Quality and patient safety

Quality Improvement and Patient Safety Programme 

Our quality improvement and patient safety programme is designed to establish, organise, implement, monitor, and document evidence of the continuous and systematic performance improvement processes. 

This programme is: 

• Leadership driven. 
• Seek to enhance the culture of the organisation. 
• Proactive in identifying and reducing risk and variation. 
• Use data to focus on priority issues. 
• Effect changes which are evidence based. 
• Seek to demonstrate sustainable improvement initiatives.

Quality improvement principles

We identify the following principles as being integral to quality improvement:

• Patient focus: The essence of our quality improvement programme is to remain patient focused. 
• Systems thinking: We seek to optimise the performance of the entire system, rather than the performance individual parts.
• Continuous improvement: - We analyse on a continuous basis the processes in place to reduce unnecessary variation and to maintain quality improvement.
• Management of data: We collect, aggregate and analyse clinical and managerial data which forms the basis for decisions required to sustain continual improvement.
• Teamwork: By engaging the talents and skills of all our people, we will build a stronger and more effective organisation.
• Continual learning: The organisation makes resources available for learning, and draws on the knowledge, perspectives, and experience of its members to improve the products and services it provides to patients. 
• Collaboration and mutual respect: Leaders have mutual respect for the dignity, knowledge and potential contribution of staff. 
• Culture of safety: We promote a culture where staff can speak up about things that would negatively affect patients or the organisation.

Clinical practice guidelines and related clinical pathways and/or clinical protocols

Each hospital implements evidence-based clinical practice guidelines to improve care by reducing variation in practice and systematising best practices.

Quality & patient safety priorities 

1. Leadership & governance
2. Empower & engage patients
3. Empower & engage staff
4. Anticipate, respond to risks & reduce common causes of harm
5. Identify system improvements
6. Nurture a continuous learning & highly reliable environment

Students

As all our hospital sites facilitate student training, with your consent, students and trainees may be part of your care team. 

Safety concerns

Concerns regarding failure to comply with Joint Commission International (JCI) standards can be reported directly to JCI. This is not the route to raise concerns about individual patient issues, which must be raised directly with the hospital.

Culture of Safety

Bon Secours Health System is strongly committed to creating a safe environment for all patients, visitors and staff. Leadership Commitment to a Culture of Safety establishes a ‘culture of safety’ which encompasses the following:

• We acknowledge the high-risk nature of the organisation's activities and are determined to achieve consistently safe operations.
• We promote A JUST CULTURE where individuals are able to report errors or near misses without fear of reprimand or punishment. We believe that this promotes accountability and transparency. This is supplemented by the Bon Secours Health System Cause for Concern Policy.
• We encourage collaboration across disciplines to seek solutions to patient safety problems.
• We commit to the allocation of resources to address safety concerns.
• We look for feedback from our staff, our patients, and their families to obtain their view of the quality and the safety of our service.

Our culture of safety programmes includes:

• Organisation commitment to the consistent implementation of the International Patient Safety Goals
• Behaviour which recklessly ignores the IPSGs, or which is not in accordance with policies and procedures will not be tolerated and will be corrected
• Promotion of a Just Culture, which distinguishes between human error, at risk behaviour and reckless behaviour
• Encouragement of teamwork, recognising that teams make wise decisions and teamwork should be promoted as a positive culture
• Evaluation of the Culture of Safety
• Evaluation of Staff Satisfaction
• Implementation of improvements identified during evaluation
• Adoption of the Science of Safety and the Three Principles of Safe Design
• Standardise when possible
• Create independent checks and learn from defects
• Education and information for staff
• Maintaining a robust, accessible reporting system which includes Incident, Medication Error and Near Miss reporting and implementing the Bon Secours Health System's Cause for Concern policy which prevents retribution against individuals who report issues of concern

Evaluation of safety culture

The safety culture is evaluated on an ongoing basis in each hospital through a variety of methods, such as adverse reporting, patient complaints and formal survey. We conduct a survey every two years on staff feedback and medical professionalism. The findings are communicated to staff and management implement improvement opportunities identified from the findings.

Safety walkabouts

Senior Leadership Safety Walkabouts are conducted at a minimum monthly in all hospitals. The purpose of Safety Walkabouts is to support a culture of safety, encourage discussion on safety, risk management, feedback and quality improvements between management and staff, to listen and to hear from staff on concerns about safety, and to hear what works well from a safety perspective. The communication and discussion of safety issues helps increase awareness and aids in identifying practical solutions.