The Process of Procedure Implementation

The overall quality approach consists of coordinating and harmonizing practices by sharing knowledge and skills in all the hospital's areas of expertise.

The Coordination of the Quality, Safety and Environment is ensured by a body formed of the General Director, the Quality Director, the Director of Medical Affairs and the Director of Nursing.

This body verifies the collection of relevant and validated data in order to have indicators covering the allocated resources and structures, the care and support processes and the results of clinical and non-clinical domains, while respecting the confidentiality of personal data.

Data collection and analysis are carried out by commissions composed of multidisciplinary qualified people in each of the areas of Quality, Safety and Environment protection.

These commissions develop quality and patient safety management programs and plans.

The return on experience conducted in the management review allows sharing results and data to prioritize quality and patient safety management projects, develop the strategic and operational plan and set up improvement processes.

Commissions Activities

In order to standardize their approach, the activities of the commissions, each in its area of expertise, can be summarized as follows:

Identify – Analyze – Organize – Promote Actions – Monitor and Evaluate

commission activities


Around a hundred professionals, coordinators and members use their expertise to ensure excellent quality of service and optimal patient safety through the development of specific programs and indicators, valuable tools for constant improvement in the quality of care.

The Quality Department ensures all the elements relating to the coordination of the Quality, Safety and Environment committees.

Complaints and Claims Management Commission

o Program to improve the satisfaction and experience of patients and professionals

o Mediation program

Risk Management and Professional Practices Assessment Commissions

o Prevention of pressure ulcers and risk associated with damage to the integrity of the skin

o Prevention of falls for patients during hospitalization

o Prevention of transfusion accidents

o Pain relief

o Fight against deep vein thrombosis

Nosocomial Infections Commission

o Program to prevent the transmission of pulmonary, manual, urinary infections, etc.

o Antibiotic prophylaxis program

o Reserved antibiotic therapy program

o Communicable disease prevention program

Morbidity and Mortality Review Commission

o Health care risk management program

o Clinical course program

Occupational Health and Safety Commission

o Vaccination program

o Chemical agent handling protection program

o Program for the prevention of blood exposure accidents

o Workplace violence prevention program

Equipment and Building Safety Commission

o Waste management program

o Fire prevention program

o Radiation protection program

o Equipment and building maintenance program

Operating Room Commission

o Patient Safety Program in the Operating Room

Patient Record Commission

o Patient record computerization program

o Patient rights protection program


Medicines and Sterile Medical Devices Commission

o Medication errors prevention program

o Prevention program for adverse drug reactions

o Prevention program for adverse effects related to sterile medical devices

Multidisciplinary Consultation Review

o Pulmonology

o Palliative care

o Digestive pathology

o Hematology


o Gynecology, ...

Organ Donation Commission

o Organ donation awareness program