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SJHH / Quality & Performance/ Quality Improvement Plan

Quality Improvement Plan

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
  • Improving transitions
  • Improving medication safety
  • Improving access

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.


At a strategic level, quality and patient safety improvements are accountable to the Joint Boards of Governors and its Quality Committee. The Quality 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 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 Joint Boards of Governors 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 Joint Boards of Governors and Senior Leadership Team track key metrics using a Quarterly Quality & Patient Safety Metrics Report that focuses specifically on Patient Outcome Measures inclusive of the following priority areas:

  • Timely Access to Care
  • Patient Safety Incidents
  • Hospital Acquired Infections
  • Healthcare Worker Safety
  • Patient Satisfaction

The Medical Advisory Committee, Professional Advisory Committee, Corporate and Program level Quality Councils and other quality and patient safety teams use these indicators and other measurement tools to track performance and set targets for quality improvement.