Quality Improvement Committee meets at least quarterly
Committee membership crosses disciplines
All documents are marked as confidential
Evaluates data, identifies potential problem areas, and approves performance improvement projects with at least the following topics:
Medication management
Blood and blood product use
Restraint and seclusion use
Behavior management
Resuscitation and resuscitation outcomes
Risk management and litigation potential
Utilization management
Re-admission rates
Quality Control
Hospital Acquired Infections
Infection rates
Sentinel Events
Data are analyzed, tracked, trended and measured against baselines
Minutes are maintained and protected from discovery
Performance improvement includes: 1) Quantifiable measures of current level of performance 2) Establishes goals for improvement 4) Analysis of current systems 5) Develop and implement action plan 6) Periodically measures progress towards goals
Methods in place to monitor compliance with committee recommendations
Safety Committee report includes inspections of all units
Medication errors are tracked and reported to the committee
Patient Satisfaction is measured, tracked and trended
Formal complaint procedures are in place; complaints are followed-up
Complaints are tracked and trended
Disaster Plan is Current
Each department has a disaster response kit
Disaster Drill is conducted at least annually
Fire Drills are conducted at least quarterly
Peer Review Committee meets at least quarterly
Minutes are kept on file and protected from discovery
Actions by the Peer Review Committee are confidential
Referral system to Peer Review is known to physicians
Intended outcome is compared to actual outcome
Security systems intended to prevent:
Unauthorized access to patients
Infant abduction
Theft
Assault
Sentinel Event is defined and distributed to all employees
Failure modes are identified and possible patient harm is assessed
Root Cause Analysis is conducted for all Sentinel Events
Sentinel Events include:
Unanticipated death
Permanent loss of function due to hospital acquired infection
Infant Abduction
Wrong site surgery
Corrective action is initiated to deter recurrence of Sentinel Events
Falls Management Program is measured for effectiveness
The committee reviews ethical issues in coordination with the Ethics Committee
Mortality rates are assess for trends, types and contributing factors
Areas needing improvement are prioritized according to potential harm to patients
Quality Improvement initiatives are data driven
All allegations of abuse or neglect are investigated
Restraint utilization is reviewed by he Quality Improvement Committee
Staff opinions and suggestions are collected and analyzed
