Quality Improvement Plan Page 29
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
FUNCTIONAL or
ROLE/RESPONSIBILITY
SERVICE-LINE COUNCIL
REPORTS TO
Safety PI Council
Monitor, asses and improve the processes around the environment of care, including:
Patient Care
Patient Safety, Employee and Visitor Safety, Security, Hazardous waste and
Chair: Medical Director,
Improvement
materials, Emergency preparedness, Life safety, Medical equipment, Utility systems,
Employee Health and Director
Council
and coordinate staff orientation and continuous education on the above functions.
of Risk Management
Establish and implement annual performance improvement plan.
Council on Infections
Establish and implement annual performance improvement plan.
Patient Care
Key functions include:
Chair: Medical Director,
Improvement
•
Conduct an effective surveillance program for the organization
Infection Prevention
Council
•
Identify and reduce the risks of infection for patients, visitors and staff
•
Analyze infection control data for patterns, trends and rates of infection
•
Establish risk reduction or prevention strategies
•
Establish effective infection control mechanisms
•
Reports, when appropriate, information about infections internally and to
public health agencies
Compliance & Ethical Practices
Multi-disciplinary council charged with measurement, assessment and improvement
PI Council
of process and outcomes associated with continual compliance and ethical practices
Patient Care
Co-Chairs: Active Member of
Role/Responsibility
Improvement
the Crouse Medical Staff and a
Establish and implement annual performance improvement plan.
Council
Hospital Director/Manager
and/or Director of Risk
Monitor and improve processes and outcomes associated with…
Management
•
Maintaining HIPAA Compliance in all areas
•
Ensuring appropriate Information Access
•
Documenting/Conducting Security Watches
•
Reviewing Excluded Providers every 30 days
•
Organ/Tissue Program
•
Advanced Directives
•
Palliative Medicine Consult Data
28
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business