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NMH | 2024 27 Governance T he Quality Risk and Patient Safety Committee (QRPS) operates under Terms of Reference approved by the NMH Executive Committee (the Board). These are reviewed annually and changes made as needed. The main aims of the QRPS Committee are to: • understand the risks to which the patients and the staff are exposed and to provide assurance that process is in place to ensure they are managed adequately; • drive quality, risk and patient safety strategy, management and improvement within the NMH and • provide a level of assurance to The Board that there is adequate and suitable governance of quality, risk and patient safety in place. The QRPS Committee met five times during the year. At these meetings, reports from various departments were reviewed, covering matters such as data protection, incident management and risk management in general. The Committee continues its work in all aspects of potential risk: Departmental Risk Registers Reports are reviewed as well as reports in relation to General Data Protection Regulation (GDPR) and Health and Safety. The IT Department continues to ensure that the Hospital follows the HSE guidelines in relation to Cyber Security, an area where that the Hospital has always been at the forefront. There was continued engagement with the National Cyber Security Centre in relation to Network & Information Systems. Consideration of the best means, and possible software to manage data extraction from various systems for the best possible risk related reports was initiated. The digitisation of administrative processes for offsite and electronic health records has progressed steadily throughout the year. Several awareness campaigns were also conducted to minimise data breaches. The HSE Enterprise Risk Management Policy and Procedures 2023 has been embraced and the QRPS Department and committee strive to comply. Further work is planned for the coming year with assistance from members of the committee. The appointment of Martin Creagh as Operational Risk Manager will also facilitate this. The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 formally commenced on 26 September 2024. To summarise, there are 13 notifiable incidents which require notification to National Incident Management System (NIMS), HIQA and NWIHP within 7 days, along with the appointment of a Designated Person to support the patient, a mandatory Open Disclosure (OD) meeting to be held as soon as is appropriate, and a written record of this meeting provided within 5 calendar days of the OD meeting. This has added a significant workload to the QRPS Department without any additional resources provided nationally. The Hospital is fully compliant with this process and the Department acknowledges the support from the Executive Management Team and The Board. During the year the Hospital was visited by the Cervical Check Quality Assurance Team. Their report was extremely favourable and noted that the service provided in NMH is of a high standard and is recognised as one of the largest and best performing colposcopy units in Ireland. They acknowledged the infrastructural limitations particularly regarding the waiting and reception areas. The embargo on recruitment continued during 2024 and was then replaced by the Pay and Numbers Strategy. This has limited the Hospital workforce to the staff census collated in December 2023. It remains an item of concern among an already stretched and stressed workforce. The provision of safe staffing is an ongoing Rensu and Sujin Thomas with their newborn daughter Irene Thomas. Quality Risk & Patient Safety Committee challenge when caring for increasingly complex patients. At the AGM on 29th May 2024, Ms Sarah Claxton was elected onto the Committee and was nominated and appointed chair of the committee at the June meeting. The Committee thanks the Master, Prof Shane Higgins, Mr Ronan Gavin, Drs Anne Twomey and Orla Sheil, and Ms Mary Connolly for their support and assistance throughout the year. Sarah Claxton, Chair.