73 Development and implementation of a quality management system in a university medical center

Abstract

Introduction An hospital organization operates in a dynamic environment and has to deal with internal and external factors. To provide good quality and efficient and effective care, continuous quality improvement is essential. 1 2 Continuous improvement, based on the Plan-Do-Check-Act (PDSA) cycle of Deming, is needed to assure continuity of the organization.In our hospital, several different systems e.g. document management system (2013) and incident reporting form (2015) were used to collect data from different sources. However, there was a lack of overview of which hospital-wide quality improvement projects were being undertaken. Improvement measures were not properly followed up, resulting in a lack of implementation hospital-wide. The goal of this project was to develop an integrated quality management system hospital-wide which could be used to both identify improvement measures and ensure that the PDSA cycle was completed.Methods To realize structure, coherence and easy accessibility of information, a quality management system (QMS) was implemented to identify potential improvement measures originating from various sources e.g., incident reporting, registration of complaints by patients, results of audits, sentinel events. A project group was established, included professionals with extensive experience in relevant areas, such as nurses and complaint officers. The focus was on further implementation of different sources and to evaluate the document management system, incident reporting form and follow-up improvement measures.Results The QMS was extended with a follow-up improvement measures (2019), patient complaint reporting (2023), and internal audit reporting (2024) to bring improvement measures and signals together. The incident reporting form and the form for registration of follow-up improvement measures were optimized in 2023 and reimplemented. The integrated dashboards in the QMS reduced the need for manual compilation of results at both central and departmental levels and ensures that the PDSA cycle is completed. The six-month post-implementation evaluation of adapted incident reporting form and follow-up improvement measures showed that the changes were well integrated into day-to-day practice.Conclusion A hospital-wide overview of various sources is available which provides information required to identify hospital-wide improvement potential and can support management at all levels. A single QMS provide overall insight and prevent departments from working on their own and from ‘reinventing the wheel’. The next step is to incorporate a risk management tool to incorporate signals form other sources but which can also be applied to reduce risks.References Jonker E, Koopman C, van der Nagel N, Schoorl M. An integrated quality management system for healthcare. The Open Medicine Journal 2017;4(1).Claessens F, Castro EM, Seys D, Brouwers J, Van Wilder A, Jans A, Vanhaecht K. Sustainable quality management in hospitals: The experiences of healthcare quality managers. Health Services Management Research 2025;38(1):50–57.

Authors 2

1. Astrid Haenen-Zijlmans Aachen Department of Quality and Patient Safety

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Quality and Patient Safety, Leiden University Medical Centre, The Netherlands

2. Anja H. Brunsveld‐Reinders Aachen Department of Quality and Patient Safety

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Quality and Patient Safety, Leiden University Medical Centre, The Netherlands