Quality Improvement Plan (Page 26 of 32) in pdf

Quality Improvement Plan Page 26

CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013

PEER REVIEW BODY

ROLE/RESPONSIBILITY

REPORTS TO

components

•

Administration of blood and blood components

•

Monitoring blood and blood components effect on patients

•

Review of all transfusion reactions

Functional/Service Line Councils

Each of the functional or service line committees/councils listed in this table is responsible for a particular

function or the processes and outcomes related to the delivery of services within a service line. Each

committee/council is co-chaired by a physician and an administrative member. Where there are more than one key

medical staff departments involved in a particular service line (Surgical services include both surgeons and

anesthesiologists) a Vice Chair will be appointed. The Vice Chair and Physician Co-Chair will rotate their positions

every two years. The Councils are interdisciplinary, as appropriate to the function overseen. Reports are submitted

to the appropriate coordinating council on at least a quarterly basis, and each is assigned a liaison from the

respective coordinating council to facilitate rapid barrier removal, decision making and clear communication.

Each council/committee develops their own objectives, indicators and measures specific for their service

or functions and includes measures of patient safety, clinical quality, cost efficiency and customer

service, as appropriate to the function overseen.

FUNCTIONAL or

ROLE/RESPONSIBILITY

SERVICE-LINE COUNCIL

REPORTS TO

Continuum of Care Council

Establish and maintain a Utilization Management Program in a continuous effort to

improve the quality of care and services the hospital provides.

Patient Care

Co-Chairs:

Improvement

Active Credentialed Member of

Develop Standards of Care and written criteria to be utilized in determining the

Council

Medical Staff and Director,

medical necessity of hospital admissions, continued stays and appropriate levels of

Care Coordination

care.

Establish and maintain a mechanism for the review of quality of care issues identified

during concurrent review.

Analyze patterns of utilization of resources and conduct focused studies and/or

Quality Improvement Plan Page 26