Quality Improvement Plan Page 16
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Access to patient or practitioner specific information is strictly controlled with access
afforded only to members of administration, departmental directors, clinical service
chiefs and Council chairpersons upon approval of the Chief Medical Officer when
specific information is needed to facilitate decisions. Reports and minutes containing
this type of specific information are retained in a secure area. All patients will be
identified by case number and physicians identification by physician number.
Conflict of Interest
No physician shall be responsible for reviewing his or her own care. When only one
physician in a specialty or sub-specialty is on the medical staff, practice will be
reviewed within the expertise of the department. If practice is not within the expertise
of the department in question, provisions will be made to have cases evaluated by an
outside expert in the same medical specialty. This outside review will be arranged when
deemed appropriate by the Chief Medical Officer after consultation with the appropriate
Chiefs of Clinical Service and/or members of the Peer Review Committee.
ANNUAL PROGRAM EVALUATION objectives, scope, organization and effectiveness of
the Crouse Hospital Quality Improvement Program will be evaluated at least annually
and revised as necessary. Emphasis will be placed on areas monitored and evaluated,
problems/opportunities for improvement identified and acted upon, success of actions
taken and improvements made in patient care.
Acknowledgment and Endorsement
_________
_________________
Derrick Suehs, Chief Quality Officer
Date
__
_______________________
_______
Anthony Scalzo, MD Co-Chair PCIC
Date
__
_______________________
_______
Ann Sedore, RN Co-Chair PCIC
Date
_________________
_______________________
_____________________
Paul Kronenberg, MD Chief Executive Officer
Date
________________________
Michael Duffy, MD, President of the Medical Staff
Date
__
_______________________
_______
Robert Miron, Chair-Board QI Committee
Date
__
_______________________
_______
Chair Crouse Hospital Board
Date
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