The successful implementation of the Quality and Safety Plan is based upon a platform of clinical governance. (See Quality and Safety Plan 2012, Appendix 1: Illustration of Clinical Governance Platform) The Leadership endorsed the platform, as an initiative to address quality and safety as unified and interdependent areas of priority focus. The scope of strategies and processes identified in this plan apply to all departments at Saint Peter’s Healthcare System (SPHS), and apply to all employees, medical staff, volunteers, physician residents, and students.

As identified in Appendix I, quality is one of the two arms of clinical governance. Quality efforts define metrics and measures based upon best practices and evidence. Key metrics are determined by national and state regulations, accreditation standards (The Joint Commission and Magnet Recognition), as well as organizational and departmental priorities. Plans for performance improvement include the identification of process and outcome measures, which need to be improved and/or sustained. Quality methods, such as rapid cycle changes, surveys, and audits are used to effectively and systematically affect positive change. Feedback loops via committees and task forces maintain a continuous loop of communication across all levels, from staff to the Quality and Patient Safety Committee of the Board of Governors.

Safety efforts are continuous and a culture of safety has been recognized as a top priority of the organization. Transparency is encouraged and supported through various venues, such as an online reporting system, the "7067" hotline, and the respectful management of serious adverse events. The management of risk is also under the safety arm of the clinical governance platform, and efforts are unified in both reactive and proactive approaches. Open communication is supported and facilitated by leadership in an effort to consistently maintain a just culture, and a systems approach to safety.