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158 Quality and Safety Services 2020 | NMH Annual Rep t Quality T hroughout 2020, the Quality Department developed and led both new and continuous improvement initiatives across the NMH in conformance with departmental and hospital objectives. This was achieved through day-to-day operational activities and underpinned by the following governance entities: • Clinical Governance Executive Committee: meeting monthly to review and approve the identification and implementation of evidence-based standards, policies, procedures and guidelines and assure compliance with all statutory and regulatory requirements. • Quality, Risk and Health and Safety Committee: meeting monthly to assure operational quality and patient safety through continuous monitoring, evaluation and improvement. The services of the Quality Department are data-driven and underpinned by three core data management systems: • Patient Feedback Management System (supporting excellence in Patient Advocacy). • Quality Improvement Registry. • Audit Management System. Externally, the Quality Department continued to represent the hospital at the Ireland East Hospital Group (IEHG) Quality and Patient Safety Forum. Quality, Risk and Patient Safety Particular Quality Department activities during 2020 (in the context of COVID-19 restrictions) included: • Continued improvement of all quality management systems. • Completion of the new Patient Safety Complaints Advocacy programme (all team members). • Facilitation of Managing Difficult Complaints Training workshop for clinical staff. • Proactive involvement with community partners to enhance integration, coordination and seamless delivery of care. This included GP Liaison Committee meetings (x3) and Patient Voice Group meetings (x2). • Coordination and management of NMH's GP Study Day (virtual). • Information Day for Community Partners (PHN's, Practice Nurses, Doulas). • Contributions to Patient Safety Awareness Week. • Management of all Patient Feedback (129 written complaints - 34 Level 1, 95 Level 2; 20 direct patient meetings) • Implementation of Quality and Safety Walk-rounds. • Implementation of online NMH and NICU Patient Experience Surveys. • Management of the NMH's participation in the first National Maternity Experience Survey for patients who attended during October 2019. The NMH had the highest response rate (56%, n=361) with 85% respondents indicating their care was "Good/Very Good".