Quality, Safety & Risk Management Directorate

Description of department/service

Welcome to the Quality, Safety & Risk Management (QSRM) Department in Tallaght University Hospital (TUH). We extend a warm invitation to patients, their families and our healthcare community, to explore and understand the vital role we play in ensuring the highest standards of care and safety within our hospital.

Professor Catherine Wall is the Director of QSRM. We are a team driven by a common purpose. Our mission is to cultivate a comprehensive culture centred on quality, safety and patient well-being throughout the Hospital. Our dedicated team works to promote a culture of patient-centred care, fostering an environment where continuous improvement is not just a goal but an ingrained philosophy.

Our primary aim is to ensure that patient safety remains paramount. Through careful risk assessment and proactive management, we strive to mitigate potential hazards around both patients and staff members. One of the cornerstones of our departments' work is our commitment to learning and growth. Incidents and risks are not merely challenges to overcome; they are opportunities to learn, improve, and evolve. We embrace each situation as a chance to glean insights, refine our practices and bolster our collective knowledge to create a safer and more effective healthcare environment.

We envision a future where excellence in care is not just a standard to uphold, but a way of life deeply ingrained in our hospital's fabric. We are here to foster a culture where quality and safety intertwine seamlessly. As you navigate through our online space, we invite you to explore the initiatives, resources, and insights that embody our quality, safety, and continuous improvement in TUH.  

QSRM Contact

Contact Names/Numbers

Professor Catherine Wall, Director of Quality, Safety & Risk Management.  Tel: (01) 4143677

Frances Ni Fhlannchadha, Risk Management Lead.  Tel: (01) 4143107.  Email: Frances.nifhlannachadha@tuh.ie

Mary Hickey, Quality Lead.  Tel: (01) 4142854. Email: Mary.hickey@tuh.ie

QSRM Strategy

TUH published their first hospital wide Quality, Safety & Risk Management (QSRM) Strategy in 2022, setting out a plan to drive improvements in quality and safety over the course of the next three years. 

The Hospital has actively driven innovation and research in quality & patient safety. The strategy published builds on the strong foundations of quality improvement such as Lean Six Sigma and is linked to important aspects of the Hospital’s strategy plan 2019-2024. It focusses on specify quality goals that are central to achieve excellence in healthcare.

The four goals are to:

  • Deliver person-centred care.
  • Grow our staff and strengthen our quality organisation.
  • Strive for excellence in Quality, Safety & Risk.
  • Support quality assurance processes.

The strategy outlines how, through quality improvement, staff will be supported in their dual roles of performing the job they were trained to do as well as improving the system within a culture that supports research and innovation that focuses on adding value. Commenting on the launch of the strategy Professor Catherine Wall, Director of QSRM and Consultant Nephrologist said “The Hospital is committed to the delivery of effective, safe, person centred care by highly trained and motivated staff as enshrined in our CARE values of Collaboration, Achievement, Respect and Equity. It is recognised that Quality is a shared accountability through the Hospital with everyone having a role to play. This QSRM strategy outlines how we will grow our people and strengthen our quality in order to deliver the best care to our patients.”

Risk & Incident Management Department

Welcome to the Risk and Incident Management Department of TUH. Our team is here to support and empower TUH staff in practicing safe and effective healthcare, fostering a mature and just culture that places patient safety at the forefront of everything that we do.

We are committed to identifying, reporting, and managing safety incidents while nurturing a positive learning environment. Our work extends beyond the Hospital walls as we contribute insights to the broader healthcare system and facilitate the exchange of knowledge and best practices.

Our Mission and Approach

At TUH, safety & risk management is ingrained in our ethos. The Risk & Incident Management Department serves as a pillar to support our staff, ensuring that they are equipped to provide care with confidence. We foster a culture that encourages the identification and reporting of safety incidents, recognising that learning from challenges is the cornerstone of growth and process improvement.

Informing and Sharing Insights

Through analysis, we extract key insights that inform our hospital and contribute to healthcare system improvement efforts. By sharing our findings, we elevate the collective understanding of best practices and lessons learned, further fortifying the foundations of patient-centred care.

Driving Improvement through Review

Central to our mission is the review of safety incidents. We may contact you or your nominated next-of-kin for feedback if we need to review your care. These reviews are guided by the HSE Incident Management Framework (2020) and provide a clear purpose: to identify the facts, understand the root causes and extract lessons that guide us toward preventing similar incidents in the future. Every review follows national policy guidelines, ensuring an open and transparent safety culture that actively contributes to our collective journey of improvement.

Engaging with Patients, Families and Staff

We understand that the most profound insights come from collaboration. The Risk & Incident Management Department is here to actively engage with patients, their relevant person, our staff, and the services we provide. Your perspectives enrich our understanding and enable us to improve care delivery, ensuring that safety remains paramount throughout our patients healthcare journey.

The safety and well-being of patients are our top priorities. If you ever have concerns about your safety or that of a loved one, we encourage you to reach out to the local manager or clinical team as your initial point of contact. For more complex matters please contact the Patient Advice & Liaison Service. Together, we are committed to creating a safer, more informed, and patient-centric healthcare environment.

Contact Us:

Quality Improvement Department

Every day in our hospital, staff undertake complicated tasks to provide patient care. Our quality and patient safety programme provides staff training to ensure that all the steps in the various processes across the organisation link up to provide high quality effective care to our patients.

We are passionate about continuously improving the care we provide. Our journey started in 2002 when we introduced the Six Sigma methodology. At that time we were the only hospital in Ireland using this method to reduce variation in the way we provided care across the hospital. In 2008, we also added the Lean tools and philosophy to reduce waste. The combined Lean Six Sigma approach has been used since then to ensure we provide more reliable systems of providing care to our patients. We have achieved national recognition for the improvements we have made but recognise there is still a lot more to do.

In TUH, there is a culture of learning and innovation. Our department has a number of Quality training programmes to build quality capacity among front line and senior staff, both clinical and non-clinical. These include Process Mapping, Meeting Facilitation Skills, and Change Management Workshops. Our core training takes place in Lean Six Sigma Green Belt training which is data driven and evidence based. Teams agree an area that they want to improve, a project lead attends training and with their team, they complete the project within 120 days. Coaching sessions are provided to assist each project lead in completing their project. A central repository of improvements is maintained and available to all staff. Below is the cycle we follow for each project.

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So how can you help us or get involved?

    • One of the ways to assess our quality service is to ask patients about their experience. Patient Satisfaction Surveys provide us with the information we needs to improve the care provided. We also need to know when things go wrong. We value your contribution.
    • We use co-design/co-delivery as a means by which patients can get actively involved in projects providing their experience and perceptions of the care provided and improvement suggestions. All Lean Six Sigma projects start by collecting the “Voice of the Customer” and translating that from “Critical to Quality”.
    • When you feeling better you might like to be a patient representation on one of our committees.


Contact Us:

Mary Hickey, Quality Improvement Lead telephone (01) 414 2854

Sinead Palmer, Clinical Audit Manager (01) 414 2855

Marie Petiet, Quality & Safety Manager (01) 414 3372

Colette Hoare, Senior Policy Officer (01) 414 4807

Clinical Audit Department

­­­­­­­­­­­About Us

Welcome to the Clinical Audit page of TUH. Clinical audit is not just a process; it's a commitment to raising the bar of patient care. Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.

A clinical audit involves checking that the care provided is of the highest quality and follows best-practice.

The Clinical Audit Cycle

Clinical Audit Cyle image

Why is Clinical Audit Important?

Clinical Audit provides the framework to improve the quality of patient care in a collaborative and systematic way. When clinical audit is conducted well it enables the quality of care to be reviewed objectively within an approach which is supportive, developmental and focused on improvement.

Stages of Clinical Audit

7 stages of clinical audit

Benefits of clinical audit include:

  • Promotes and enables expected practice
  • Provides opportunities for education and training
  • Builds relationships between clinicians, clinical teams, managers and patients
  • Leads to improvements in service delivery and patient outcomes

What our Department offers:

  • Dedicated education sessions for Clinical Audit
  • One to one team support for audit design
  • Electronic register for Clinical Audit
  • Annual Clinical Audit & Quality Improvement Symposium

The information that we hold about you in your patient record may also be reviewed as part of the clinical audit process. This is vital in helping us to review and improve patient care.  All data is anonymised and patient names or other identifying details are not used in audit reports.

Contact Us:

Sinead Palmer, Clinical Audit Manager – Sinead.Palmer@tuh.ie

Policies, Procedures, Protocols & Guidelines

The Quality team in TUH work closely with the staff in providing educational resources for developing Policies, Procedures, Protocols and Guidelines (PPPGs) in both clinical and non-clinical specialties.

This is all based on evidence, best international practice and legislation. PPPGs function to ensure that standards are being met and are reviewed on an ongoing basis.

Opportunities for quality improvement are continuously identified in our hospital. Procedures, processes and importantly patient outcomes are improved by consistently delivering ‘High quality, enhanced patient centred care and support’.

Contact Us:

Colette Hoare, Senior Policy Officer – Tel: (01) 4144807, Email:  Colette.Hoare@tuh.ie,

Patient Safety

This is a dedicated space where we come together to foster a safer and more informed healthcare experience for all. At TUH, we recognise that patient safety is a shared responsibility that spans healthcare workers, service users and their families. Our mission is clear: to provide up-to-date patient safety information that empowers everyone involved in our health service.

Our Commitment:

We understand that a safer healthcare environment is built upon knowledge, collaboration, and proactive measures. On this page, we are committed to sharing crucial patient safety information. We aim to create a culture where safety is at the forefront of every interaction and decision by offering insights, guidance, and best practices.

Our Involvement:

As a testament to our commitment, our QSRM directorate actively engages with various committees within the Hospital. These committees are dedicated to the proactive improvement of patient safety topics, ensuring that our efforts are both comprehensive and impactful.

Empowering Patients & Families:

We firmly believe that patients and their families are essential partners in their care journey. By equipping you with information on these critical safety topics, we empower you to actively engage in your healthcare decisions. We invite you to explore the resources and insights provided here, enabling you to play an informed role in your care and the care of your loved ones.