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Our quality commitment to you

As part of Health PEI's commitment to safe, high-quality patient care, the health system has a quality improvement activity process that is supported by the Health Services Act legislation. The purpose of a quality review is to look at the situation identified and make improvements so that the system is safer.

Not all complaints require a formal review.  When there is an incident or expression of concern related to patient care that requires a quality review, the process below is followed:

  • First, a meeting occurs with the patient and/or family members to discuss the situation.

  • When the Executive Director responsible for the area of care determines a quality review is required, a quality improvement committee is formed to carry out the review.

  • The committee meets with individuals involved, selected experts, and others who can contribute to the analysis of the situation.

  • To support a culture of learning and openness, conversations that are part of the review are confidential so that those involved are free to have discussion without fear that the information will be used against them. Research shows this is an important component of these reviews. Information and knowledge received from these conversations will be used to improve quality and increase patient safety. For this reason, details of the reviews will not be made public. This is similar to the approach used in other areas of the country.

  • The Quality/Risk Coordinator is responsible for completing a report based on the results of the review, including recommendations for improvement. Recommendations are based on many things, such as:

    • input from front line individuals involved in the incident and from patient/family to identify areas for improvement

    • use of leading best practice evidence from other sites

    • current clinical standards adopted by groups such as physicians, nurses, medical directors, chief nursing officers, allied health professionals and in some instances, external experts

    • prior knowledge obtained from previous incident reviews and other jurisdictions

  • The Executive Director with responsibility for the area of care involved will receive the report and sign to accept responsibility for implementing the recommendations. The Quality/Risk Coordinator is responsible for monitoring to ensure recommendations are carried out.


Last, and most importantly, recommendations for improvement are discussed in private with patient and/or family members. Due to patient confidentiality and the confidentiality of reviews, information about the patient involved or details related to the review will not be made public.
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