Guidance on how to develop a best practice Quality and Safety Management System

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In today’s rapidly evolving healthcare landscape, the delivery of high-quality health and social care is of paramount importance. To achieve this, healthcare organisations must establish a robust Quality and Safety Management System (QSMS) that ensures consistent excellence in patient / service user care, quality improvement, operational efficiency, and regulatory compliance.

In this blog, we will explore the four key steps to successfully implement a Quality and Safety Management System in a health or social care organisation.

Step 1: Planning for the QSMS

Begin the implementation process by defining a clear vision for quality improvement within your organisation. This involves looking at the governance system, the aims and objectives of the QSMS, the structures in place and the communication pathways. You must also identify the regulations and/or standards that you plan to use as a framework for the QSMS.

Perform a comprehensive Gap Analysis of your organisation’s current quality practices, processes, and systems against the relevant regulations and/or standards. The gap analysis will identify areas of strength and areas that require improvement. When conducting a gap analysis, utilise a triangulation approach consisting of a documentation review, staff interviews and process observation. Engage relevant stakeholders, including quality managers, clinical staff, and administrative personnel, to gain a holistic perspective.

From the gap analysis being completed, an organisation can identify the quality improvement plans (QIPs) that need to be put in place, along with a timeframe and responsibility. Initiate a project team to start looking at evidence-based practice to provide assurances to the governance team and service users.

Step 2: Implementation of the QSMS

When implementing the QSMS framework it is important for a healthcare organisation to take the approach of developing structures, processes, and outcomes.

Step 3: Continuous Review of the QSMS

Once the QSMS has been implemented, the service must establish a robust system for monitoring and oversight of the QSMS. One of the key ways to do this is through internal Quality of Care Auditing. Auditing allows a service to determine if they are doing what they say they should be doing within their agreed policies and procedures. It should be completed on a regular basis, by trained, competent staff. It must be vigorous and review all aspects of a services’ conformance to the regulations, standards and the organisations policies and procedures. Once an audit is completed, the service must look at the findings and identify what action plans need to be implemented to correct any non-conformances and drive quality improvement.

Another important mechanism for monitoring the effectiveness of the QSMS, is through Key Performance Indicators (KPIs).  A healthcare KPI is a specific and measurable element of healthcare that can be used to assess quality and safety of care (HIQA, 2012). The Governance Team must identify and agree what the appropriate KPI’s should be for the service and put in place a structure for the monitoring and reporting of the data to the Governance Team on a monthly basis. Any gaps or changes in the data needs to be interrogated to identify the causes.

Leverage digital health transformation solutions such as HCI’s QualSIPTM to support the collection and analysis of real time key governance, quality and safety data from the Quality Management Information System.

Gathering and reviewing feedback such as service user feedback, complaints and incidents can also provide valuable data for areas for improvement. As can staff surveys such as Staff Survey the Patient Safety Culture of an organisation. This can help understand how staff perceive patient safety within the organisation and identify quality improvement initiatives to support embedded a culture of safety.

Step 4: Continuous Improvement within the QSMS

Developing a best practice QSMS is not a one-time project; it requires a commitment to continuous improvement. Establish oversight mechanisms for ongoing evaluation and review of the QSMS effectiveness. Review data from the QSMS on a regular basis from audits, risks registers, incidents, complaints, service user feedback, training compliance, KPIs and external inspection reports to identify areas for improvement. Implement the appropriate Quality Improvement Plans, with a timeframe and responsible person. Follow up on these to ensure that they are implemented and closed off in a timely manner.


Implementing a Quality and Safety Management System is a crucial step towards achieving excellence in health and social care delivery. By following these four key stages, health and social care organisations can establish a framework that promotes continuous improvement, patient safety, and regulatory compliance. Implementing a QSMS requires strong leadership, staff engagement, and a commitment to fostering a culture of quality and safety.

At HCI we help providers of health and social care make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance. We have almost two decades of experience helping health and social care providers to implement robust Quality and Safety Management Systems.  We support and guide you through the entire process and can provide ongoing, independent quality assurance of the QSMS through our Quality of Care Audit Programme.

If you would like further information on our QSMS support contact HCI at +353 (0)1 629 2559 or email

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