Quality & Safety
Fraser Health Authority is committed to delivering the highest quality of care, while keeping patient safety at the forefront. In this section of the website, you will find a variety of useful links and resources relating to physician orientation and learning summaries.

Health Authority Medical Advisory Committee

The Board of the Directors appoints a Health Authority Medical Advisory Committee (HAMAC).

The HAMAC makes recommendations to the Board of Directors with respect to cancellation, suspension, restriction, non-renewal, or maintenance of the appointments and privileges of all members of the medical staff to practice within the facilities and programs operated by the Fraser Health Authority.

HAMAC provides advice to the Board of Directors and to the CEO on:
  • the provision of medical care within the facilities and programs operated by the Fraser Health Authority
  • the monitoring of the quality and effectiveness of medical care provided within the facilities and programs operated by the Fraser Health Authority
  • the adequacy of medical staff resources
  • the continuing education of the members of the medical staff
  • planning goals for meeting the medical care needs of the population served by the Fraser Health Authority
  • the availability and adequacy of resources to provide appropriate patient care in the Fraser Health Authority


  • the HAMAC recommends chairs and members of standing committees to the Board and HAMAC ensures these committees function effectively including recording minutes of meetings
  • the HAMAC makes recommendations to the Board of Directors on the development, maintenance and updating of medical staff rules, policies and procedures pertaining to medical care provided within facilities and programs operated by the Fraser Health Authority
  • the HAMAC advises on matters pertaining to clinical organization, medical technology, and other relevant medical administrative matters
  • the HAMAC reviews recommendations from the HAMAC Credentials and Privileges Committee concerning the appointment and review of medical staff members including the delineation of clinical and procedural privileges
  • the HAMAC makes recommendations to the Board of Directors concerning the appointment and review of medical staff
  • the HAMAC makes recommendations to the Board of Directors regarding disciplinary measures for violation of Bylaws, Rules or policies of the medical staff.
  • the HAMAC may require a member of the medical staff to appear before the committee whenever necessary to carry out its duties.
  • the HAMAC receives, reviews and provides advice on reports from quality review bodies and committees concerning the evaluation of the clinical practice of members of the medical staff
  • the HAMAC reviews recommendations concerning the establishment and maintenance of professional standards in programs funded and operated by the Health Authority in compliance with all relevant legislation, Bylaws, Rules, and policies of the medical staff
  • the HAMAC submits regular reports to the Board of Directors and the CEO on the quality, effectiveness and availability of medical care provided, in relation to professional standards, in facilities and programs operated by the Health Authority
  • the HAMAC makes recommendations where appropriate concerning the quality of medical care in the Health Authority
  • the HAMAC makes recommendations where appropriate concerning the availability and adequacy of resources to provide appropriate patient care in the Health Authority
  • the HAMAC reviews reports regarding human resource requirements required to meet the medical, dental, midwifery and nurse practitioner needs of the population served by the Fraser Health Authority and following the review provides advice to the Board of Directors and the CEO
  • the HAMAC reviews and reports on any concerns related to the professional and ethical conduct of physicians to the Board of Directors, and, where appropriate, reports those concerns to the appropriate regulatory College
  • the HAMAC advises on and assists with the development of formally structured ongoing programs in continuing medical education and orientation and refresher training of medical staff
  • the HAMAC advises on and assists with programs in continuing education of other health care providers in the facilities and programs operated by the Health Authority
  • the HAMAC advises on, and makes recommendations concerning, the teaching and research role of the health authority
  • the HAMAC advises on and assists with the development of formally structured ongoing programs in physician health and wellbeing


The membership of HAMAC shall be described in Medical Staff Rules, and shall include representation from the following areas:

  • members of the medical staff who have been appointed to medical leadership positions within the Health Authority
  • members of the medical staff who have been elected by the medical staff of the Health Authority
  • the Chief Medical Health Officer of the Health Authority
  • the Vice President Medicine of the Health Authority, who shall provide secretariat services to the HAMAC
  • the CEO of the Health Authority, who shall be a non-voting member
  • other senior administrative or medical staff of the Health Authority as appropriate, in a non-voting capacity

The Chair and Vice-Chair of the HAMAC are appointed by the Board of Directors after considering the recommendation of the HAMAC

The Chair and Vice-Chair of HAMAC will be selected from among the members of the Active Medical Staff.

The Chair of the HAMAC is appointed for a term of not more than three years and may be reappointed for up to three consecutive terms.

The Chair or Vice-Chair of HAMAC shall provide a report to the Board of Directors and to the CEO on a regular basis. The Chair or Vice-Chair of HAMAC shall attend meetings of the Board of Directors, and the appropriate committee of the Board, to participate in discussion pertaining to the purposes identified for the HAMAC under Purpose.

Quality Agenda

Health Authorities are responsible for ensuring the quality of care and services within their catchment area. The Board of Directors of the Health Authority is ultimately accountable for the quality of care in and provision of appropriate resources to the facilities and programs operated by the Health Authority. This includes having systems in place to monitor and report on the “quality agenda”. One important facet of the larger Fraser Health Authority (FHA) quality agenda is engagement of medical staff in quality management activity. It is important to recognize and understand how the interdependent relationships between the Board of Directors (of the HA), administration, medical staff, clinical staff and patients advances the quality agenda.

The Medical Staff in Quality Agenda

The FHA Medical Staff Organization exists as means for the Board to apply its statutory authority to all members of the medical, dental, midwifery and allied health professions who are granted permits by the Board to practice their disciplines within FHA, and to maintain and support the rights and privileges of the Medical Staff as provided herein.

The purpose of Medical Staff Organization is to:

  • ensure all members thereof are aligned with the FHA quality agenda - the provision of high quality patient care, and
  • provide advice to the Board in order to achieve the quality agenda and strategic directions of FHA.

HAMAC Representing the Medical Staff in the Quality Agenda

The Medical Staff Organization fulfils this purpose through the (Health Authority) Medical Advisory Committee (HAMAC). On behalf of the medical staff and through representation from the Regional (Medical) Departments, acute care sites and Medical Staff Associations, HAMAC is responsible to meet the statutory obligations of the Medical Staff Organization.

HAMAC is required to:

  • act in an advisory capacity to the FHA Board of Directors;
  • be accountable for the quality of medical care provided in the programs and facilities of FHA;
  • assist in providing adequate and appropriate documentation for the purpose of maintaining a health record for each patient;
  • participate in relevant activities such as: quality improvement; risk assessment and management; resource utilization; education and research; program development and evaluation; and
  • promote a high level of professional performance by medical staff.

Medical Staff Committees

  • Medicine RDMQC
  • Abbotsford Regional Hospital and Cancer Centre Medicine Quality Committee
  • Burnaby Hospital Medicine Quality Committee
  • Delta Hospital Medicine Quality Committee 
  • Eagle Ridge Hospital Medicine Quality Committee
  • Royal Columbian Hospital Clinical Teaching Unit Medicine Quality Committee
  • Surrey Memorial Hospital Short Stay Unit Medicine Quality Committee 
  • Division of Endocrinology Quality Committee 
  • Division of Gastroenterology Quality Committee 
  • Division of General Internal Medicine Quality Committee 
  • Division of Infectious Disease Quality Committee
  • Division of Nephrology Quality Committee 
  • Division of Neurology Quality Committee 
  • Division of Oncology Quality Committee 
  • Division of Rehab Medicine & Physiatry Quality Committee 
  • Division of Respirology Quality Committee


  • Jim Pattison Outpatient Care and Surgical Centre
  • Delta Hospital
  • Abbotsford Regional Hospital
  • Burnaby Hospital
  • Chilliwack General Hospital
  • Peace Arch Hospital
  • Ridge Meadows Hospital/Surrey Memorial Hospital
  • Langley Memorial Hospital
  • Royal Columbian Hospital


OR Safety, Patient Safety and Learning Summaries

OR Safety

Culture of Safety in the Surgical Suite

A new culture of safety in the operating rooms has developed over the last 5 years. The aim is to improve safety for patients and staff. In adopting this new culture, Fraser Health has established the following components:

1. Site Marking 

Where surgery is to be performed on one side of the body (inguinal hernia surgery, amputation), site marking is done by the surgeon in the preoperative holding area.

2. Surgical Safety Checklist 

The FHA Surgical Safety Checklist is based on WHO checklist. All FH operating rooms have the Checklist mounted on the wall. Surgeons and operating room personnel are expected to conduct all 3 phases for each operation:

  • Pre-induction
  • Pre-incision
  • Debriefing

Combined with the surgical pause and site marking, the checklist has been shown to reduce medical errors and improve engagement and morale of the nursing staff.

3. Patient Warming 

To reduce the risk of surgical site infection efforts are directed at keeping the patient warm before, during, and after surgery. Patients should arrive in the PACU with a core temperature of at least 36 degrees.

4. Neutral Zone 

The frequency of penetrating injuries suffered by nurses and surgeons can be reduced by using a designated area (neutral zone) between the scrub nurse and the surgeon for exchange of sharp instruments. Contact your Head of Department (local) or Regional Division Head for information.

Blood and Body Fluids

Assistance for Medical Staff Exposed to Blood or Body Fluids

Blood and Body Fluids

Policy, protocol, and a team of Occupational Health Nursing professionals are in place to provide assistance to medical staff who have been exposed to blood or body fluids.

Fraser Health provides immediate clinical remediation and ongoing post-exposure follow-up to any member of the medical staff, including physicians, nurse practitioners, midwives, and dentists. Letting the experts guide you will keep you on a well-established path to peace of mind, and allow you to avoid frustrating tangles with confidentiality issues.

To access these services and ensure that policies and protocols are followed, it is essential that you take the steps outlined below. For ease of reference, we suggest you print the Blood and Body Fluid Exposure Journal for Medical Staff (BBF Journal) - a handy reference document to get the process started right, and make note of instructions and information provided to you.


Inform the Manager/designate of the department or unit where the exposure occurred so they can initiate Source patient testing. Then go to Emergency as soon as possible and absolutely within two hours of the exposure.

The immediacy is important for several reasons: 

  • A baseline blood test is needed to establish your health status at the time of exposure. If you do contract an illness, clearly linking it to the exposure incident will help with any future claims or benefits entitlement.
  • The ability to assess the subject patient can diminish rapidly. If they leave the site for whatever reason, it may be impossible to locate and test them within an appropriate timeframe.
  • If the exposure has the potential to be high-risk, such as HIV, antiretroviral medications needs to be administered within two hours of exposure.
  • Your presence in Emergency starts the Workplace Health tracking process – when you are triaged in emergency identify yourself as Fraser Health Physician/Medical Staff and the established protocol will ensure that the Workplace Health Occupational Health Nursing team will receive your results so they can reach out to you for post-exposure follow-up.

Contact the Provincial Workplace Health Contact Centre (PWHCC) – Occupational Health Nursing team at 1-866-922-9464, select option one.

  • Waiting on your blood work results following an occupational blood or body fluid exposure can be stressful. Contact the PWHCC to discuss your exposure details and get a receive guidance from an Occupational Health Nurse.
  • The Contact Centre is staffed 7 days a week, 7 a.m. to 6 p.m. You can leave a voice mail message at any time. Be sure to provide both your name and contact phone number for a call back.
  • An Occupational Health Nurse will explain everything you need to do, and how they will help you monitor and remediate.

File a report with WorkSafe BC

  • As “independents,” all medical staff (with rare exception) are required by BC law to establish and maintain coverage with WorkSafe BC. This means you must also report all incidents.
  • While Fraser Health will provide any prophylactic treatment indicated, should you become ill and/or unable to work, you may be entitled to WorkSafe BC insurance benefits.
  • Call WorkSafe BC at 1-888-967-5377 for more information.

Follow instructions given

At each of the above encounters, you’ll be given instructions and there may be a few complexities.

  • If you, the person exposed, are the MRP for the patient who was the source of the exposure, an alternative MRP will be sought for ordering source blood work. You only need to focus on being the patient following the exposure and report to the nearest emergency room for blood work.
  • In the case of WorkSafe BC you are likely the employer and the employee, so you may need to submit two reports.

Step 1 - Go to Emergency as soon as possible and absolutely within two hours of the exposure

Step 2 - Call Workplace Health at 1-866-922-9464, select option one to speak with an Occupational Health Nurse, or leave a message. Now open seven days a week between 7 a.m. to 6 p.m.

Step 3 - Call WorkSafe BC at 1-888-967-5377 to report your occupational exposure

Step 4 - Follow instructions from Emergency, Occupational Health Nurses, and WorkSafe BC

Medication Reconciliation

  • Medication reconciliation is a formal, systematic process in which healthcare professionals partner with patients to ensure accurate and complete transfer of medication information at transitions of care.
  • Medication Reconciliation is based on the premise that "An up-to-date and accurate medication list is essential to safe prescribing in any setting".1
  • It is an Accreditation Canada ROP (required organizational practice).2
  • Research indicates that over 50% of patients have at least one medication discrepancy upon admission to hospital, with many discrepancies carrying the potential to cause adverse health effects.4,6
  • Over half of medication errors occur at the interfaces of care.3

For information regarding implementation of medication reconciliation initiatives at Fraser Health, contact the Fraser Health MedRec Team:

.Med Rec Facilitators


1. Safer Healthcare Now! Getting Started Kit: Medication Reconciliation version 3.0

2. Accreditation Canada Required Organizations Practices 2013

3. Rozich JD, Resar RK. Medication Safety: One Organization’s Approach to the Challenge. J Clin Outcomes Manage 2001; 8(10):27-34

4. Cornish P.L., et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005; 16: 414-429.

5. World Health Organization. Assuring Medication Accuracy at Transitions of Care; Medication Reconciliation. Patient Safety Solutions, Volume 1, Solution 6, May 2007

Related Links

QIPS Physician Orientation


These education modules provide an initial introduction to the concepts of Quality Improvement and Patient Safety (QIPS) for new Fraser Health Physicians/new Fraser Health Employees. They are intended to foster personal behaviours that support Fraser Health’s quality and safety culture and improvement initiatives.

At the completion of the modules, you will be able to:

  • access the Fraser Health processes that help you to react when patient harm occurs
  • describe the reasons for healthcare’s emphasis on quality and patient safety strategies and creation of a patient safety culture
  • support the mechanisms Fraser Health is using to improve patient outcomes, foster a culture of quality and patient safety, and prevent patient harm.

Please let us know what you think of your QIPS Orientation by completing our brief online survey here:

QIPS Physician Orientation Survey

Module 1: Introduction to Quality & Patient Safety

Quality in Healthcare - Everyone's Business

Quality is…

“Meeting the needs and exceeding the expectations of those we serve; delivering all and only the care that the patient and the family needs.” - Institute for Healthcare Improvement

"The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." - Institute of Medicine

Welcome to Fraser Health. You are joining a work environment that values the quality of care and service we provide to our patients, residents, clients and their families, and continually strives to make improvements.

The patient, resident and client must always be the centre of our concern; recognition of their experience, and their perceptions of the quality they receive, are fundamental to improving what we do for them.

For the purposes of these online modules, ‘patient’ refers collectively to ‘patient, client and resident’.

The Fraser Health Board expects all staff, physicians and volunteers to integrate quality improvement and patient safety principles into every day health care and service delivery.

Required Review - Patients, Clients, and Residents Safety Policy (PDF)


  • What if patients were as safe in our care as they are at home (safety)?
  • What if all care was based on best-known science (effectiveness)?
  • What if patient values helped guide all clinical decisions (patient-centredness)?
  • What if waiting was not a normal part of getting and giving care (timeliness)?
  • What if we never wasted supplies, equipment, time, energy or ideas (efficiency)?
  • What if care did not vary in quality because of personal characteristics (equity)?
  • What if all health care workers loved their jobs (workforce vitality)?
  • What if all health care students learned that quality improvement is their responsibility (professional education)?

Dr. Don Berwick, CEO, Institute for Healthcare Improvement

Some simple questions to ask yourself:


  • Who are our patients?
  • How do we know what they want, need and prefer?
  • What are their perceptions of the service they receive?


  • Are we doing the right things?
  • Are we doing things right?
  • How safe are patients in our system?
  • How do we know?
  • How can we be certain that we do things right the first time, every time?


  • Do we have a systematic process for improvements?
  • Do we have accountability for improvements?
  • How do we know we are making a difference?
  • Do we promote leadership by example to foster change?
  • Do we learn from other industries?
  • Do we foster sustainability and spread of learnings and innovation?

All improvement is change

All change is not improvement

Medical Errors account for more deaths than accidents and AIDS combined - Professor James Reason

The first step to a safer healthcare system is to acknowledge that the current system poses many risks that are preventable. Patients enter the health care system for care, but sometimes they are harmed in ways unrelated to their original condition or illness. For example, a patient might acquire an infection or fall while in hospital. It is estimated that approximately 3% of Canadian inpatients experience one or more preventable events. While most patients recover, they often experience complications and their length of stay is longer; a small percentage of patients die or have permanent disability. Fraser Health is estimated to have 435 preventable deaths annually in acute care (Canadian Adverse Events Study, 2004).

Managing Patient Safety – James Reason

The culture of safety “…that exists in most health care organizations is weak compared to other high risk, complex businesses such as the airline, petroleum and nuclear power industries.” Most airline pilots believe they make mistakes, so the airline industry designs its equipment and processes to mitigate these. In healthcare, only 30% of providers believe they make mistakes. (Laura Adams, Faculty, Institute for Healthcare Improvement, 2005 and IHI Online Learning Program Module, Q101, 2010) Fraser Health is committed to reducing the likelihood of harmful events and designing systems of care to be as safe and reliable as possible. No matter what role you have in health care, patient safety is everyone’s responsibility.

When a process has:

the probability that every person completes that one step, every time is:

1 step 95%
25 steps Falls to 28%
100 steps Falls to 0.6%

- Laura Adams, Faculty, Institute for Healthcare Improvement, 2005

Health care is complex. If we want to ensure reliable practices in healthcare, we need to simplify the number and complexity of the steps in the care we deliver. A stable process in health care typically is 40% to 70% reliable. Other high-risk, complex industries strive for 99% and higher.

Healthcare needs a range of strategies to improve reliability:

  • information
  • education
  • rules and double checking
  • checklists protocols and pre-printed orders
  • automation and computerization and
  • forcing functions which do not allow the incorrect action to be taken (E.g. dosing ranges for medications delivered by infusion pumps can be pre-programmed so that a harmful dose cannot be delivered; oxygen and medical air hoses that attach to anaesthetic machines are fitted with different coupling joints so they cannot be mixed up).

It is critical to understand what matters most to our patients, and to appreciate their health care experience. In honouring this principle and demonstrating our Values of ‘Respect, Caring and Trust’, Fraser Health continuously seeks their feedback in order to:

  • challenge the assumptions we tend to make as healthcare providers; for example, clinicians may believe they have done a good job in meeting the patient’s needs for treatment or pain management, but of equal importance to patients is information and emotional support
  • identify our strengths and areas for improvement
  • understand the impact of service changes on patients
  • incorporate the patient’s experience in improvements

Fraser Health obtains ongoing and periodic feedback from patients through:

  • complaints and compliments
  • patient experience surveys (national, provincial, regional, program, area)
  • patient councils and advisory committees, and
  • interviews and focus groups to discuss specific topics.

The BC Ministry of Health views patient feedback as essential – it requires all Health Authorities to conduct ongoing BC Patient Experience Surveys, in various sectors, such as acute care, residential care and emergency services.

Fraser Health has many policies, processes and protocols that reflect a valued, respectful relationship with our patients, such as consent for health care, complaint management, privacy policies, and disclosure.

You can do your part by:

Keeping 'patients first': Putting yourself into your patient’s shoes and listening to his/her stories keeps us focused on how patients experience our relationship with them.

Taking pride in what you do: “The kind of pride I’m talking about is not the arrogant puffed-up kind: it’s just the whole idea of caring – fiercely caring.” (Red Aurbach, Professional Basketball Coach).

“Speaking Up”: Be alert to the potential for harm. ‘Looking’ does not always mean ‘Seeing’ – ask yourself what you might be missing. Question and report unsafe practices. Discuss these openly so they can be addressed promptly – you may save someone’s life or prevent them from being harmed in our care. Identify opportunities to improve - sometimes the small things can make a big difference to the quality and safety of care. Share your improvement ideas with your team - every idea counts.

Meeting standards and increasing reliability: Make yourself aware of the standards and processes of care for your practice or area, and commit to consistently meeting these.

Fostering patient self responsibility: Provide the education and support to enable patients to assume responsibility for their well-being.

Holding yourself accountable: What will you do to become more aware and improve patient safety in your office or work setting?

Module 2: Improving Outcomes & Preventing Harm

Evidence shows the administration of prophylactic antibiotics within 60 minutes of surgery results in fewer post surgical infections.

Research has confirmed the appropriate and effective care for patients with certain conditions, in order to impact health outcomes. Yet, such evidence-based care often is not well integrated into daily care. There exists a gap in what we know and what we do.

For example, the Canadian Diabetes Association has established guidelines for pressure control less than 130/80 mmHg and A1C less than or equal to 7.0% (Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada). In general, health care is not able to attain this consistently for even 80% of patients, let alone reach 99% and higher, the level attained by highly reliable organizations in other industries.

In many instances practitioners genuinely believe they are providing evidence-based care for most of their patients. Until it is measured, practitioners are often unaware of the gap between what we know should be in place and what is actually in place. For example, many practitioners expect PharmaNet, which is a record of prescriptions filled, to list the medications an individual is regularly taking, so that a medication history need not be verified. At one Fraser Health site, staff discovered PharmaNet was only 30% accurate in outlining what medications patients were regularly taking (Bruchet, Davidson, Buchkowsky, 2006). Data collection helps inform decision making i.e. patient safety indicators, performance scorecards.

You play an important role in implementing evidence-based practice, through:

Risk Assessment to identify risks and mitigate risks before incidents occur or a patient is harmed.

Standardization and Integration of care processes across programs, sectors and sites i.e. Care Policies, Care Protocols, Care Paths or Care Guidelines such as: prophylactic antibiotics to prevent surgical infections, hand hygiene guidelines, limited access to concentrated medications, diabetes protocols, stroke protocols, least restraint policies, Code Yellow, safety checklists.

Pre-approved Order Sets which outline the medical orders to support timely interdisciplinary management for a given diagnosis, high volume or high risk situation, in order to reduce practitioner variation and standardize care e.g. post-surgical procedures, emergency care for cardiac patients, weaning from ventilator care.

Reduction of waste and inefficiencies

Identification of successful innovations and spread elsewhere.

In today’s complex healthcare industry, safety, or patient harm, is of particular concern. Fraser Health is working in alignment with a wide variety of organizations (Safer Healthcare Now!, Institute of Safe Medication Practices - Canada, Canadian Patient Safety Institute, Accreditation Canada, BC Patient Safety and Quality Council) to focus on the following themes:

  • Culture of Safety
  • Infection Control
  • Medication Safety
  • Safer Systems for Patient Care
Maturity of Safety Culture Characteristics
Level 1 Why waste our time on safety?
Level 2 We do something when we have an incident

Level 3

We have systems in place to manage all like risks
Level 4 We are always on the alert for risks that might emerge
Level 5 Risk management is an integral part of everything we do

- Adapted from The Manchester Patient Safety Framework (MaPSaF ) Kirk et al, QSHC, 2007

Every workplace generates its own culture of quality and safety - shared ways of thinking and behaving that lead to ‘norms’ for that setting.

A desirable culture of safety occurs when: 

  • No patient is harmed due to their interaction with health care;
  • No family experiences the pain and frustration of caring for a loved one who is harmed;
  • The organization acknowledges the risk and error-prone nature of health care, promotes open disclosure and fosters reporting, open communication and learning from adverse events in a just and trusting environment;
  • No provider thinks that reporting an adverse event will compromise their career;
  • Health care providers assume shared accountability with the organization to actively seek potentially harmful situations and take action to address these before harm occurs.

(Adapted from CPSI, Building the Foundation for a Safer Health System, Strategic Business Plan 2004/05to 2007/08 and BC Patient Safety and Quality Council website statement, 2010)

Fraser Health has a number of mechanisms to foster a culture of safety, including its integrated approach to risk management. Take a moment to think about the characteristics of the culture in your office practice or work setting.

Required Review - FHA Integrated Risk Management Policy (PDF)

“Moving from a culture of safety to inculcating safety as a core value of who people are within the organization…requires behavioral and cultural changes. Patient safety goals are not recited from a card each year, but become intrinsic to what everyone within the organization does. Not only do they own it and question it, they demand it from their co-workers, as well.”

- Interview with Dr. Daniel Salinas, Senior Vice President and Chief Medical Officer, Children's Healthcare of Atlanta, January 2010, Zero is a Real Number: The Children's Journey to Excellence in Paediatric Quality Outcomes, National Initiative for Children’s Healthcare Quality Forum

Embedding a culture of safety into daily work is essential to supporting staff and contributing to a safe environment for our patients. Each of us contributes to the culture by applying patient safety knowledge, skills and attitudes to our daily work (CPSI Background document to The Safety Competencies, Aug. 2009).

Engaging all members of the healthcare team as valuable sources for system improvement when patient harm occurs is pivotal to creating a culture of quality and safety.

Many patient safety events occur due to a chain of events; a series of individual system failures, each of which might not be significant, but when they are not caught before they reach the patient might align to cause an adverse effect.

Many patient safety events occur due to a chain of events. If the event results in patient harm it is considered an ‘adverse event’; if it does not, it is considered a ‘near miss’. An adverse event can happen anytime, to anyone. If you happen to be at the end of the chain, it can happen to you.

Fraser Health acknowledges this, and is actively involved in creating a ‘culture of safety’:

  • improving the system that people work in
  • creating an environment that is both just and trusting when reporting and reviewing harmful events, and
  • shifting from the traditional ‘blame and shame’ approach to harm (‘who did this and why did they do it?’) to a learning approach (‘what conditions were present that made it possible for harm to occur?’).

You have an important role to play:

  • Expect that harm might occur and identify potentially harmful situations in the system before harm does occur (‘near misses’ and ‘good catches’).
  • Attend to the little problems to prevent a more significant problem further down the chain.
  • Identify ways to mitigate errors before they reach the patient or result in patient harm (keep antidotes close at hand, standardize processes, train via simulation, control access to high-risk medications, etc.).
  • Support your co-workers and avoid blame – seek to understand the system causes for the harm.
  • Simplify and strengthen your communication; avoid multiple entries for communication, clearly communicate information at hand-offs (shift changes and on transfers), do not use confusing or unsafe abbreviations.
  • Cooperate with other clinicians – it’s in the patient’s best interest.
  • Avoid reliance on memory and ‘trying harder’ – create resilience in the system through the use of checklists, simple protocols, double-checks for high risk activities.
  • Participate in improvements to care.

If you are interested in viewing the related videos "Beyond Blame" or "Delivering Patient Safety", contact Quality Improvement and Patient Safety at 604-535-4500 extension 757755.

When harm occurs or a complaint is expressed, we need to listen and support the patient, family and practitioners involved, and take steps to understand the patient’s experience. As a health care system, we need to report, study and learn from patient harm when it occurs, in order to make the healthcare system safer.

You can do your part:

Partner with patients : encourage and listen to your patients’ stories; include patient experiences when planning improvements

Hold regular team safety huddles and conversations that focus on barriers to patient safety in the care delivery setting;

Report harm or ‘near-misses’ so that concerns can be followed-up for an individual patient, and the system causes of harm and near-misses can be reviewed and trends identified;

Physicians - Patient Safety Learning Summaries and Morbidity and Mortality Rounds provide a rich source of information.

See Module ‘ What To Do When Harm Occurs .’

Patient outcomes are highly dependent on safe, collaborative, patient-centred team practices. Effective teamwork and communication are essential for preventing things from going wrong. Patients are vulnerable especially during transition points in their care (shift changes, transfers between levels of care, etc.) and due to communication gaps or multiple entries causing confusion. Many patient/family complaints are due to ineffective communication.

What are the characteristics of strong, high performing interdisciplinary teams?

  • They view their work as serving patients’ needs.
  • They assist patients to engage in decision-making and appropriately direct their own care.
  • They commit to shared objectives, clear roles and responsibilities, and interdependent decision-making. To ensure continuity of care, they effectively communicate pertinent patient information across teams and, when necessary, across organizations.

(Adapted from CPSI Safety Competencies Framework, 2009)

On average, it takes 133 staff members to care for one acute care patient. The complexity of your working environment makes it essential to work and communicate cooperatively as teams. Effective communication, both within teams and between the healthcare team and patients, is founded on trust, caring and respect. Key elements are the use of diplomacy and tact, as well as respect for the wisdom patients and providers bring to health care. Disrespectful communication is detrimental to everyone, whether you receive it or witness it. Fraser Health has developed the “Keep it Real” program to assist staff in creating effective relationships.



A concise statement of the problem

What is going on now?



Brief information related to the situation
What has happened? 



Analysis and consideration of options
What you found / think is going on? 



Request / recommend action
What do you want done? 

S ituation, B ackground, A ssessment, R ecommendation

SBAR is a concise communication technique to increase clarity, enhance communication and foster positive relationships amongst health care providers and with patients and families.

CHAT is a similar approach ( C urrent Condition, H istory, A ssessment, and T reatment).

Leadership Walkabouts and Safety Huddles are unit-based opportunities to discuss patient safety concerns in a supportive environment. They help to identify issues early, before problems become bigger and before they cause harm to patients. Please make a note now to ask your Medical Director or Supervisor about how this is done in your area.

Fraser Health regularly uses a variety of industry and professional standards, such as:

  • General healthcare standards including minimal standards for patient safety - Accreditation Canada
  • Medication Safety - Institute for Safe Medication Practices (ISMP - Canada)
  • Hand Hygiene – Canadian Centre for Disease Control
  • Medical Imaging and Laboratory standards - Diagnostic Accreditation Program
  • International Organization for Standardization (ISO) standards.

Staff are expected to know the standards of care for their area and for their profession. Ask your Supervisor or Medical Director for more information.

Two key areas of risk for patients are acquired infections and medication safety. Standards for medication safety focus on:

  • clear labelling
  • controlled access to and protocols for high risk medications
  • clear communication patient responsibility for knowing which medications are taken and how.


Patient poster for your practice – What’s on Your Medication List?

Ask Me – template for patient personal medication list (available in English, Chinese, French, Punjabi)

All staff, physicians and volunteers are expected to do your part to reduce the rate of infection and keep patients safe by performing regular Hand Hygiene:

  • Before touching a patient
  • Before clean/aseptic procedures
  • After a procedure or body fluid exposure risk
  • After touching a patient / patient’s environment
  • Before and after glove use.

A. Alcohol Based Hand Rub (ABHR):

  • Is quicker than using soap and water
  • Is more accessible than soap and water as is not dependent on sink location
  • Provides emollients that reduce skin irritation
  • Is effective in reducing organisms on hands.

Correct technique for ABHR:

  • Apply a loonie size amount of ABHR in the palm of dry hands
  • Spread the ABHR to cover all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
  • Rub nail beds against the opposite palm
  • Rub hands together for 15-20 seconds until dry.

B. Soap and Water is required:

  • When hands are visibly soiled
  • When caring for patients with diarrhea
  • After 5 to 6 applications of an alcohol based hand rub to remove residual emollients.

Correct technique for Hand Hygiene with Soap and Water:

  • Wet hands with water
  • Apply an adequate amount of appropriate soap
  • Use friction to wash all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
  • Rub nail beds against the opposite palm
  • Wash for 15-20 seconds
  • Rinse thoroughly with a steady flow of warm water
  • Dry hands with clean paper towels
  • Use paper towels to turn off taps
  • Discard paper towel.

Use Routine Practices to reduce the rate of infections:

  • Gloves:for contact with body fluids, mucous membranes and non-intact skin
  • Facial protection (mask & protective eyewear): when spraying of body fluids is likely or for providing care for patients with respiratory symptoms
  • Gown: worn when contamination of clothing is possible

Use other mechanisms to reduce the rate of infection:

  • Antibiotic stewardship
  • Environmental cleaning and housekeeping services
  • Appropriate use of Personal Protective Equipment (PPE) and isolation precautions
  • Reprocessing standards and guidelines
  • Surveillance reports and trends for infection rates
  • Audits and feedback reports – hand hygiene, reprocessing, bed pans cleaning practices, etc.
  • Bed accommodation algorithm
  • Construction/renovation planning and support
  • Mandatory reporting of communicable disease to Public Health.

For more information: Infection Prevention and Control Practitioners 604 587-4455 

Module 3: What to Do When Harm Occurs

A story of a health system failure and hope for the future. Esther was a vibrant woman who entered Fraser Health for elective surgery. Despite her best attempts to communicate her risk factors, the system’s gaps, in design, communication and assessment of an elderly individual, resulted in a chain of small system failures and her subsequent death.

Unfortunately, on occasion a patient does have a complaint or experiences harm unrelated to the natural progression of the disease or condition.

When this occurs, Fraser Health’s first priority is to ensure no further immediate harm occurs, as well as support the patient, their family and the staff involved. Then, it is critical for physicians, staff and volunteers to report patient safety events (harm and near-misses) and complaints as promptly as possible, in order to:

  • manage the situation in a timely way,
  • determine whether the harm is preventable and
  • identify issues and solutions in order to prevent their recurrence.

You are expected to:

  • report Complaints and Patient Safety Events as they occur (see next topic,"Reporting Harm")
  • participate in review follow-up if required to do so by your Medical Director or Supervisor.


Disclosure is “the process by which an adverse event is communicated to the patient by healthcare providers”

- Canadian Disclosure Guidelines, Canadian Patient Safety Institute, 2008

Disclosure of harm facilitates open, honest communication with our patients and families when something goes wrong. Transparent discussion enables the health care team to meet the patient’s immediate care needs as well as support the physical and emotional healing related to the adverse event. Disclosure addresses a range of events from ‘near harm’ to ‘actual harm’.

Required Review

Fraser Health Disclosure Policy (PDF)

Adverse events: Disclosure - Canadian Medical Protective Association

BCPSQC Pamphlet: Conversations when things go wrong/Information for Patients (PDF)

Fraser Health values complaints as ‘gifts’ to provide insight into the harm patients and their families experience due to unmet expectations. This sharing of concerns provides perspective to focus our improvements as well as improve relationships between patients and the health care team. Complaints cause us to challenge the assumptions we tend to make as healthcare providers regarding the issues of significant concern to our patients and their families.

All staff, physicians and volunteers are expected to report and address patient complaints when these occur, so that the issue is resolved as soon as possible for that person:

  • Staff and volunteers - report through your Manager, for local resolution, and then to the Patient Care Quality Office.
  • Physicians - report through your Program Medical Director.

The BC Ministry of Health requires each Health Authority to provide a Patient Care Quality Office for patients to voice the concerns that cannot be resolved at the point of care:

Patient Care Quality Office
32900 Marshall Road, Abbotsford, BC, V2S 0C2
Toll free: 1-877-880-8823
Fax: 604-854-2120
Email: pcqoffice@fraserhealth.ca

Click here to download poster for your office

Required Review

Complaints Management Policy (PDF)

All physicians, staff and volunteers are expected to report patient harm or near-misses (patient safety events) that occur in a Fraser Health site or service, using one of the two established systems (accessible only through the Fraser Health intranet):

  • Patient Safety Learning System (PSLS) – a web-based mechanism for reporting events and near misses (available in all acute care sites – April 2010)
  • ENCON – an alternate mechanism for reporting events used in parts of the health region which do not have access to PSLS (currently being phased out as PSLS is implemented).

Reporting provides the opportunity to learn from these events, identify trends and determine priorities for improvements, through Patient Safety Event Aggregate Reviews, Physician Patient Safety Learning Summaries and Morbidity and Mortality Rounds.


Quality Improvement and Patient Safety Consultants 

Required Review - Fraser Health Patient Safety Incident Management Policy (available on FH Pulse)


Module 4: Making Improvements

"Every system is perfectly designed to achieve the results it achieves...we can put competent providers into a (problematic) system, and the system will win every time... Therefore, if you want new levels of performance, you must change how the system works.”

- Institute for Healthcare Improvement,CEO, Dr. Donald Berwick

1. Improvement focuses on closing the gap between:

  • what we know (the scientific evidence and what we know about our patients) and
  • what we do - what practices actually occur and how much inappropriate variation and practitioner preference occurs.

2. In order to make changes, you need to create the will and test ideas that will embed and sustain the desired change in daily routines.

3. Quality Improvement requires a systematic approach to plan the strategy and measurable goal, test ideas, gather data and develop strategies to sustain and spread the learnings. The team should include a triad of champions: clinical experts, operational leaders and process experts.

4. Every change has both a social and technical aspect. “Technical performance depends on the knowledge and judgement used in arriving at the appropriate strategies of care and on skill in implementing those strategies. The goodness of technical performance is judged in comparison with the best in practice…known or believed to produce the greatest improvement in health…the interpersonal process is the vehicle by which technical care is implemented and on which its success depends. Therefore, the management of the interpersonal process is to a large degree tailored to the achievement of success in technical care.” (Dr. Avedis Donabedian, 1988)

Whenever you have an improvement idea, discuss it with your colleagues or Director/Manager/Supervisor. The ‘ Model for Improvement ’ (Institute for Healthcare Improvement) is a helpful tool.


Quality Improvement and Patient Safety Consultants

  • Maintain your focus on the patient; listen to their stories and experiences.
  • Base changes on evidence and data; confirm what you know and what you don’t know.
  • Involve providers of care as the expert clinicians.
  • Assess the potential for harm.
  • Be clear about the outcome you want to achieve and how the changes you make in processes (the way you do things) and resources (staff, equipment, budget, supplies, etc.) will affect this. If you want a certain outcome, ask yourself what processes will support it? If you want to put a certain process into place, ask yourself what resources are needed?
  • Set an ambitious Aim with clear, measurable targets for performance – what is in the best interests of your patient? A clear Aim will shape provider practices.
  • Health care is complex. Testing is almost always needed prior to implementation.
  • Measure at two levels. As you test, use simple measures to assess whether your efforts are moving you in the right direction toward your Aim. Also measure the impact – whether you are achieving your Aim.
  • Look for ways to increase the reliability of your process; standardize your approach and reduce variation in practices. Remove practitioner preference as the key reason for a change, or the reason to continue an existing process.
  • Consider how humans work in their environment (science of human factors).
  • Keep it simple – simplify processes and follow simple rules.
  • Remove waste and inefficiencies.


Quality Improvement and Patient

BC Medical Quality Initiative (BC MQI)

The BC Medical Quality Initiative (BC MQI) is a provincial collaborating committee with representatives from the health authorities, the College of Physicians and Surgeons of BC, the Ministry of Health, the BC Patient Safety & Quality Council and the BC Medical Association.

Learn more


A physician, midwife, dentist or nurse practitioner must have an appointment to the Fraser Health Medical Staff prior to practising in a FH hospital.

Credentialing & Privileging

All processes for Fraser Health credentialing and privileging are managed under Medical Affairs by a central Credentialing Office, in the Office of the Vice President Medicine. They are part of an ongoing process of confirming licensure, insurance and assessing competence.  These processes are defined in accordance with the Medical Staff Bylaws and Rules.


An application will be provided for appointment to the Medical Staff following a prescribed Search and Selection process, as described in the Medical Staff Rules, when a vacancy exists.  Vacancies are determined by a Program, Regional Department or Regional Division. 

Applications for appointment to the medical staff are requested through the appropriate Medical Leader of a Regional Department.  

Credentialing is the processes of screening and evaluating a providers qualifications and experience including licensure with a regulatory body, education, training, experience, reputation and malpractice insurance.

Privileging is the process used to define the clinical activities and procedures performed as part of the providers’ role in the department of a specific facility.

An appointment does not entitle Medical Staff to perform procedures or treat patients. The ability to engage in these activities is defined by the clinical privileges granted.

Privileges are defined and requested through the provincial privileging dictionaries, for all medical staff applying to or holding privileges in any BC Health Authority.  The dictionaries are based on the providers specialty certification or supplementary area of practice, and outline the practice objectives and standards within each.  These dictionaries support the standardization of privileging across the province and enhance patient safety through defined practice parameters.

You can view the Provincial Privileging Dictionaries or provide feedback on a specific dictionary through the BC Medical Quality Initiative (BCMQI) website.


Medical Staff members must renew their membership with Fraser Health (annually for Temporary or Locum Tenens staff, triennially for permanent categories) and undergo review by their Medical Leader(s) through the reappointment process. 

Regular assessment of medical staff competence is a critical component to promote the continuous provision of high quality care to patients.

Questions regarding credentialing and privileging?

Contact CredentialsOffice@fraserhealth.ca

Questions regarding BC registration and licensure?

College of Physicians & Surgeons of BC - Physician's Area

BC College of Nurses & Midwives

College of Dental Surgeons of BC


Credentials Office Staff

Name Assigned Department(s) or Role Phone
Alana Donnelly
  • Surgery
  • Geriatric Medicine
Brenda Ogren
  • Family Practice
  • Palliative Medicine

Cindy L. Dawson

  • Medicine
  • Critical Care




Debbie Provost
  • Anesthesiology
  • Cardiac Services
  • Addictions Medicine & Substance Use Services
  • Mental Health & Psychiatry
Endang Prabawati 
  • Lab Medicine and Pathology
  • Obstetrics & Gynecology
  • Pediatrics
Fatima Rahiem
  • Emergency Medicine
  • Nurse Practitioners
Melinda Skwarok
  • Administrative Assistant 
  • Reappointment Support
Michelle Kumar
  • Medical Imaging
  • Hospital Medicine



Sarah Gusan Manager, Credentialing & Privileging Operations 236-632-7359
For all other credentials-related requests or questions, please email credentials.office@fraserhealth.ca


SSC Funded Quality and Engagement


SSC and various BC health authorities have partnered together with a goal to increase physician and medical staff engagement across the province.

Programs supported by SSC  include:

• Physician Quality Improvement training. Recruitment ongoing. 
• Health System Redesign Funding
• Sauder Physician Leadership Program
• Facility Based Engagement Initiative
• Physician Leadership and QI Scholarship
• Advisory Board Talent Development Program

Contact PhysicianQI@fraserhealth.ca for more information

Are you passionate about Quality Improvement? Have you identified an area in your Fraser Health workplace that could use QI?

Watch the video to learn more.



To work in collaboration with BC health authorities to enhance physician capacity by providing training and hands-on experience on quality improvement projects ultimately promoting a culture of learning, openness and dedication to quality improvement in the health care system.

Here’s how PQI can help:

  • Teach you the key principles and techniques about QI, Leadership and Change Management.
  • Support your QI activities with dedicated technical staff.
  • Ensure your project receives strong support and oversight from the Joint Steering Committee which includes representation from senior leaders of FHA, MAC, SSC.


Fraser Health PQI offers three levels of training:

LEVEL 1 - IHI Open School Access (Email physicianQI@fraserhealth.ca for enrollment)

LEVEL 2 - PQI Fundamentals | 2022 Poster 

LEVEL 3 - PQI Certificate 

To learn if PQI is right for you, please read: Getting Started with Quality Improvement

If you are interested in learning more about PQI, please contact physicianQI@fraserhealth.ca. Recruitment ongoing.

PQI ANNUAL Summaries:

Physician Engagement in Health System Redesign Funding

The Health System Redesign (HSR) initiative was established to facilitate physician leadership and engagement in the redesign and/or quality improvement of health services provided by the health authorities. Funding for the Health System Redesign initiative is provided jointly by the Specialist Services, Shared Care, and General Practice Services Committees. The goal of HSR funding is to ensure that physicians are engaged and have the opportunity to participate in planning, decision making and implementation of new or revised health services, in a manner that contributes to alignment across the health system, and reflects the application of the IHI Triple Aim Improvement Framework.

Fraser Health Priorities

  1. Projects must align with Health System Focus and Priorities of the Ministry of Health (Responding and Recovering from COVID-19 Pandemic, Commitment to Indigenous Health and Reconciliation and Performance Planning).
  2. Highest Priority given to projects aligned with 2023/24 Fraser Health Objectives and Key Results (OKRs)
  3. Projects must align with Fraser Health Strategic Priorities (Patient Experience, Provider Experience, Healthy People and Communities or Create Value)
  4. Projects supported by Senior Clinical Leadership Committee (SCLC) members and approved by Executive (where applicable).

Please note, funding is for the purpose of physician engagement (sessions) only and cannot be used to pay for program administration, staff-related positions, ongoing medical leadership roles or ongoing committee/working groups activities.

If “Health System Redesign” funding was approved for a project in Fiscal Year 2022/23, a new application must be completed and submitted for Fiscal Year 2023/24.

Key Points about HSR funding:

  • Projects driven from the Fraser Health Executive and Senior Clinical Leadership Committee (SCLC) as funding intended to support meaningful physician engagement in Fraser Health priorities.
  • Annual call for applications sent to SCLC and three-year funding cycle to March 31, 2025 (aligned with anticipated PMA renegotiation term).
  • Most projects typically lead by senior physician leaders and/or clinical leaders.
  • Funding only eligible to be applied to physician sessional payments to engage physicians in redesign activities (see HSR Criteria Memo).
  • Download the HSR application word document before submitting to SharePoint 
  • Applications may be submitted at any time – ‘rolling application’ no deadline; approval subject to funding availability. 
  • HSR Steering Committee meetings are held every third Tuesday of the month, however applications must be submitted two weeks prior to the meeting to be considered (E.g., if the next meeting is Sept 20, 2022, applications must be submitted by Sept 6, 2022).
  • Pre-approved OKR funding memo 

Additional Context and Project Successess

  • Historically, projects have had difficulty with anticipated physician participation and projects underutilize approved funding with only 30-40 per cent of the annual budget utilized.
  • In 2018-2019, the HSR Steering Committee implemented a strategy to over-allocate budget and increased monitoring/tracking of budget utilization in order to maximize physician engagement in projects. (Physician participation/engagement increased 24 projects in 2018-19 compared to less than 12 in prior years since 2010). Budget utilization increased 103 per cent in 2018/19 and 115 per cent 2019/20.
  • $721,306.37 funding is available for 2023/24
  • Project evaluation reports for completed 2018-19 – 2022/23 projects available upon request.
  • Project Summaries and contact info (see HSR Projects)

Applications may be submitted online at http://fhworkspaces/projects/SystemRedesign  (accessible only through a Fraser Health computer).

If you have any questions, please contact Jag Sandhu, Leader, Specialist Services Committee Initiatives at jag.sandhu@fraserhealth.ca or 604-613-2042.

The Physician Leadership Program through the Sauder School of Business Executive Education has been developed in partnership with B.C. Health Authorities, B.C. Patient Safety Quality Council and UBC Faculty of Medicine. This program is available to physicians only. Funding for this program is provided by SSC and participation is endorsed by Fraser Health.

Cohort 20 Dates

  • Module 1 - September 7-9, 2023 (In person at UBC Robson Square)
  • Module 2 - October 12-14, 2023 (Virtual)
  • Module 3 - November 23-25, 2023 (Virtual)
  • Module 4 - March 8, 2024 (Virtual)

If you are interested in developing your leadership skills, please contact Jag Sandhu as soon as possible in order to secure your seat.

View informational brochure here.


Provided by the SSC and endorsed by FHA, physicians within the health authority can access up to $10,000 annually for tuition and travel costs in order to develop leadership and QI skills. Potential training programs include, but are not limited to, Six Sigma, Quality Academy, and Physician Leadership Institute (formerly PMI).

Please contact Jag.Sandhu@fraserhealth.ca or view the Leadership Training Scholarship website here for more information.