As part of our year-long 20th anniversary celebration, we asked the leaders in our Hospital to share their stories and highlight the growth and evolution of their team, program and the services they provide.
This week’s feature: Quality & Risk Management
Summitted by: Tram Dao, Manager, Quality & Risk Management
1. Briefly describe your program/service.
The Quality and Risk Management department provides corporate level direction and support in the areas of quality (including accreditation), risk, ethics, and patient relations. As part of our Strategic Plan 2026, one of our primary goals is to “focus relentlessly on quality to deliver services that are free from preventable harm, accessible, appropriate and integrated.” This includes continuous quality improvement through all levels of the organization – from frontline to the Board of Directors.
2. How has your program/service grown or evolved over the past 20 years?
Although a relatively small department, the Quality and Risk Management team has continued to grow over the past 20 years and continues to support a wide range of activities, including but not limited to:
- Supporting staff/teams through the Accreditation process
- Overseeing the Compliments & Concerns Console and patient safety Incident Learning System (ILS)
- Providing ethics support to staff/patients/families
- Coordinating support/guidance on legal and insurance matters
- Developing/updating applicable policies & procedures
- Overseeing the HIROC Risk Register & Risk Assessment Checklists
- Supporting the implementation of Quality Huddles
- Developing our annual Quality Improvement Plan (QIP)
- Leading/supporting Quality Improvement projects/initiatives
- Conducting/supporting Quality of Care Reviews
3. What is your most cherished accomplishment, milestone or memory?
Some of our most cherished accomplishments include:
- During the Accreditation survey in May 2022, the Hospital achieved Exemplary Standing status, a major milestone which highlights the hard work, dedication and resilience of all of our Hospital staff.
- Since January 2023, the implementation of Quality Huddles has been a major initiative undertaken to support the Hospital’s mission, vision, values, and strategic directions. Although the Quality Huddles are directly aligned with our Patient Experience pillar, it has also impacted: Equity, Diversity and Inclusion; Staff Experience; Innovation and Learning; and Sustainable Future. One of our primary goals is to highlight that everyone has a role to play in quality and safety. Currently, the Quality Huddles have been established in nearly 30 departments, including clinical, non-clinical, inpatient and outpatient; with continued expansion underway. Over the course of 2023, there were > 450 huddles held, > 4,000 staff in attendance, > 750 change ideas generated, and > 450 change ideas implemented.
- To further drive quality and safety to the forefront, the Quality and Risk Management team hosted a Foundations of Quality Improvement workshop in March 2023. Building from the success of the first workshop (30 participants), a second 2-Day workshop was held in February 2024 (with nearly 60 new participants). These workshops have provided participants with the tools, skills and resources to drive meaningful change within the organization.
