Quality assurance

The HSC, as a large medical institution, made use of a variety of committees and practices to review quality assurance issues, such as patient care and patient outcomes. The following list outlines the main committees that were or might have been expected to become involved in the events of 1994.

Quality Assurance Committee

The HSC had a Quality Assurance Committee that was required to meet at least four times a year. The members were appointed by the board and included the Chairman of the Medical Staff Council. Non-voting members of the committee include the President and three vice-presidents.

The committee was charged with ensuring that:

• A quality assurance program was established and met the requirements as set out in the Canadian Council on Hospital Accreditation Standards Manual;
• Standards for patient care delivery were defined;
• Established standards were appropriately monitored;
• Quality assurance activities were recorded and outcomes reported; and
• Adequate resources were allocated to undertake the activities of the program.

The committee was required to report monthly to the board. The quality assurance program was meant to deal with broad issues on a retrospective basis, rather than deal with specific problems in specific units.

Morbidity and Mortality (M & M) Rounds

Morbidity and Mortality Rounds were meetings at which incidents, particularly deaths, would be given a detailed review. Pediatric cardiac surgery Morbidity and Mortality Rounds were to be conducted once a month to address surgical issues. The meetings were open to everyone in the hospital in addition to the surgical team and other professionals involved in the case. The CVT surgery section also conducted its own monthly M & M Rounds.

Incident reports

When there was an untoward event at the HSC, according to the bylaws of the hospital, staff members who had been involved in the event, witnessed the event or were advised that it had taken place were under an obligation to report the event by completing an incident report.

An incident was defined in the HSC Corporate Policy and Procedure Manual as:

a patient care-related or non-patient care-related event which:

2.1.1 is normally not anticipated under usual circumstances and may adversely affect patient care, the provision of service, or the assets or reputation of the centre; or

2.1.2 has the potential to result in litigation. (Exhibit 107)

If the incident involved a patient, it was to be documented in the patient's HSC medical record, along with a description of the injury and the treatment. The incident report itself, however, did not become part of the patient's hospital record. Departments were expected to develop lists of reportable incidents and categorize them as being of Minor or No Consequence, Moderate Consequence or Major Consequence.

Staff were expected to take immediate remedial action, report the event to the appropriate supervisor and then fill out an incident report. This could be a general incident report, a medication discrepancy incident report, a fire and false alarm report, or a security incident report.

Supervisors were expected to investigate the incident and take the appropriate follow-up measures. Department heads were to be informed of incidents with major consequences and incident report forms were to be forwarded to department heads.

Department heads were required to take steps to prevent the recurrence of such incidents and to contact any other departments that were involved in the incident. In the case of incidents with major consequences, the department head was expected to notify the appropriate vice-president. In the case of patient-care related incidents, the head was expected to provide a copy of the report to the director of the Medical Information Department. The director of medical information was then responsible for notifying the Health Sciences Centre insurance adjuster and the hospital's legal counsel, securing the medical records, co-ordinating meetings, collecting information, photocopying records and corresponding with relevant parties.

There was no requirement to inform the patient or the patient's family that such a report had been filed or to provide them with a copy of the report. The patient or patient's family might be informed that an incident report had been filed. A copy of the incident report was not kept as a part of the patient's chart.