| CRITERIA MEASURE |
Met |
Not Met |
Comments |
Refer to Department |
 Quality Improvement Committee meets at least quarterly |
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| All documents are marked as confidential |
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| Evaluates data, identifies potential problem areas, and approves performance improvement projects with at least the following topics: |
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| Medication management |
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| Blood and blood product use |
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| Referral tracking and trending |
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| Risk management and litigation potential |
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| Utilization management |
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| Re-admission rates |
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| Quality Control |
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| Wait times |
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| Infection rates |
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| Data are analyzed, tracked, trended and measured against baselines |
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| Minutes are maintained and protected from discovery |
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| 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 |
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| Methods in place to monitor compliance with committee recommendations |
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| Safety Committee report includes inspections of all areas in the clinic |
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| Prescription errors are tracked |
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| Patient Satisfaction is measured, tracked and trended |
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| Formal complaint procedures are in place; complaints are followed-up |
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| Complaints are tracked and trended |
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| Disaster Plan is Current |
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| A disaster response kit is available and properly stocked |
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| Disaster Drill is conducted at least annually |
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| Fire Drills are conducted at least annually |
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| Intended outcome is compared to actual outcome |
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| Security systems intended to prevent: |
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| Unauthorized access to patients |
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| Theft |
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| Assault |
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| Failure modes are identified and possible patient harm is assessed |
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| The committee reviews ethical issues in coordination with the Ethics Committee |
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| Areas needing improvement are prioritized according to potential harm to patients |
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| Quality Improvement initiatives are data driven |
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| All allegations of abuse or neglect are investigated |
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| Staff opinions and suggestions are collected and analyzed |
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Copyright © OmniSure Consulting Group, Inc., 2008
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