Quality Improvement Plan Page 3
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Table of Contents
Crouse Mission Statement................................................................................................................ 3
Our Vision ........................................................................................................................................ 3
Our Guiding Beliefs .......................................................................................................................... 4
Executive Summary ......................................................................................................................... 4
2013 Quality Improvement Plan ....................................................................................................... 6
Purpose ............................................................................................................................................ 6
Our Commitment To Quality ............................................................................................................ 6
Our Core Values ............................................................................................................................... 6
Quality Goals And Objectives ........................................................................................................... 7
Program Methodology ....................................................................................................................... 8
Measurement ................................................................................................................................... 7
Patient-Focused Functions ............................................................................................................... 7
Organizational Functions ................................................................................................................. 8
Quality Indicators ............................................................................................................................. 9
Data Sources .................................................................................................................................... 9
Assessment ...................................................................................................................................... 9
Setting Improvement Opportunities ................................................................................................ 10
Performance Improvement Model: PDSA ....................................................................................... 10
Quality Improvement Structure ...................................................................................................... 12
Corrective Actions .......................................................................................................................... 12
Communication Of Results ............................................................................................................ 13
Staff Involvement In Performance Improvement ............................................................................. 13
Patient And Employee Safety .......................................................................................................... 13
Role Of Risk Management .............................................................................................................. 14
Confidentiality ................................................................................................................................ 14
Conflict Of Interest ......................................................................................................................... 15
Annual Program Evaluation ........................................................................................................... 15
Acknowledgment And Approval ...................................................................................................... 15
Appendix A: Family Of Measures .................................................................................................... 16
Appendix B: Council Structure ....................................................................................................... 17
Appendix C: Council Summaries .................................................................................................... 22
Oversight Councils ......................................................................................................................... 22
Coordinating Council ..................................................................................................................... 23
Medical Staff Peer Review Committees ............................................................................................ 24
Functional/Service Line Councils ................................................................................................... 25
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Parent category: Business