QI Ethics

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Welcome to the QI Ethics team homepage. We are a group of ethics experts from different departments across Island Health.

If you are unsure whether your project is quality improvement or research, please use our QI Ethics Decision-Making Screening Tool. All submissions to our tool will automatically register your project in the Island Health QI Registry and connect you with your local QI Ethics team for guidance and support.

If you would like ethical consultation or review for non-research activities happening at Island Health, or have any questions, please email us at QIEthics@islandhealth.ca. We support projects and teams working in quality improvement (QI), quality assurance (QA), program evaluation (PE), innovation, and beyond.  

Why register?

Registering a project in the QI Registry enhances visibility, ensures alignment with institutional priorities, and supports ethical and regulatory compliance. It facilitates collaboration, prevents duplication, and connects teams working on similar initiatives. The registry also enables structured evaluation, continuous improvement, and access to institutional resources, fostering a culture of accountability and knowledge sharing.

Without ethical consultation and project registration, projects may lack oversight, leading to duplication, missed collaboration opportunities, and inefficient resource use. Ethical and regulatory risks increase without proper screening, while teams may struggle to access institutional support, funding, or mentorship. The absence of a centralized registry also weakens tracking and knowledge sharing, making it harder to measure success and spread best practices. Ultimately, this can undermine the effectiveness and sustainability of quality improvement efforts.

For example, between 2021 and 2025, our team saw 7 different QI project submissions on reducing metered dose inhalers (MDIs) throughout Island Health in order to reduce the carbon impact of hydrofluorocarbons (HFCs). 

How Can We Help?

QI Ethics Screening Tool: This tool screens projects as meeting the definition of research and/or quality improvement and assigns it a risk score based on answers to a 10 minute REDCap survey. This tool is available for Island Health employees, affiliates, and community members who conduct work at our health authority. 

Consultations: We help project leads & teams identify and address ethical considerations in their QI/QA initiatives, program evaluations, and innovation projects. Reach out for one at QIEthics@islandhealth.ca.

Exemptions: We provide support in distinguishing quality improvement (QI) from research, determining if research ethics board (REB) review is required, and connecting teams with the Research Ethics & Compliance office for letters of exemptions that can be used for publication, data requests, and other regulatory processes.

Support with Approval Processes: We facilitate data requests with Decision Support by vetting projects and their data management strategies, connecting with the Information Stewardship, Access & Privacy (ISAP) Office when needed. 

Project Design and Patient Safety: We offer tailored guidance on employee & patient consent, confidentiality, and data use. 

Best Practices & Policy Adherence: We help project teams navigate institutional policies & regulatory requirements, privacy laws, and data governance best practices. 

Presentations & Education: We offer workshops, education sessions, and presentations to units, departments, and institutions on the importance of ethical consultation and oversight for projects that do not undergo research ethics board (REB) review. 

Ethics Risk Assessments: We perform assessments of high-risk projects to identify potential harms and unintended downstream effects and develop appropriate mitigations.

Quality Improvement Oversight & Data: We manage the Island Health QI Registry, publishing quarterly reports showcasing the quality improvement work happening in our organization. 

Who Are We?

Current Team Members (as of March 2025)

  • Sarah Bennett (she/her): Manager, Research Ethics & Compliance
  • Jaclyn Morrison (she/her): Manager, Patient Safety
  • Catherine Marrie (she/her): Consultant, Patient Safety
  • Victoria Philibert (she/her): Health Research Ethics Board (HREB) Coordinator, Research Ethics & Compliance. 
  • Kaitlin Blackwood (she/they): Consultant, Patient Safety
History

While the QI Registry was established in 2014 at Island Health, the QI Ethics team formalized our review process for QI projects in 2017. In 2020, our screening tool was revised to better support project leads throughout the organization. In 2024, we surpassed 300 QI Ethics project consults.

Our Partners

Physician Quality Improvement (PQI)
Pharmacy PGQ1 Residency Program 
Quality Academy (BCPSQC)

Health Quality BC (HQBC)
Island Health: Quality, Safety, and Improvement Homepage
Strategic Quality Improvement 

QI For You and I Report

All projects in the registry are assembled and shared in our QI For You and I Report.

Issue #15: December 2024
Issue #14: April 2024
Issue #13: June 2023 
Issue #12: November 2022
Issue #11: May 2022
Issue #8: August 2020
Issue #7: March 2020
Issue #6: November 2019
Issue #5: July 2019 

QI Ethics Guidance & Resources

QI Resources for your Project

Island Health Resources

Ethics Resources Broadly