Quality Improvement Plan Page 24
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
OVERSIGHT BODY
ROLE/RESPONSIBILITY
REPORTS TO
•
Act upon recommendations from the Medical Care Evaluation Committee, or
such other committees as appropriate when questions are raised about the
quality of care provided by a staff member.
•
Review medical staff compliance with standards and regulations imposed
through Crouse’s participation with the JCAHO, through state or federal
agencies or other entities as required.
Coordinating Council
The following Coordinating Council is the clearinghouse for the coordination of all quality and performance
improvement activities within the organization.
COORDINATING COUNCIL
ROLE/RESPONSIBILITY
REPORTS TO
Systematically monitor and improve processes and outcomes associated with the
Medical Staff
Patient Care Improvement
environment of care (safety), infection control, patient’s right and organizational
Exec
Council
ethics, information management, human resource management, the use of
Committee, QI
Co-Chairs:
medications and regulatory and accreditation compliance.
Committee of
Vice President of the Medical
the Board
•
Measure and improve processes and outcomes associated with the delivery of
Staff &
patient care at Crouse Health
Chief Nursing Officer
•
Support the multi disciplinary patient care performance improvement councils
through the provision leadership, prioritization, barrier removal and allocation
of resources for improvement initiatives
•
Establish accountability and completion time lines for patient care
improvement projects prioritized for action
•
Provide coordination among patient care improvement councils to eliminate
duplication of effort or conflicting goals
•
Approve and support service line performance improvement councils’ annual
performance improvement plans.
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