Quality Improvement Plan Page 15
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Each performance improvement council and hospital department is responsible to
review, assess, identify, improve and monitor key patient safety opportunities
(including the goals and recommendations set forth by the Joint Commission’s
National Patient Safety Goals, Agency for Healthcare Research and Quality, and the
Institute for Healthcare Improvement ) within their realm of responsibility. The Safety
Performance Improvement Council provides hospital-wide leadership and coordination
to ensure a system’s approach for the hospital’s patient and employee safety
program/efforts.
Patient and employee safety concerns with improvement strategies and results will be
communicated to the hospital’s Quality Improvement Committee of the Board through
the PI infrastructure.
ROLE OF RISK MANAGEMENT
Risk management activities, aimed at loss control activities, are one component of an
integrated Quality Improvement Program. The Risk Management Department works in
collaboration with the QI Department and the Office of Medical Staff Administration to:
1. assemble information related to negative healthcare outcomes and incidents
resulting in injury
2. report the implementation of risk reduction strategies including safety management
activities to protect the financial assets of the hospital.
Patterns and trends identified through the measurement and assessment of quality
improvement data are reported to the Risk Manager for review from a risk management
perspective. Likewise, any patterns or trends of significance identified through the
tracking of risk management data are reported to the QI Department.
An annual report providing a synopsis of actions undertaken by Risk Management is
submitted to the Quality Improvement Committee of the Board.
CONFIDENTIALITY
In accordance with Subsection 3 of 6527 of the Education Law and 2805(m) of the
Public Health Law no proceeding, documentation, records, or Council action related to
the performance of medical review, participation in a medical and dental malpractice
program, incident reporting or investigation for renewing professional privileges and
association shall be subject to disclosure under Article 31 of the civil practice law and
rules. Furthermore, no person in attendance at such meetings shall be compelled to
testify as to what transpired.
Based on these provisions, the hospital is afforded protection for the confidentiality of
information that is directed through the Quality Improvement Program.
However,
statements made by any person in attendance of such Council meetings and, who is
party to an action or proceeding of the subject reviewed, are subject to disclosure in
accordance with Section 6527 Education Law and 2805(m) of the Public Health Law.
Therefore, quotes and statements by persons in attendance at such meetings shall not
be included in minutes.
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