The Niagara Health System’s Quality Reporting Framework serves to co-ordinate quality monitoring and reporting of information to continuously improve and enhance patient care and to meet Accreditation Canada standards. The NHS has adopted the Accreditation Canada definition of quality which is “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”.

This quality framework serves as the foundation for quality improvement throughout the NHS. The quality improvement system includes:

• Selecting areas to monitor and improve, and setting priorities
• Developing an annual quality improvement work plan
• Involving appropriate stakeholders and assigning responsibility
• Having programs/teams monitor care and service
• Monitoring and evaluating progress in completing the work plan
• Communicating the results of activities and improvements to various stakeholders as necessary.

This corporate framework provides focus and strategic alliances for all departments and services supporting quality care.

Quality Improvement Monitoring & Reporting Structure

The quality improvement monitoring and reporting structure is a series of linked committees and support departments responsible to the Senior Executive Team, Medical Advisory Committee and the Niagara Health System Board of Trustees. The co-ordinating and connecting link within the structure is the primary role of the Quality Council.

Reporting to the Quality Council on matters of quality are a wide range of committees and programs. Through a series of reports and continuous monitoring of indicators, the structure allows the NHS to maintain a continuous cycle of quality improvement and to ensure Accreditation Canada expectations of a quality system are met.

The teams/committees organizing Quality Improvement activities, and reporting to the Quality Council are:

• Quality Committee of the Board
• Quality/Risk/Patient Safety Committee
• Infection Prevention and Control Committee
• Pharmacy & Therapeutics Committee
• Accreditation Steering Committee
• Program Accreditation Teams
• Diagnostic Imaging, Laboratory & Pharmacy Departments
• Risk Management & Patient Safety
• Interprofessional Practice Advisory Committee
• Nursing Professional Practice Committee
• Nursing Professional Development Committee
• Decision Support Team
• Utilization Management Team