Quality Improvement Plan Page 13
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
frames for completion and work with leadership to allocate resources for project
completion. Opportunities for process improvement identified at the unit, department,
or service level, which do not involve other areas, are acted upon using systematic
process improvement techniques within the department. Departmental initiatives are
prioritized based upon the process's relevance to the department’s mission, impact
upon patient safety and care or other department-specific factors.
QUALITY IMPROVEMENT STRUCTURE
The structure used to support the quality improvement program reflects Crouse
Hospital’s commitment to quality and the core values of clinical excellence, service
excellence and teamwork. Members of our committees, councils and teams represent
diverse departments, services and disciplines throughout the organization. There is a
bias for action at each council, committee or team level. The use of the PDSA
methodology allows organizational leadership to have confidence in the results of team
efforts without imposing layers of bureaucratic checks and balances that may stifle
team activity.
•
Oversight entities are responsible for ensuring that the quality improvement
plan is approved and implemented throughout the organization.
•
Coordinating council supports the functional and service line Councils through
leadership, barrier removal, prioritization and allocation of resources.
•
Peer review entities review individual cases that emerge through the Quality
Improvement program that require a determination pertaining to the standard
of care delivered. Proceedings of these committees are protected from discovery
under 2805m of the New York State Public Health Law.
•
Functional/Service line councils measure, assess and improve the quality of
care and delivery services throughout the organization. These groups function
largely as self-directed work teams within the overall framework of the Quality
Improvement Plan.
There are four types of Quality or Performance Improvement councils/committees:
See Appendices B & C for the table of organization and descriptions of important
committees/councils in the Quality Improvement Structure.
CORRECTIVE ACTIONS-reference Crouse policy (ISO 9001)
In keeping with the goal of achieving organizational excellence by improving existing
processes, the primary focus of the Crouse Quality Improvement Program has shifted
over time from scrutinizing individual performance to examining the performance of the
organization’s systems and processes. With that in mind, the following actions may be
recommended in the resolution of identified problems:
•
Process modification, redesign, or re-engineering
•
Implementation of new or revised services, policies, or procedures
•
Development of educational programs
•
Equipment or facility changes
•
Staffing or skill mix changes
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