Quality Improvement for
Boards & Executives

Local Health District and Specialty Health Network Boards play a key role in ensuring care is safe and harm is reduced, by the questions they ask about the organisation's commitment and core values to patient safety.

Measurement for Quality Improvement
for Boards & Executives

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Seven Key Questions

Board members and Executives can identify gaps in their safety culture and work to improve it by answering seven key questions:

Question 1: Does everyone understand the importance of patient safety?

A clear and explicit view of patient safety is the foundation for setting goals and standards. Patient safety is everyone’s responsibility and everyone needs to understand what it means for them.


Question 2: Do we really have an open and fair culture?

Staff are less likely to report errors or raise safety concerns if they are punished or blamed. Most errors are as a consequence of weaknesses in the system which then affect the performance of the individuals within that system.


Question 3: Are we actively encouraging reporting of incidents?

Organisations that report more incidents usually have a better and more effective safety culture. We can’t learn and improve if we don’t know what the problems are.

  • LHD & SHN Patient Safety Incident Management Notifications

Question 4: Do we get the right information?

Learning from all sources of data together provides an organisation with a true reflection of where things are going wrong and what is needed to prevent minor incidents from becoming more major and serious incidents.

  • Local incident & harm data
  • Key performance indicators
  • Patient experience feedback
  • Staff engagement feedback

Question 5: Are we always open when things go wrong?

Communicating effectively with patients and their carers is a vital part of dealing with errors or problems in their treatment.


Question 6: Do we learn from patient safety incidents?

The response system is always more important than the reporting system. A robust methodology should be in place to ensure incidents are thoroughly investigated so that all contributing factors and root causes are identified and any recommendations are implemented successfully.

  • Trending themes from SAC1 and SAC2 incidents
  • Regular review of all LHD/SHN patient safety incidents
  • Sharing good practice across facilities
  • Morbidity & Mortality meetings

Question 7: Are we actively implementing recommendations and safety alerts?

A resilient organisation strives to continuously improve safety practices rather than being content to keep one step ahead of regulatory sanctions. It is vital to learn lessons from outside the organisation as well as from local information.

Adapted from the NHS National Patient Safety Agency's "Questions are the answer? Seven questions every board member should ask about patient safety" under the UK's Open Government Licence v3.0. Available from http://www.npsa.nhs.uk/nrls/reporting/seven-questions-every-board-member-should-ask-about-patient-safety/