Using data for decision making to improve quality and safety


Governance of quality and safety can be very challenging in large complex healthcare organisations such as the Irish Health Service Executive, writes Dr. Gemma Moore, Qualitative Evaluation and Research Officer, National Quality and Patient Safety Directorate, HSE.

Including a quality agenda item at meetings can support a board, committee or leadership team to improve oversight and accountability of quality and patient safety. The HSE National Quality and Patient Safety Directorate has published the Data for Decision Making Case Study: Co-designing the Quality Agenda with the HSE Leadership Team, and has developed the Data for Decision Making Toolkit to assist committees, boards and leadership teams interested in developing their own quality agenda items.

The case study describes the quality improvement and co-design methodologies that were used to iteratively develop a Quality Agenda with the HSE leadership team. The toolkit is based on our experience of co-designing quality agenda items with the Mater Hospital Board, Children’s Health Ireland at Temple Street Board, the HSE Directorate and the HSE Board’s Safety and Quality Committee. Two complementary quality agenda items were co-designed during these projects providing a quantitative and qualitative picture of quality:

  1. A ‘Quality Profile’ where a selected critical few indicators across domains of quality are presented. Statistical Process Control (SPC) methodology are used to analyse and display variation over time and across a system, and to differentiate between expected and unexpected variation.
  2. ‘People’s Experience of Quality’ where both positive and negative patient, service-user, family and staff experiences are shared at meetings via ‘stories’, videos, research findings or people attending meetings to describe their experience face-to-face.

How to use it?

The Data for Decision Making Case Study and Toolkit provides a case study, tools, resources and guidance for those wishing to develop their own quality agenda item. Part one of the toolkit helps you plan and test your quality agenda item through the use of quality improvement (QI) and co-design methodologies. Part two and three contain guidance, tools and resources to support you developing a Quality Profile and People’s Experience of Quality. Part four contains useful resources to gather feedback and evaluate your project. There is an introduction to each tool to assist you in deciding which tools are helpful for you. Links are provided directing you to further resources on our website.

Part One: Planning and Testing a Quality Agenda Item

Part Two: Producing a Quality Profile

Part Three: Producing People’s Experiences of Quality

Part Four: Evaluation and Feedback

Benefits of using the toolkit:

Regularly discussing quality and safety through a quality agenda item will help boards, committees or leadership teams:

  • To evolve their approach to overseeing and improving quality at organisational or service level
  • To develop of a culture of assurance in their organisation or service
  • To establish whether care in their organisation or service is safe or unsafe
  • Help identify patient safety issues and system failures
  • Take appropriate actions to reduce the risk to patients and staff
  • Understand the lived experiences of those who use and work in their organisation or service

Opportunity to get involved

You can download the case study and toolkit on our website.

Listen to our recent podcast Walk and Talk Improvement: Ideas for Safe Quality Care Episode 4: Using data to improve. In this episode, we cover how data can be used for assurance and improvement. You’ll hear how combining different types of data presented in the right way can help boards and committees in leading and overseeing healthcare organisations in quality and patient safety. You’ll also hear the importance and value of board and committee members engaging with people’s lived experiences of using and working in healthcare. You can find the series by searching for “Walk and Talk Improvement” on Spotify, Amazon Music Prime, YouTube, or Google Podcasts.


We would also like to acknowledge our colleagues across HSE National Quality and Patient Safety Directorate who developed a number of tools contained in the toolkit.

Sincere thanks to members of the Mater Hospital Board, Children’s Health Ireland at Temple Street Board, the HSE Directorate and the HSE Board Safety and Quality Committee who through co-design have helped refine our approach and help identify the key steps to develop a Quality Agenda Item.


Board on Board with Quality of Clinical Care’ Quality Improvement Project: Case Study Report (2015)

Bringing the Board of Directors on Board with Quality and Safety of Clinical Care at Temple Street

Children’s University Hospital: A case study and Toolkit (2018)

Martin, et al (2022), "Board level “Picture-Understanding-Action”: a new way of looking at quality",

International Journal of Health Governance, Vol. 27 No. 1, pp. 105-117. 0047

Quality and Safety Data for Decision Making: Co-designing the Quality Agenda with the HSE

Leadership Team (2023)

Data for Decision Making Toolkit (2023)