Medical Quality

Medical Quality describes the contribution of medical staff to the delivery of high quality of care through individual practice, quality improvement, and team-based care.

Explore the links or expand the accordion headings below to learn more about current projects and initiatives that are using quality improvement to improve care.

Interested in learning more about medical quality or finding ways to get involved? Email


Medical quality centers on improving individual provider practices.

Governance of Clinical Improvement

Provider quality is overseen by the Health Authority Medical Quality Committee (HAMQC). HAMQC is responsible for the making recommendations to the Health Authority Medical Advisory Committee (HAMAC) on: (1) Medical Staff Quality Assurance (QA) data and measures; (2) Medical Staff Quality Improvement (QI) initiatives; (3) Development and implementation of Island Health QA/QI programs; and (4) Medical Staff related issues identified by HAMAC that potentially impact the quality of patient care. (Medical Staff Rules). Through Clinical Decision Support and Clinical Analytics, advanced analytical support is provided as identified by the HAMAC.

Reducing Unnecessary Variation in Care – Choosing Wisely Canada

Choosing Wisely is a campaign designed to promote conversations between providers and patients to help both parties choose care that is supported by evidence, free from harm and truly necessary.

With the help of local champions, the Choosing Wisely Canada (CWC) Oversight Committee has tackled all five Level 1 “Quick Wins” and has earned the Level 1 Designation. The committee is currently on the path to achieving Quality Improvement status as we work towards becoming a Choosing Wisely Canada designated hospital. 

For more information on how the CWC Oversight Committee is helping to improve quality and patient care at Island Health or to learn about physician and program led Choosing Wisely projects please visit the Island Health Choosing Wisely page.

Reducing Unnecessary Variation in Care – Sepsis QI Project

The aim of this project is to improve outcomes through standardization of early recognition and management of sepsis at all Island Health facilities.

A review of order sets and clinical care pathways identified variation in the processes for recognition and management of sepsis. This variation in processes, combined with variation in practice confirms an opportunity for standardization of practice and improvement of outcomes.

New and updated clinical order sets, an antibiotic module, algorithm and protocols are available, developed in support of standardization and evidence-based best practice.

Emergency Department, Medicine, Infection Management and Adult ICU Quality Councils are leading this work.

For more information please visit the Island Health Sepsis QI Project page or the Sepsis Resource Centre on the Island Health Intranet. *Island Health login required*. 

Morbidity & Mortality Rounds 

Introducing a new standardized Morbidity & Mortality (M&M) Rounds framework adapted for Island Health by the Health Authority Medical Quality Committee (HAMQC) M&M Rounds Working Group from “The Ottawa M&M Model”.

Visit the Morbidity & Mortality Rounds page to learn more about the new model for rounds at Island Health and for resources on how to present and facilitate M&M rounds including guidance on how to select a case for discussion and what comes next.

If you are interested in learning more about facilitating rounds, please click here.

If you are interested in learning more about presenting rounds, please click here. 

If you are interested in learning more about attending rounds, please click here. 


M&M Rounds – Use the data repository to share your findings.

Already hosting M&M Rounds? Report the findings from your M&M Rounds using the Data Repository. Sharing findings and actions helps prioritize organization-wide change, and spread across the organization.

Click here to upload your bottom line slide. 

*Island Health Login Required*

The M&M Rounds Data Repository works best with Google Chrome, Microsoft Edge or Safari

Provider Profile

The Island Health Provider Profile is an interactive web-based tool for providers at Island Health. The goal of the Provider Profile is to allow individual providers to use Enterprise Data Warehouse data repositories to support them in quality improvement and to inform their practice.

Specific measures relevant to each department and/or division are being identified in collaboration with medical staff, and access to the Provider Profile will be made available by Division as appropriate measures are developed.  The roll out so far includes Pediatrics, Midwifery, Obstetrics, Anesthesia and Hospitalists. Progress is reported through HAMQC.

To learn more about the Provider Profile including details on what’s in scope, rollout, features, and professional development visit the Provider Profile page.

Data Access for Monitoring and Improving the Health System


Looking for data? Have you checked out the Report PORTAL accessible through the Island Health intranet? Site level data available on the Island Health performance dashboard, organizational priorities, patient flow and more.

Island Health launched the Report PORTAL in fall 2020 – an intranet site to share reports with appropriate Island Health intranet users.

The material contained and linked in the Report PORTAL is for internal Island Health use, for work associated with understanding, monitoring, and improving the health system only. Use of this information for research is not permitted. For opportunities related to Research please contact Island Health Research & Capacity

Some reports are available to everyone, others have restricted access depending on your role in the organization. If you think you need access to a particular report, you will be directed to the correct person to connect with. 

You can find Report PORTAL on our intranet at: 

Your Island Health Network login is required to access the site.

Are you looking for reports specific to Quality Improvement? Navigate to Quality Improvement under the Heading ‘Medical Quality’.


Questions about Report PORTAL or access to reports, please contact

Are you looking for help with data?

Want to know what kind of data Island Health can provide? Need access to Island Health data for research or quality improvement?

For specific requests for data, email with a brief description of your project and the data you think you’ll need.

Not sure what data you need and would like to discuss, contact

Want to learn more? Watch this video about the lifecycle of data at Island Health (Island Health login required)

BC Medical Quality Initiative – Medical Staff Practice Enhancement

The BC Medical Quality Initiative (BC MQI) brings health care partners together to develop ways to improve the quality of medical care for people living in BC. 

Medical Staff Practice Enhancement (MSPE) is a project of BCMQI. The focus is quality improvement at an individual practitioner level, including the roll out of multi-source feedback, as one of several practice enhancement tools. A soft launch will begin with pilot sites and departments in 2021. Practice enhancement encompasses the activities that help medical staff to understand, reflect on and improve their practice, in alignment with the British Columbia Medical Quality Improvement Initiative, the Hospital Act and medical staff rules.

Referencing Quality – The Case for Quality and Other Tools for Improvement

Collecting past “The Case for Quality” articles and the future home of medication and documentation improvements, Referencing Quality serves as a library for past news articles shared on the medical staff website to guide improvements in care.

Please email if you have suggested articles for inclusion in this resource library.

Visit the Referencing Quality page for opportunities to learn about improvements for safe patient care.

Past articles are linked below.  


The Case for Quality: Major Hemorrhage Protocol
New: February 7, 2022

The Case for Quality – Medication Errors
New: June 7, 2021

COVID-19 and Order Set Development
New: April 8, 2021

Treatment of procedure-related sepsis

January 14, 2020

How do you know your equipment is sterile?

November 27, 2019


M&M Rounds – Use the data repository to share your findings.

Already hosting M&M Rounds? Report the findings from your M&M Rounds using the Data Repository. Sharing findings and actions helps prioritize organization-wide change, and spread across the organization.

Click here to upload your bottom line slide. 

*Island Health Login Required*

The M&M Rounds Data Repository works best with Google Chrome, Microsoft Edge or Safari

Are you interested in learning more about the difference between Quality Improvement and Research Projects? Click here to learn more about how the Quality Improvement (QI) Ethics Decision Making Tool and Registry can be used to determine whether a proposal is QI or Research.