Healthcare Quality Program

The St. Mary’s General Hospital and the Grand River Hospital face challenges in improving quality and safety standards in line with the quality benchmarks and national standards developed in Canada. Even though they have adhered to some standards such as creating quality committees to monitor safety and quality standards, they have failed in other important criteria such as reporting critical incidents to the medical advisory committee (Cestnik & Sharma, 2012).  The staff in both hospitals has also not changed their mindsets to support quality improvement initiatives. This paper will evaluate the safety and quality cultures at the St. Mary’s General Hospital and the Grand River Hospital, and develop recommendations on how both facilities can attain quality outcomes. 

Data analysis against benchmarks and national standards

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In the development of national standards of patient safety, the Canadian Patient safety Institute was created with the goal of enhancing improvements in patient quality and safety. It attains this objective through developing evidence-based best practice, measurement of results, supporting research, nurturing partnerships, promoting communication and celebrating successes (Cestnik & Sharma, 2012). It has implemented several programs and projects such as ‘Safer Healthcare Now!’, which develops resources and tools for use by clinicians to improve healthcare quality and safety. 

Moreover, there are certain regulatory standards that are enforced by Canada through legislation, which promote patient safety. One of these is Bill No. 46 which requires hospitals to create quality committees that report to the hospital board.  The bill also requires hospitals to undertake surveys on patients annually and employees bi-annually regarding their view on the quality of care offered. Moreover, the bill requires hospitals to remunerate executives based on whether quality improvement plans were achieved. Another national standard is the Regulation 156 which requires the reporting of critical incidents to the medical advisory committee (Cestnik & Sharma, 2012). These are incidents where unintended events caused serious injury, harm, disability or death to patients. 

Additionally, the Ontario Health and Long Term Care Ministry implemented a funding model that is patient-centered over a course of three years. Its goals were to improve patient wait times and access, evidence based care, healthcare quality, and cost containment. Moreover, the funding was allocated to each Ontario resident based on their age, socioeconomic status, sex, clinical group and geography. The resultant funding comprising of 70% of the funds were allocated based on quality outcomes to community care access centers, hospitals and long term care homes (Cestnik & Sharma, 2012). This form of funding was expected to enhance quality, sustainability and appropriateness of care given to patients and the general healthcare system.

The Grand River Hospital developed quality frameworks that include a patient safety and quality committee, clinical programs and services councils and a senior quality team to enforce accountability for safety and quality within the hospital (Cestnik & Sharma, 2012). This move is consistent with national standards and adheres to Bill No. 46 which requires hospitals to enforce quality committees that monitor adherence to patient safety and quality. The hospital committee evaluates dimensions of safety and quality that include appropriateness of care, access to care, patient experience with care and safety of care. These roles not only conform to Bill No. 46 of the Canadian legislation, but they are also consistent with the goals of the Canadian Patient safety Institute and other government programs that seek to enhance patient quality and safety. 

The St. Mary’s General Hospital sought to become the most effective and safety hospital in Canada that features qualities such as compassion, innovation and respect & St. Mary’s General Hospital. It has partnered with the management science researchers from Waterloo University to conduct deep analysis of the outcomes and actions by the hospital. It also applies management concepts such as lean management to attain continuous improvement (Cestnik & Sharma, 2012). According to Hines et al. (2004), lean management entails improving efficiency and eliminating wastage in each part of a process to attain continuous improvement. It also celebrates employee efforts to create a safety culture, which is consistent with the goals of Canadian Patient safety Institute, of celebrating successes when quality and safety outcomes are achieved. 

Moreover, both hospitals have not yet attained a safety culture from the frontline to administration levels, and this has affected improving quality of care (Cestnik & Sharma, 2012). For instance, they experience poor attendance and underreporting during QCIPA reviews, in violation of Regulation 156 which requires reportage of all critical incidents to the medical advisory committee. Additionally, many physicians question the role of quality improvement initiatives. One of the major challenges facing both hospitals is changing the intangible facets of culture of safety such as the beliefs, attitudes and values that clinicians embrace. The physician behavior and attitude has not changed despite the QCIPA legal protection, legislative requirements, clear positive outcomes and administrative encouragement (Cestnik & Sharma, 2012). Generally, the data available shows that both the St. Mary’s General Hospital and the Grand River Hospital have fallen short of the quality benchmarks and national standards in terms of patient quality and safety. 

Observations about where quality improvements are needed

There are several areas where quality improvement is needed in both the St. Mary’s General Hospital and the Grand River Hospital. The first area is in the organizational culture of both institutions. From the case study, it is clear that physicians and other stakeholders in the facility have not embraced the importance of quality and safety improvements. They have not internalized the need for change, and they have failed to understand why they should implement strategies to enhance patient quality and safety. Unless the stakeholders shift in their mindsets and the organizational culture is tailored towards quality improvement, then any changes that are implemented in the facilities will be unsuccessful. This is because physicians and staff may sabotage the changes or fail to adhere to the new quality and safety standards. 

The second area where quality improvement is needed is in reporting of critical events. Both facilities have violated Regulation 156 with reads to reporting of adverse events facing patients, and they need to embrace reportage so that they can enhance transparency in quality improvement efforts (Cestnik & Sharma, 2012).  Additionally, the hospitals have not adopted a safety culture from the frontline levels to the administration, and this is manifested in poor QCIPA reviews. The hospitals therefore need to implement the quality benchmarks and national standards set out by the Canadian government and organizations such as the Canadian Patient safety Institute.

Goals for initiatives that address those deficiencies/opportunities in quality

The first goal of addressing the deficiencies that have been outlined is to change the organizational culture at both hospitals and motivate clinicians, physicians and staff to embrace quality improvement initiatives. The biggest obstacle towards implementing a culture of safety and quality in both facilities is the lack of stakeholder support for the same (Joshi et al., 2014). If the clinicians, physicians, nurses and other staff do not support the idea of creating a safety culture, then this goal will not be attained.  The St. Mary’s General Hospital and the Grand River Hospital will have achieved a major milestone if they are able to implement organizational change and seek support from stakeholders in implementing patient quality and safety initiatives. 

The second goal is adherence to national standards and quality benchmarks regarding patient safety.  Some of these standards include reporting critical incidents, implementing patient and employee surveys on quality and safety, remunerating executives based on quality outcomes, and integrating evidence-based care in enhancing quality and safety.  Once the St. Mary’s General Hospital and the Grand River Hospital implement these national standards and benchmarks, then they will improve the patient outcomes through minimizing medical errors, improving quality of service offered to patients, and enhancing patient safety by reducing critical incidents during provision of care.

Outcomes that are anticipated in order to accomplish the initiatives

There are certain outcomes that will prove that the hospitals have accomplished their initiative to enhance patient quality and safety. The first will be a positive review from patient and staff assessment on the quality culture. A periodic assessment will be undertaken to evaluate the perceptions that patients and staff have regarding the hospitals’ approach to quality and safety. If the results from the assessment reveal positive feedback, then this outcome will have proved that the facilities have achieved their goals (Wolf & Hughes, 2010). 

The second outcome is the reduction of critical incidents within both hospitals. The goal of improving quality and safety is to reduce the risk of medical errors and critical incidents that place the lives of patients at risk. By achieving the quality and safety goals, then the number of critical incidents will significantly decline (Brennan et al., 2017). 

The third outcome is a positive attitude by stakeholders with regard to the quality and safety initiatives. Currently, clinicians, physicians and other staff at both hospitals do not understand and support the quality and safety standards. However, after the achievement of the change goals, their perceptions will also change and they will be at the forefront in advocating for improvement in quality and safety standards. 

Recommended actions that will attain expected initiatives

There are various recommendations that will help Dr. Sharma to change the organizational culture at the St. Mary’s General Hospital and the Grand River Hospital, and transform both facilities into centers of excellence as far as safety and quality standards are concerned.  The first recommendation is adjusting the organizational structure to increase accountability on metrics associated with quality (Frank & Brien, 2009). The hospitals should include accountability for patient safety within the job description of department heads, and they should be held accountable for critical incidents that occur within their watch. Moreover, the department heads and senior management should also receive remuneration based on the quality metrics they attain, and they should be rewarded for strong performance as far as quality and safety standards are concerned. 

The second recommendation is the implementation of teamwork and communication training for all staff as a means of enhancing quality of service given to patients (Banja, 2014). The hospitals may consider introducing workshops where the communication and teamwork skills by clinicians can be enhanced. The management should also consider funding communication and teamwork courses for essential staff to improve these core skills that directly impact the satisfaction levels by patients.  To further motivate employees, the hospitals should integrate competitions between staff in different departments concerning the quality and safety outcomes attained (Aiken et al., 2002). The department that attains the best outcomes should be rewarded. Moreover, individuals who show exemplary performance with respect to quality and safety should also be acknowledged and rewarded.   

The third recommendation is the introduction of technologies that improve quality of service while minimizing human error. There are various medical technologies that are used in management of hospitals to enhance safety and efficiency. For instance, electronic health records are effective in improving safety and quality by ensuring that the multidisciplinary team treating patients has access to real-time patient information (Zhang et al., 2008). Such a system links stakeholders from physicians to pharmacists to ensure that they use accurate and timely patient information when developing diagnosis and treating patients. This reduces the risk of medical errors and improves patient safety. In addition to technology, the hospitals should integrate evidence-based practice in treatment to ensure that treatment interventions are guided by empirical evidence and best practices in healthcare. 

Appropriate time frames to re-evaluate data and provide a new analysis

In order to evaluate whether organizational change has been successful and the hospitals have attained their quality and safety goals and outcomes, it is imperative to conduct periodic evaluations. Evaluation should be done after every six months since this is a suitable timeframe for implementing the necessary changes such as staff training, changes to the organizational structure, and motivational strategies that include departmental competitions and rewards.  The anticipated outcomes such as positive staff and patient feedback, reduction in critical incidents and changes in organizational culture to embrace quality and safety improvements, should be assessed based on data available. Through assessing the periodic changes, for instance, the number of critical incidents after every six months, the hospitals will be able to ascertain whether they are improving in quality and safety. 

Moreover, if the anticipated outcomes have not been attained after six months, and there is evidence that staff perception on quality improvement has not changed, then the facilities should change strategy and incorporate assistance from healthcare professionals in facilities that have successfully implemented similar changes. Any manager or staff that has resisted change after the six months are over should face disciplinary action, including termination. However, the facilities should focus more on motivating staff to embrace the quality and safety changes as opposed to disciplining staff that resist the changes. It is prudent that the management does not relent on following the established national standards and quality benchmarks since breaching the law may result in legal liability for the hospitals. 


In summary, the St. Mary’s General Hospital and the Grand River Hospital have made positive strides towards improving the quality and safety culture within their organizations. However, they have not attained the national standards and quality benchmarks set out by the law and healthcare regulators. It is imperative that the management implement recommendations that will enable the hospitals to attain the expected goals and desired outcomes from quality improvement. It should implement initiatives such as changing the organizational structure to enhance accountability for healthcare quality and safety, incorporating evidence-based research and technologies that improve patient safety and motivating staff through competitions and rewards that acknowledge individual and group contributions towards improving the quality culture. The management should evaluate the outcomes attained after every six months and it should develop new strategies of improving quality in case the expected outcomes and goals are not attained within this timeframe. 


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