Quality Improvement Plan Page 25
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Medical Staff Peer Review Committees
The following medical staff peer review entities are established according to the Constitution and Bylaws of the
Medical Staff of Crouse Hospital.
PEER REVIEW BODY
ROLE/RESPONSIBILITY
REPORTS TO
Medical Staff Executive
Crouse Hospital Peer
Subcommittee of the Medical Staff Executive Committee, as needed.
Committee & QI
Review Committee
Committee of the Board
Review all clinical issues where different committee or department chiefs
Chair: Chief Surgical or
have made conflicting standard of care determinations addressing the
Medical Quality Officer
same peer review incident.
The committee may chose to review patient care or clinical issues referred
from the QI department or gleaned from other committee minutes.
The committee shall recommend the policies outlining the information to
be included in the QI files and coordinate medical staff investigations,
including those initiated from inquiries from outside supervisory
agencies.
Medical Staff Executive
Credentials Committee
Investigate the credentials of all applicants and re-applicants for
Committee
membership on the medical or affiliate staff, review their privileges and
Chair: Senior past president
make recommendations as to their approval.
of the medical staff
Make recommendations as to additional privileges for current members of
the medical or affiliate staff
Investigate anything pertaining to the conduct and practice of the
members of the medical staff as referred to it by the Medical Staff
Executive Committee.
Peer Review
Transfusion Services PI
Establish and implement annual performance improvement plan.
Committee & Patient
Council
Care Improvement
Monitor and improve processes and outcomes associated with the use of
Chair: Medical Director of
Council
blood and blood products, including:
Laboratory Services
•
Ordering practices
•
Processes for distribution, handling and dispensing of blood and blood
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