Quality Improvement


The PEFHT QI Committee consists of an enthusiastic group of doctors, nurse practitioners, nurses, and other health professionals and administrative staff who endeavour to share their excitement for quality improvement successes across all of the programs and services offered by the PEFHT. The desire is to provide comprehensive continuous quality improvement processes to ensure a high standard of patient care and consumer satisfaction.

QI Committee projects are based on the priorities, needs and interests of the PEFHT and are consistent with the Health Quality Ontario's described attributes of a high-performing health system; accessible, effective, safe, patient-centred, equitable, efficient, appropriately resourced, integrated and addressing and considering population health as able.


To foster a culture within the PEFHT that encourages and enables individuals, programs, and the organization as a whole to reflect on current practices and observed outcomes, and to engage in continuous quality improvement with priorities of patient safety and ready access to effective, seamless patient-centered care.


To develop an annual quality improvement plan, incorporating the requirements of Health Quality Ontario, in consultation with PEFHT team members, community service partners and patient partners that will:

a) identify certain projects with focused areas for improvement

b) spread the QI methodologies that would allow all health care providers to observe and reflect on areas of their own practice, and help them develop tests of changes in response to their analysis of their observations.


QI Committee membership consists of a QI team leader and members representing a cross-section of the PEFHT, from PEFHT programs/services and primary care practices.

Representation from the following positions/groups is required:

  • PEFHT QI Team Leader
  • Clinical Services Coordinator
  • PEFHT EMR Co-ordinator/Privacy Officer
  • Physician QI Champion
  • Plus selected members and staff from:
  • Primary Care Providers (NPs, MDs)
  • PEFHT Program Staff
  • Doctors’ clinical and office staff

The QI Committee team leader may be appointed independently or chosen by the group from among its members


QI Committee team leader: person with QI experience who can provide guidance to and oversight of thecommittee as well as liaison with PEFHT board

QI Committee chair: work with the team leader to develop and implement meeting agendas; chair meetings; assist with PEFHT board liaison

QI Committee Physician champion: physician with QI experience who can be a resource to the committee, assist with PEFHT board/membership and QHC liaison, where applicable.

Meeting Notes: rotating voluntary assignment

Meeting Schedule:

  • Quarterly meetings of three hours duration
  • Sub Committees as required
  • Annual fall retreat (one day)

Functions of PEFHT QI Committee:

  1. Prepare an annual Quality Improvement Plan for submission to the Ministry of Health and Long-term Care, subject to the approval of the PEFHT board.
  2. Develop an implementation strategy for the QI Plan; oversee the implementation of the QI Plan; troubleshoot any difficulties arising from or impeding the implementation.
  3. Report to the PEFHT board quarterly on current activities and progress with the QI Plan.
  4. Prepare an annual Quality Improvement Report on the preceding year’s activities for presentation to Board of Directors.
  5. Conduct educational activities pertaining to QI: EMR "Tips & Tricks” sessions, break-out sessions at AGM, presentations at PEFHT members’ meetings, etc.
  6. Beyond the individual projects in the QI Plan, review overall outcome measures, input from stakeholders, relevant legislation and Ministry directives to ensure PEFHT’s QI efforts both are responsive to needs of the PEFHT and the community it serves, and provide information helpful to program planning.
  7. Make recommendations for improvements in care, changes in processes and/or policy development within the PEFHT and through our linkages with community agencies and other health care organizations.
2014/15 Quality Improvement Plan for Ontario Primary Care "Improvement Targets and Initiatives"
2015/16 Quality Improvement Plan for Ontario Primary Care "Improvement Targets and Initiatives"
2016/17 Quality Improvement Plan for Ontario Primary Care "Improvement Targets and Initiatives"

PEFHT QI Committee Contact Info:

Dr. Helen Cluett
Sandbanks Medical Centre

Janice Hall
Harbourview Clinic

Sally Cowan

PEFHT Ministry of Health Quality Improvement Plan 2013/2014

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