Refresher session for Residency R3s

Learning objectives

Review the key concepts of Quality and Safety.

Understand the Work Processes relating to Quality and Safety .

Understand your Roles, as an Individual & as a Team member, how you can contribute to Quality and safety

2

3

Programme

1. Introduction

2. SHP Quality and Safety Framework

3. Overview of SHP Quality and Safety Programs

4. Your Role in Quality and Safety

5. Review

Introduction

6 Dimensions of Quality

5

How do we ensure balancing of the different dimensions of quality?

6 Dimensions of Quality

6

Paul Batalden

through Don Berwick

Systems include people, things and processes

Better Care , Safer Care Everyday

System include *people, things & processes

Use of protocols and guidelines in managing patient’s conditions

Equipped and trained to handle emergency

situation e.g. code blue

Early identification of the infectious patient and potentially emergent patient

1 2

3

* People include roles & responsibilities

9

10

Teamwork

Continual Improvement

Clear processes

Communication

Measurement and learning

Better Care , Safer Care Everyday

SHP Quality and Safety Framework

Better and Safer Care

Governance Learning Improvement

Quality Assurance

Safety

Risk

Culture

CGSC

CGSC

Quality Dashboard /

Planned feedback

Continual improvement

Incident reporting / Unplanned feedback

Address root causes

ERMSCRisk

analysisRisk

mitigation

Established processes

Unplanned observations

Proactive risk analysis

Experience

Staff Training

SHP Quality Framework

Clinical Governance

13

Business Continuity Management (BCM)Steering Committee

CEO

Workplace Improvement, Safety and Health

(WiSH)

Clinical Governance Steering Committee

(CGSC)

HQ Management

Polyclinic Directors

Enterprise Risk Management (ERM) Steering Committee

Clinical Leaders/

Workgroups

Quality and Improvement

committee (QIC)

Pharmacy and Therapeutic committee

(P&T)

Infection Control and Infectious

Disease (ICID)

Facilities Management and

Safety (FMS)

Patient Education Committee

(PEC)

Clinical Governance

14

Patient

Safety Group

Patient Safety Collaborative

Clinic Patient

Safety Team

Clinic Patient

Safety TeamClinic Patient

Safety Team

Clinic Patient

Safety Team

Clinic Patient

Safety Team

Quality Improvement

Committee

Clinical Governance

Steering CommitteeSHP P&T

Committee

SHP ICID

Workgroup

SHP FMS

Committee

SHP Clinical

Workgroups

SingHealth

Medication

Safety

Workgroup

SingHealth

Infection Control

and Prevention

Workgroup

SingHealth

Operations and

Environmental

Safety

Workgroup

SingHealth

Clinical Specialty

Partners

Collaboratives

Example : Patient safety collaborative

Overview of Quality and Safety programs

Building a Culture of Quality, Safety and Improvement Together

Leadership Patient Safety & Experience Walkrounds

Quality and Patient Safety related Trainings

Infection control Activities

Incident Reporting of Actual Events and Near

Misses

Enterprise Risk Management

Dashboard , Quality Awards, Audits

Patient Safety Culture Survey

Continual Improvement

Committees, Workgroups and

Collaboratives

Quality & Safety Programs

International Quality Standards

1. Quality Assurance

18

Bukit Merah

Pasir Ris

Outram

Sengkang

Marine Parade

Punggol

Bedok

Tampines

Clinic Dashboard ( Quality indicators) & Audits

1. Quality Assurance

Audits Clinic Dashboard

19

IPSG 1 Identify Patients Correctly

IPSG 2 Improve Effective Communication

IPSG 3 Improve the Safety of High-Alert Medications

IPSG 4 Ensure Correct Site, Correct-Procedure, Correct-Patient Surgery

IPSG 5 Reduce the Risk of Health Care-Associated Infections

IPSG 6 Reduce the Risk of Patient Harm resulting from Falls

Quality standards ( JCI Primary care standards 2nd Edition)

International Quality Standards

1. Quality Assurance

System include *people, things & processes

Use of protocols and guidelines in managing patient’s conditions

Equipped and trained to handle emergency situation

e.g. code blue

Early identification of the infectious patient and potentially emergent patient

1 2

3

* People include roles & responsibilities

1. Quality Assurance

21

1. List is categorised into

• English language

• Medical Terminology

• “Do Not Use” list

2. Index list

• Alphabetical order

3. Abbreviations should follow the standard list

4. Every abbreviation to have only one meaning (Exception where unlikely to confuse in the context of use, some abbreviations will have more than 1 meaning)

5. “Do Not Use” list

• All medicine names should be spelt out in full.

• Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms

Use of Abbreviations

Manage variation through agreed processes

1. Quality Assurance

22

ePrescribing Guidelines Important for team communication& patient safety

Manage variation through agreed processes

1. Quality Assurance

23

2. Safety

24

Speak up

24

25

TeamSPEAK® is a program that promotes Speaking Up for Patient Safety

TeamSPEAK® includes strategies to:

i. promote a safe and supportive working environment, and

ii. help each other to be safe together

2. Safety : TeamSPEAK

26

Psychological Safe Working Environment

Positive Response

• Giving attention

• Acknowledging and listening to the concern

• Addressing the concern (However, this does not mean that the other party must agree to what you have raised.)

Positive response when someone speaks up

2. Safety : TeamSPEAK

27

First Challenge: Be RespectfulAsking sounds more respectful than tasking.

By asking, you are inquiring or clarifying.

1. Two-Challenge Rule

If you task, you are telling or instructing your colleague.

e.g. “You should check if this is the correct

patient.”

e.g. “Shall we verify this is the correct

patient?”

Second Challenge: Be AssertiveState your concern. Share what you know, and why it matters.

Avoid using “I think”, “maybe”, or “perhaps” as they sound passive and unassertive.

e.g. ““I saw a different name just now. Let’s verify this is the correct patient before proceeding.”

If there is no positive responseafter First Challenge

Proceed to

28

“Two-Challenge Rule”

“CUS” words

Continue to highlight the safety concern by using:

If you did not receive a positive response from the

other party after the “Two-Challenge Rule”

29

CUS words are trigger words which help to trigger the attention of your colleague of potential harm that may occur.

I am Concerned.

I am Uncomfortable.

This is a Safety issue.

2. “CUS” words

Raise your concern by using the phrase

Example

“I am concerned. (pause) Shall we confirm if the patient is the correct patient?”

“I am uncomfortable. (pause) This is not the correct patient. We should verify the two patient IDs before proceeding.

“This is a safety issue. (pause) I will inform my supervisor.

Ask instead of task

State the concern and why

Consider escalation

How do we Speak Up for safety concerns ?

1. Two-Challenge Rule

First Challenge: Be RespectfulAsking sounds more respectful than tasking.

Second Challenge: Be AssertiveState your concern. Share what you know, and why it matters.

2. “CUS” words

CUS words are trigger words which help to trigger the attention of your colleague of potential harm that may occur.

I am Concerned.

I am Uncomfortable.

This is a Safety issue.

31

Leadership Patient Safety & Experience Walkrounds

32

• Opportunity for leadership to show

commitment to patient safety and

experience

• Engage clinic staff on general / specific

safety as well as experience issues

• Reflect on what can be improved and

to implement the appropriate changes

• To build a strong patient safety and

experience culture

2. Safety : Leadership Patient Safety & Experience walkrounds

33

Findings for “Environment”

• Door swing : To have obvious indication (painted area) to warn passers-by

Recommended yellow box

Safety Concerns from Leadership Patient Safety & Experience Walkrounds Year 2018:Breakdown using Vincent’s Categorisation

• Potential falls risk - Poor contrasting steps at stairway

RecommendedNot recommended

• Padded cushion on side of table – for child safety ( Immunization room)

Good practice

• Potential falls risk – Step bin

Not recommended

2. Safety : Leadership Patient Safety & Experience walkrounds

Incident Reporting( including incident alert, escalation & notification)

34

Reason, J. BMJ 2000;320:768-770

Active failures

Latent failures

Drug Allergy

Prescription errorInconsistent use of 2 patient ID

Frequent interruptions

Doctor selected wrong patient from patient list

35

Swiss Cheese Model of Safety

What can be reported?

Any event with learning potential

• Something happened

• Something did not happen

• Something nearly happened

• Something could have happened

• Something didn’t go well

• Something went well

36

Ask 3 questions

• What happened?

• Why did it happen?

• What can we learn about it?

Focus on improvement

What can be done to improve it ?

What have we done about it ?

Incident Reporting

Initial incident report (Part I) For high severity or impact incidents,report the incident to your Supervisor, QMD and relevant departments (i.e.

Data Breach to SHP DPO; Staff workplace safety to SHP WISH)

immediately

37

Incident Reporting

Final incident report (Part 2)

• Systems issues

• Individual performance issues

• Recommendations to prevent occurrence of similar events

38

Mortality & Morbidity Reviews

Mortality and Morbidity Reviews

• Monthly at each clinic

• Reviews incidents

• Review both systems factors as well as

individual performance factors

• Recommends improvements

39

Terms of Reference of Clinic M&M QAC 1. M&M reviews are conducted under the provisions of Section 11 of the Private

Hospitals and Medical Clinics Act (Cap 248). 2. Review all mortalities, morbidities and clinical incidents that have been reported to it,

to evaluate the quality and appropriateness of the services provided and the practices and procedures carried out

a. by assessing the adequacy, competency and appropriateness of care given by

an individual healthcare professional; and b. by ascertaining whether any procedure carried out was done in accordance with

the credentialing requirements under regulations 25(1) and (2) of the PHMC Regulations.

3. Conduct a review to identify system failures and contributing factors by

assessing and categorizing each Mortality according to the classification criteria set out in in SHP Policy on Review of M&M (SHP-QM-IR-003) Annex A and:

a. refer all Category 3 Mortalities and clinical incidents notifiable under the SRE Directives to the SRE QAC; and

b. review all remaining Mortalities and Morbidities.

4. Make recommendations for improvement at the Polyclinic/Department and/or institution level in order to prevent the occurrence of similar events.

5. Complete the M&M review within 3 months from the date of occurrence of the clinical

incident.

Mortality & Morbidity Reviews

Have you received your M&M QAC appointment letters ?

Qualified privilege under the PHMC Act

SRE QAC Structure

CGSC

Standing SRE QAC

QICQMD

Ad-hoc QAC to conduct RCA

Additional Membersas appointed by CEO

M&M QAC Structure

CGSC

Standing M&M QAC

QICQMD

Clinic M&M QAC

Additional Membersas appointed by CEO

Quality Assurance Committees ( QACs)

Serious Reportable EventsSurgical or Invasive Procedure Events

1. Surgery or other invasive procedure performed on

the wrong body site

2. Surgery or other invasive procedure performed on

the wrong patient

3. Wrong surgical or invasive procedure performed on

a patient

4. Unintended retention of a foreign object in a patient

after surgery or other invasive procedure

5. Intra-operative or immediately post-operative/post-

procedure death in an ASA Class 1 patient

Product or Medical Device Events

6. Patient death or serious injury associated with the

use of contaminated drugs, medical devices, or

biologics provided by the healthcare institution

7. Patient death or serious injury associated with the

use or function of a medical device in patient care in

which the device is used or functions other than as

intended

8. Patient death or serious injury associated with

intravascular air embolism that occurs while being

cared for in a healthcare institution

Patient Protection Events

9. Discharge or release of an infant, a child or any

person who lacks capacity, as referred to in section

4(1)of mental capacity Act (Cap.177A), other than an

authorised person

10. Patient death or serious injury associated with

patient abscondment (disappearance)

11. Patient suicide, attempted suicide or self-harm

that results in serious injury, while being cared for in a

healthcare institution

Environment Events

12. Patient death or serious injury associated with an

electric shock in the course of a patient care process

in a healthcare institution

13. Any incident in which systems designated for

oxygen or other gas to be delivered to a patient

contain no gas, the wrong gas or are contaminated by

toxic substances

14. Patient death or serious injury associated with a

burn incurred from any source in the course of a

patient care process in a healthcare institution

15. Patient death or serious injury associated with the

use of physical restrains or bedrails while being cared

for in a healthcare institution

Care Management Events

16. Patient harm, death or serious injury associated

with a medication error (corresponding to Category E

to I of Appendix 2, e.g. errors involving the wrong

drug, wrong dose, wrong patient, wrong time, wrong

rate, wrong preparation or wrong route of

administration)

17. Patient death or serious injury or risk thereof

associated with unsafe administration of blood or

blood products

18. Transmission of diseases following blood

transfusion, organ transplant or transplant of tissues

19. Maternal or serious injury associated with

pregnancy or delivery

20. Infant death or serious injury associated with

labour or delivery in a low-risk pregnancy

21. Patient death or serious injury associated with a

fall while being cared for in a healthcare institution

22. Stage 3 or 4 and unstageable pressure ulcer

acquired after admission/presentation to a

healthcare institution

23. Patient death or serious injury resulting from the

irretrievable loss of an irreplaceable biological

specimen

24. Patient death or serious injury resulting from

failure to follow up or communicate laboratory,

pathology or radiology test results

25. Unexpected death or serious injury as a result of

lack of treatment or delay in treatment which would

have been prevented otherwise.

26. Unexpected death or serious injury as a result of

medical intervention which would have been

prevented otherwise

27. Any assisted human reproductive procedure

which has or, may have, resulted in insemination of

wrong gamete or transfer of wrong embryo

Radiological Events

28. Radiological procedure performed (a) on the

wrong patient, (b) on a pregnant patient

29. Radiopharmaceutical administered (a) to the

wrong patient, (b) with a wrong type or dose

30. Radiation therapy delivered (a) to the wrong

body site, (b) to the wrong patient, (c)with a wrong

dose

31. Death or serious injury of a patient associated

with the introduction of a metallic object into MRI

area

41

Serious Reportable Events ( SREs)

• High impact incidents

• Examines the system rather than focusing on individuals

• Identifies fundamental systemic weaknesses

• Following through with improvements to make recurrence less likely

42

Root Cause Analysis

43

Category 1 2 3

Definition An incident of high severity and impact at the national or systemlevel, or where life is endangered, including but not limited to:

An incident of moderate/ medium severity and impact at the national or system-level, including but not limited to:

An incident of low severity and impact at the national or systemlevel, or moderate/ low severity and impact at the individual institutionallevel, including but not limited to:

Outbreak of diseases of high severity/ transmissibility in institutions or in the community; no treatment is available; immunocompromised/ vulnerable population at risk; hospital-wide/ community-wide spread;

Outbreak of diseases of moderate severity/ transmissibility in institutions or in the community; some treatment is available;

Cases or small clusters of diseases of low severity/ transmissibility in the community or in institutions; treatment is available;

Severe incident involving loss of life or critical injuries as a result of the incident, extensive damage to healthcare institution’s property or extensive degradation of clinical capability/ capacity/ services;

Major incident involving serious injuries, moderate damage to healthcare institution’s property or moderate degradation of clinical capability/ capacity/ services;

Minor incident in healthcare institution involving minor injuries or minor disruption to clinical capability/ capacity/ services;

Incident that could affect public confidence in the healthcare sector, MOH, the Public Service and/ or the Government.

Incident that could affect public confidence in the healthcare sector, MOH, the Public Service and/ or the Government.

Incident that could affect public confidence in the affected institution

Incident where an institution have to activate their business continuity and other mitigation plans (e.g. downtime processes).

Types of Reportable Incidents(from MOH Incident Management and Reporting Framework, MOH Circular No. 29/2017)

Incidents that can have significant adverse impact on

• Public health

• Access to health services

• Safety and security

• Public confidence in the healthcare system

Please report to your supervisors immediately

Examples of cases:

• Potential or actual medico legal implications (litigation against SHP)

• Patient safety (including Serious Reportable Events)

• Public confidence (reputation of SHP, SH and public healthcare)

• Disruption to care delivery or access

• Data breach

Incident Alert, Escalation & Notification

Reference : SOP on Incident Alert, Escalation and Notification ( SHP –QM-AEN-S001)

Analysis and Learning from Incidents

Clinic– Incident report

SRE report to MOH

QMD- secretariat

- report of 6 monthly review

SHP expert groups- system improvements

QIC – 6 monthly

review

- learning from incidents

Domain owner - System improvements

SRE report to SingHealth

Local analysis

RCA

Outcomes

Knowledge management

SHP

CGSC

Knowledge management

Knowledge management

Knowledge management

Knowledge management

Analysis and Learning from Incidents

Just Culture

45

• Blame culture?

• No blame culture?

• Just culture?

• Seek first to learn

• Accountability in proportion to individual responsibility

46

Just & Learning Culture

• We are still responsible for our actions

• Distinguish between system and individual factors

• Distinguish between violations and errors

• Understand importance of human factors in performance and system design

• Accountable for behavioural choices rather than outcome

• Our biggest responsibility is to continually learn and improve the system

SystemIndividual

47

Responsibility

Reason, J., Managing the Risks of Organizational Accidents

Decision Tree for Determining Culpability of Unsafe Acts

Sabotage, malevolent

damage, suicide, etc

Substance abuse without

mitigation

Substance abuse with mitigation

Possible reckless violation

System-induced violation

Possible negligent

error

System-induced

error

Blameless error

Blameless error but corrective training,

counseling needed

Were the actions as intended?

Unauthorized substance?

Knowingly violate safe operating procedures?

Pass substitution

test?

History of unsafe acts?

Were the consequences as

intended?

Medical condition? Were procedures

available, workable, intelligible and correct?

Deficiencies in training & selection

or inexperience?

No Yes

Diminishing culpability

No

Yes

No No

No Yes

YesYes

Yes

NoYes

No

No Yes

NoYes

Was there

malice involved ?

Was the individual

knowingly impaired?

Was there a conscious

unsafe act ?

Did the person(s) make a mistake

that someone of similar skill nad

training could make under those

circumstances?

Accountability in proportion to individual responsibility 48

The Three Behaviours

Inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake.

49

Human Error

1

Behavioral choice that increases risk where risk is not recognized or mistakenly believed to be justified.

At-Risk Behavior

2

Behavioral choice to consciously disregard a substantial and unjustifiable risk.

Reckless Behavior

3

From Just Culture _ David Marx

Just Culture

Product of Our Current System Design and Behavioral Choices

Manage through changes in: • Choices • Processes• Procedures • Training• Design• Environment

50

Human Error

1A Choice: Risk Believed insignificant or Justified

Manage through:• Removing reasons for

at-risk behaviors • Increasing situational

awareness

At-Risk Behavior

2Conscious Disregard of Substantial and Unjustifiable Risk

Manage through: • Remedied action• Punitive action

Reckless Behavior3

CONSOLE COACH PUNISH

And, do it all independent of outcomeFrom Just Culture _ David Marx

Patient Safety Climate Survey

52

Patient Safety Climate Survey

SHP Patient Safety Culture Survey

2017

2017 2018 2019

Launch of Target Zero Harm

article

TeamSTEPPS/TeamSPEAK/Just Culture Trainings

Set up of Patient Safety Collaborative

Introduction of ‘Better Care Safer Care

Everyday’

Launch of ‘Better Care Safer Care

Everyday’ E-bulletin (Replace TZH article)

• Leadership Patient Safety and Experience Walkrounds• Incident Reporting of Actual Events and Near Misses• Learning from International Standards

• Enterprise Risk Management • Clinical Dashboard – Monitoring and benchmarking • Continual learning and improvement

Ongoing

SHP Patient Safety Culture Survey 2019

(1 – 31 Aug 2019)

Patient Safety Climate Survey

3. Experience

• Acknowledge Appropriately

• Be Polite

• Show Care

• Deliver Promises

• Explain Clearly

• Find a ‘Yes’

55

Igniting

as easy as ABCDEF

3. Patient Experience , interactions

4. Risk: Enterprise Risk Management

Different types of risks

Clinical Risk

– Medication errors

– Healthcare associated infections

– Diagnostic and treatment errors

Breach of Regulatory Requirements

Information Security Risk

Research Risk

Workplace hazards ( including needle stick injuries)

Social Media Risks

57

Lost thumb

drive

4. Enterprise Risk Management

• We can prevent problems before they happen.

• Watch out for risks and speak up.

• Everyone is a Risk manager

Improvement

Albert Einstein

61

Learn more at the QI workshop

62

Quality Improvement (QI)

Quality improvement (QI) is an approach that consists of systematic actions that can lead to improvement in different levels (individual, team, organization).

Four approaches of quality improvement are:

From the problem identified for solving, decide which level of quality improvement and approach needed to improve or rectify the problem.

Quick Improvement

Team-level Process Improvement

Organizational-level Process Improvement

Innovations

QUALITY IMPROVEMENT – EVERYONE PLAYS A PART

63

Quality Improvement (QI)

Description: • Local issues which can be addressed quickly without formal team structure• Can be done at individual/local team level

2. Labelling of containers that contained dirty instruments to avoid confusion

1. Re-organizing the placement of the outgoing mails to increase efficiency in sorting out mails

Examples

Quick Improvement

Ways to start and participate: • Speak Up! Raise the issue to your supervisors• Pin the issue on your clinic QI board• Test ideas using rapid-cycle PDSA

Before After

64

Quality Improvement (QI)

Ways to start and participate: • Identify a process that needs improvement• Form a QI team and get sponsorship from your Clinic Director or HOD• Register your QI project with Quality Management department

Learn process improvement skills: • Attend the QI workshop to learn the QI concept and tools

Team-level Process Improvement

Description: • Process related issues

- Patient care related - Organizational processes

• Can be done by team who has significant control over the process

Example

QI project done by IPID workgroup and BM polyclinic

Hand Hygiene QI project• Low hand hygiene compliance rate observed of

staff assigned to Health Monitoring Station (HMS)

• Through observation and survey, interventions developed were: fixed sequence steps on hand hygiene and training for HMS staff

65

Quality Improvement (QI)

Organizational-level Process Improvement

Description: • Complex organizational issues • Requires the involvement of many stakeholders • Requires higher level project coordination

Ways to participate: • Be part of the improvement - accept changes and improve together • Provide your feedback on the new initiatives or processes that are implemented

Example

Improving Patient Flow • Mapping patient care processes • Gathering data on process steps • Calculating flow rates of patients • Balancing capacity at each step

66

Quality Improvement (QI)

Innovations

Description: • Testing of new innovations• Can be a standalone test of an idea or part of other improvement work

Ways to start and participate: • Provide ideas by participating in the clinic QI board discussion session• Speak to you supervisors or relevant personnel on the ideas you have • Tap on the innovation grant to test on new ideas

Example

• Proper holder and dispenser for tongue depressors so as to reduce healthcare associated contamination

Tongue Depressor Dispenser

Innovation by PR polyclinic team

Improvement : QI Board

Punggol Polyclinic

Outram Polyclinic

Look out for it at your clinic

68

Learning & Improving Together

1. Teams Clinic teams project teams

2. Workgroups, Committees3. Collaboratives :

CVD Respiratory Patient safety

P&T Committee Respiratory Collaborative

Clinic Patient Safety Teams

69

Training Programs

70

SHP QID 2018 Poster AwardTarget Zero Harm 2018 Team Award Quality Service Awards

SHP Quality Award

Celebrating Together

• Clinical Governance – We function as an Organisation.

• Measurement and reporting – Measure to learn and improve.

• Safety – Establish clear processes, keep observing and learning.

• Experience – “I don’t care how much you know until I know how much you care.” ;

“Nothing about me, without me.”

• Risk Management– Don’t wait for something to happen.

• Improvement – The only way to keep getting better.

• Learning – Empowering our people, our most precious asset.

• Culture – What happens when no one is watching.

Summary of the SHP Quality Framework

Commitment to Better Care, Safer Care Everyday

We are all healthcare workers.

- We deliver good and safe care together.

Quality , Safety and Experience as a system.

- People, things and processes and how they interact together to achieve a common goal.

Keep learning & improving

Culture binds us :

Target Zero Harm

Everyone a Risk Manager

Just & Learning culture

72

Key points

73

1. Adhere to safe processes.This requires effort and diligence.

2. Speak UpSometimes things need fixing

3. Be part of the Improvement.For Better Care, Safer Care Everyday

Your Role in Quality & Safe patient care

Review

75

1. Adhere to safe processes.This requires effort and diligence.

Your role in Quality & Safe patient care

What are the examples for safe processes ?

2. Speak UpSometimes things need fixing.

Your role in Quality & Safe patient care

How can we speak up?

79

3. Be part of the Improvement.

Your role in Quality & Safe patient care

‘ How can you be part of the improvement ? ‘

For Better Care, Safer Care Everyday

Building a Culture of Quality, Safety and Improvement Together

Leadership Patient Safety & Experience Walkrounds

Quality and Patient Safety related Trainings

Infection control Activities

Incident Reporting of Actual Events and Near

Misses

Enterprise Risk Management

Dashboard , Quality Awards, Audits

International Quality Standards

Patient Safety Culture Survey

Continual Improvement

Committees, Workgroups and

Collaboratives

Thank You