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SJHH / Quality & Performance/ Quality Patient Care

Quality Patient Care

St. Joseph’s Healthcare Hamilton’s Quality Improvement Plan

St. Joseph’s Healthcare Hamilton is committed to providing quality care, which we define as safe, kind, effective and timely, delivered in an environment of inquiry and learning. We are proud to share our Quality Improvement Plan, which outlines our annual strategy to improve the quality and safety of care to you and your family receive in our hospital.

Our Quality and Patient Safety Plan Goals

St. Joseph’s has identified four quality and patient safety priorities as our overarching corporate priorities:

  • Reducing infections
  • Preventing falls
  • Reducing medication errors
  • Improving patient flow

At a program and department level the Quality Councils identify, address and monitor specific patient safety and quality issues. At a corporate level SJHH also continues to focus on projects related to Safer Healthcare Now and Accreditation Canada Standards.

Quality Plan Infrastructure

Quality and patient safety improvements are operationalized through Program and Department Quality Councils, through Safer Healthcare Now Teams, Accreditation Canada Teams, and other project specific teams.

Accountability

At a strategic level, quality and patient safety improvements are accountable to the Hamilton Board Committee and its Quality and Mission Committee. The Quality and Mission Committee tracks high level clinical outcome and process improvement metrics on a quarterly basis and meets with quality teams in priority areas. Presentations to the Quality and Mission Committee are made via WebEx, and meeting time is reserved for questions and answers. Feedback and expectations are providing in writing by the Committee.

At a strategic, tactical and operational level, Quality Councils and other improvement teams are accountable to the Senior Leadership Team through the Quality and Patient Safety Steering Committee. This committee sets, monitors and investigates quality and patient safety priorities. The Senior Leadership Team also engages in Patient Safety Walkabouts.

Both the Hamilton Board Committee and Senior Leadership Team monitor and respond to Critical Incidents as they occur.

Clinical Outcome and Performance Monitoring

Key quality and patient safety indicators are monitored by leaders and teams on a real time basis. For example never events, critical incidents, infections, access to inpatient care, and patient flow are tracked as they are identified.

The Hamilton Board Committee and Senior Leadership Team track key metrics using a Quarterly Big Dot and Mission Excellence Scorecard that focuses specifically on Patient Outcome Measures in the following Big Dot priority areas:

  • Timely Access (Heal Me)
  • Incidents (Don't Hurt Me)
  • Infections (Don't Hurt Me)
  • Mortality (Don't Hurt Me)
  • Satisfaction (Be Nice to Me)

The Medical Advisory Committee, Professional Advisory Committee, Quality Councils and other quality and patient safety teams use balanced scorecards and other measurement tools to track performance and set targets.