1. A Governance Framework for Quality and Patient Safety John Sweeney, CEO

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6. 6 Organisations that fail?

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8. “There is a fundamental and worrying deficit in our health system - namely the ability to implement system-wide learning from adverse events across the system in a timely and appropriate manner in order to prevent the recurrence of patient safety events that may cause harm, or worse, to patients.” Phelim Quinn, HIQA Director of Regulation, 2013 8

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10. 10 Quality and Safety Framework Incident Management Complaints Management Process Management Risk Management Audit and Regulatory Management Key Performance Indicators

11. 11 Incident Management

13. 13 Incident Management The Incident The Escalation The Trends – All Incidents? Complications – Returns The So What Factor The Learning – PA’s

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15. 15 Complaints Management

16. 16 Process Management

18. 18 Governance Demonstration Out of Date Approval – Accountability Communication Regulatory – Best Practice Audit Requirements Process Management

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21. 21 Risk Management

22. 22 Demonstrable Accountability The Schedule Proactive – Quality The Tracking - QIPs No Single Point – Regulation The Learning Audit and Regulatory Management

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24. 24 Key Performance Indicators

25. 25 Quality and Safety Framework Incident Management Complaints Management Process Management Risk Management Audit and Regulatory Management Key Performance Indicators