Quality and Risk Management

The goal of the Quality and Risk Management Department at St. Mary’s Hospital Center (SMHC) is the reinforcement of quality of patient care and safety in service delivery.  To achieve this goal, the department supports the clinical programs, support services, and the three professional councils (Council of Physicians, Dentists, and Pharmacists (CPDP), Nurses’ Council, and Multidisciplinary Council) in their quality assessment and improvement activities as well as their risk management activities.  The current quality structure presented here exists since 1999.

Quality Assessment and Continuous Quality Improvement

The Quality Assessment (QA) Unit’s role at SMHC is to assist with improving the quality of care and support services at SMHC by evaluating key aspects of quality of care and services.

Quality Improvement is the responsibility of the clinical programs, support services, and the three professional councils. Every year, each quality improvement team presents their annual report to the Quality and Risk Management Coordinating Committee and every two years to the Patient Services Committee of the Board of Directors.

Risk Management and Patient Safety

The QRM Department collates and maintains a database of Incident-Accident reports (AH-223 forms – Local Registry of Incident-Accidents) received from hospital staff. From this database, unit-based reports are produced on a quarterly basis as well as special reports upon request on incidents and accidents for the teams, Senior Management, the Quality and Risk Management Coordinating Committee (QRMCC) and the Board of Directors.

Public reporting of incident-accidents at SMHC is done through the hospital’s Annual Report. In the past three years, the numbers of incident-accident reports have decreased. For the 2008-2009, there were 2323 incident/accident reports filed. This is a decrease of 9% from 2007-2008. For the 2009-2010, there were 1934 incidents/accidents reported . This is a 17% decrease from 2008-2009. One of the main reasons for this decrease was the closure of the long-term unit on April 1st, 2009. Finally, for the 2010-2011, there were 1791 incidents/accidents reported . This is a 9.5% decrease from 2009-2010.

Quality and Risk Management Activities at SMHC

• Annual Symposium on Quality and Research: For the past 12 years, SMHC has celebrated collaboration between quality and research through a symposium featuring quality projects and research conducted at SMHC.

• Patient Safety Week: Every year, SMHC celebrates Patient Safety Week to mark the importance of patient safety in the care we provide at SMHC.

• Human Factor and Patient Safety Training: For the past four years, SMHC has trained over 100 staff in the importance of human factors in patient safety. Through this training staff are provided with essentials on communication, teamwork, situational awareness, and reporting incidents-accidents in order to analyze and improve the quality of care we give to our patients.

• Risk Inventory Monitoring System: Annually, SMHC monitor 21 risks where specific reporting mechanisms and tracking of quality improvements are conducted.

• Failure Modes and Effects Analysis (FMEA): SMHC conducts annually a FMEA of one of its processes. An FMEA helps to identify processes, the ways they may fail, and improve on processes that are more at risk of failing. This is done prospectively and takes into account the risk, severity, and frequency of the failure.

For more information, please contact:

Marc Pineault
Quality and Risk Management Department

514-345-3511 extension 6586