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Quality Safety and Risk Management meeting minutes Q4 2024

Meeting details

Date of meeting

Monday 9th December 2024

Time of meeting

3pm to 5pm

Meeting format

MS Teams Meeting

Members Present

Dr Deirdre Mulholland (DM, Chair), Area Director of Public Health

Dr Jennifer Martin (JM, Deputy Chair), Director of National Health Service Improvement, Public Health

Ms Jan Yates (JY), Chair CervicalCheck Quality Assurance Committee

Dr Alissa Connors (AC), Chair BreastCheck Quality Assurance Committee

Mr Andleeb Zafar (AZ), Chair Diabetic RetinaScreen Quality Assurance Committee

Dr Louise Campbell (LC), Irish College of General Practitioners Representative

Apologies

Dr David Burling (DB), Chair BowelScreen Quality Assurance Committee

Dr Caroline Mason Mohan (CMM), NSS Public Health Representative

Prof Nóirín Russell (NR), Clinical Director, CervicalCheck, National Screening Service

Ms Grainne Gleeson (GG), Programme Manager, CervicalCheck, National Screening Service

Ms Helen Kavanagh (HK), Programme Manager, Diabetic RetinaScreen, National Screening Service

Prof Pádraic Mac Mathúna (PMcM), Clinical Director, BowelScreen, National Screening Service

In attendance

Ms Colette Brett (CB), Head of Quality, Safety and Risk, National Screening Service

Ms Hilary Coffey (HC), Programme Manager, BowelScreen, National Screening Service

Ms Suzanne Lynch (SL), Programme Manager, BreastCheck, National Screening Service

Mr Declan O’Reilly (Do’R), Deputy Programme Manager, Diabetic RetinaScreen, National Screening Service

Ms Michelle Lynch (ML), Quality, Safety and Risk Manager, National Screening Service

Ms Karolina Guzek (KG), Quality, Safety and Risk Executive Officer, National Screening Service - Secretariat

Meeting minutes

1. Welcome, Introduction and Apologies

The Chair welcomed meeting attendees. Apologies for the meeting were noted.

2. Conflicts of Interest

There were no conflicts of interest to be noted.

CB informed that in line with the National Screening Service (NSS) Quality Assurance Policy Framework and new committee’s Terms of Reference, the conflict of interest form is to be signed by members not employed by the NSS.

Action: Quality, Safety and Risk (QSR) Department will be liaising with relevant members in due course regarding signing conflict of interest form.

3. Minutes of Meeting 30th September 2024

Minutes of the previous meeting were reviewed and approved by the Committee.

4. Cross-Programme Review

BreastCheck Programme Review Q3, 2024

  • Update given by BreastCheck Quality Assurance Committee chair and acknowledged, including update on new BreastCheck Information Management System (AIRE), and the European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services (EUREF) programme accreditation scheduled for first quarter of 2025.

CervicalCheck Programme Review Q3, 2024

  • Update given by CervicalCheck Quality Assurance Committee chair and acknowledged, including update on new Information Management System development, recruitment of priority posts within the programme and challenges maintaining International Standards Organization (ISO) accreditation by the National Cervical Screening Laboratory due to challenges with recruitment of medical scientists nationally. Update to be shared with committee members for information.
  • JM commended CervicalCheck programme for recent launch of the Cervical Cancer Elimination Action Plan 2025-2030, which sets out steps to be taken to make cervical cancer rare in communities. JM also highlighted programme’s robust process for both Quality Improvement and Quality Assurance.

BowelScreen Programme Review Q3, 2024

  • Update given by BowelScreen Programme Manager and acknowledged, including noting issues with hospitals capacity for screening colonoscopies which has an impact on screening invites numbers. HC also informed members of collaboration with Louth Hospital; this regionalisation procedure will allow service continuity until full capacity is available.

Diabetic RetinaScreen Programme Review Q3, 2024

  • Update given by DRS Screen Quality Assurance Committee chair and acknowledged, including update on treatment centres, first DRS conference and developments for use of Healthlink for both the receipt of referral forms and the issuing of result letters to GPs.

5. NSS Quality, Safety and Risk (QSR) Information Report

Quality, Safety and Risk Review Q3, 2024

  • Update given by CB and acknowledged, including information on five NSS projects being shortlisted for Irish Healthcare Awards and HSE Annual Controls Assurance Review Process (CARP) 2024 completed with steady increasing compliance by NSS staff year on year.

Quality, Safety and Risk Dashboard Q3, 2024

  • Update given by CB and acknowledged.
  • Members made a suggestion for annual trend to be considered for Your Service Your Say analysis.

NSS Corporate Risk Register Report Q2, 2024

  • Update given by CB and acknowledged.

QSRM Committee Terms of Reference and Membership

  • Proposed updated Terms of Reference (ToR) that are now aligned with the NSS Quality Assurance Framework were presented for approval and discussed. Members noted that current committee’s name suggests direct responsibility for management of quality, safety, and risk matters within the National Screening Service. However, as per ToR, its role is rather to assure itself and provide assurance to the NSS Chief Executive that the risks relating to the NSS are being effectively managed. Members proposed that name containing "Oversight" or "Assurance" instead of “Management” would more accurately reflect the Committee’s purpose.

Action 66: QSR Department to draft a letter to the NSS Chief Executive on behalf of committee chair with name change proposal for consideration.

  • CB informed that, in line with Quality Assurance (QA) Policy Framework QA Governance Procedure, which outlines duration of maximum tenure for NSS committee membership, QSR Department will be liaising with all committee members whose membership tenure is coming to an end.

Action 67: QSR Department to draft a letter on behalf of committee chair to all committee members, whose membership tenure is coming to an end and to initiate recruitment process for replacement posts.

6. Documents for Noting

No documents for noting were presented.

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 that QSR Department is currently working on End of Year Report for 2024 and draft document will be circulated to members for feedback in due course.

Committee chair thanked members and all NSS programme and department staff for all hard work and commitment throughout the year.

10. Date of next meeting

Proposed Calendar of Events for 2025 was presented and placeholders for quarterly meetings to be circulated by QSR Department, if no feedback from members is received by end of December 2024.