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Introduction: The Department of Emergency Medicine (DEM) quality assurance and peer review program was established in 2015 and has been successful in formalizing the quality assurance. A gap existed in the translation of identification of gaps to translation to quality improvement and process improvement projects. Quality management systems document processes, procedures, responsibilities for achieving quality policies and objectives. They’re designed with a purpose to enhance the quality of care delivered to patients. Methods: Beginning in January 2023, the DEM operations team performed a needs assessment and analysis of current state and accounting for growth opportunities in a future state regarding development of a quality management system. Key needs included incorporating the pillars of quality assurance, quality improvement and quality control while creating a culture of safety. The goal was to design a framework to address the inter-relationship of quality assurance, quality improvement and patient safety whilst maintain robust quality control. Results: Development of a framework for quality management. To achieve the 3 identified pillars a new committee was formed: Quality Improvement and Patient Safety (Qu.I.P.S) Committee to complement and drive the quality improvement and patient safety efforts in the DEM. Conclusions: The development of a departmental quality management effort addressing quality assurance, quality improvement and patient safety is feasible. Other departments across the hospital may use this framework to develop local structures.

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Henry Ford Health


Detroit, Michigan


Quality Expo, posters, poster competition

Project #59: Framework for building a departmental quality and safety program



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