Quality Improvement Plan Page 14
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
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Counseling of individuals
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Modification/limitation or removal of clinical privileges
•
Enhanced communication
COMMUNICATION OF RESULTS
Results of process improvement initiatives will be communicated as appropriate
throughout the organization in an effort to share ideas, gain a better understanding of
relevant
processes,
encourage
collaboration,
instill
concepts
of
continuous
improvement into the organizational culture, and to stimulate creative and innovative
improvement initiatives. The findings, conclusions, recommendations, actions and
results of interdepartmental or multi-disciplinary process improvement teams should
be reviewed at relevant hospital and departmental meetings.
The Patient Care Improvement Council will receive reports from the councils a
minimum of two times per year unless immediate assistance is required in the removal
of barriers for improvement. Minutes recording quality improvement activities from
any source shall clearly reflect problem identification, corrective action, resolution and
follow-up monitoring.
The Quality Improvement Committee of the Board and the Medical Staff Executive
Committee will receive, at each of their meetings, an executive
summary of the PI
Councils’ activities and indicators.
STAFF INVOLVEMENT IN PERFORMANCE IMPROVEMENT
Employees at all levels are encouraged to participate in performance and quality
improvement activities as appropriate and necessary. Also, staffs are encouraged to
participate by offering suggestions and recommendations for quality improvement
projects through their involvement in event reviews, performance improvement
initiatives, departmental meetings, and other formal and informal means. Staff
participating on committees/councils or teams will be provided just-in-time training in
the methods and techniques of the adopted improvement methodology (FOCUS-PDSA).
PATIENT AND EMPLOYEE SAFETY
Patient and employee safety are to be a part of all work and clinical performance
improvement initiatives. The hospital’s patient and employee safety program includes:
Critical Event Review Process
Root Cause Analysis Process
Failure Mode Effects Analysis Process
Occurrence Reporting Process and Analysis, including NYPORTS
Safety Performance Improvement Council
Standards and Review Committee
PI Infrastructure
13
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