risk Register Report Q1, 2024
- 2024, Q1 Risk Register Report was reviewed and acknowledged.
NSS Quality Assurance Framework presentation
- Not presented due to time pressure.
- Action 64: Presentation slides were circulated with the meeting pack and will be presented at the next meeting.
- The Quality Assurance Policy Framework: Quality Assurance Governance Procedure draft is to be circulated to QSRM committee members for their input before finalising.
QSRM Committee Membership
- QSRM Committee updated membership was shared with the Committee members prior to meeting.
- It was noted CMM was inadvertently listed under attendees and should be included in members list.
- CB informed attendees that MB, Quality and Patient Safety representative resigned from the Committee as her role had changed and QSR Department is working on replacing this vacant post with a Quality safety and risk representative from Health Regions. MB’s expertise, support throughout the years and advocacy for Quality Assurance was commended.
- CB advised that QSR Department is in process of recruiting GP Rep and sought advice of Committee members on same.
Committee members were reminded, that due to the timeframes of meetings, all data presented to the Committee in review reports is as of end of previous quarter, however attendees are available to provide current updates, if required.
7. Documents for Noting
No documents for noting were presented.
8. NSS Stakeholders Update
The National Screening Service stakeholders’ updates were shared with the Committee members for noting.
9. Actions Update
All actions reviewed and updated on the Action Log.
Action 54: Paper on BowelScreen FIT threshold change in 2014 was shared and acknowledged. Members queried on the process for next review and the governance of same. This action was closed.
Action 65: QSR Department will follow up with Public Health Department and BowelScreen for an update on review of BowelScreen FIT threshold.
10. AOB
The role of National Screening Advisory Committee (NSAC) in regard to new screening programmes and revisions to existing programmes was discussed following a query posed by DN prior to the meeting. DM thanked DN for his question.
JM reminded meeting attendees of Patient Safety Day on 17th September and advised more information will be forwarded to NSS QSR Department, when available.
11. Date of next meeting
Next meeting Monday, 30th September