The subcommittees of the MEC and the Integrated Performance Excellence Committee are the primary methods by which the medical staff monitor and analyze for trends all quality performance data as well as trends more specific to medical staff performance. The subcommittees, in turn, report their findings on a monthly basis to the Medical Executive Committee and to the Clinical Director for any needed action. The respective committees monitor the following indicators: Integrated Performance Excellence Committee (this is not a subcommittee of the Medical Staff but the Clinical Director serves as a member and is the primary liaison to the Medical Executive Committee). Psychiatric Emergencies Seclusion and Restraint Events Staff or Patient Injuries Priority I Incident Reports Other clinical/administrative department monitoring activity Pharmacy and Therapeutics Committee: Medication Errors Including Unapproved abbreviations Adverse Drug Reactions Pharmacy Interventions Antibiotic Monitoring Medication Use Evaluations Psychiatric Emergency process Medical Records Committee: Chart Completion Rate/Delinquencies Clinical Pertinence of Documentation of Closed Records Infection Control Committee: Infection Rates (hospital acquired and community acquired) Staff Vaccination Rates/Titers Utilization Management Committee: Admission Denials Timeliness of Discharges After Denials Peer Review and Quality Assurance Committee: Hospital-wide Core Measures and NASMHPD Data Patient Satisfaction Surveys Administrative concerns about quality Special quality improvement monitors for the current year (see also the Appendix and number 6 below). Reports from the Human Rights Committee regarding patient rights and safety issues Specific case reviews STRATEGIC PERFORMANCE EXCELLENCE 3. Performance or Process Improvement Teams: When requested by or initiated by other disciplines or by hospital administration, or when performance issues are identified by the medical staff itself during its monitoring activities, the Clinical Director will appoint a medical staff member to an ad hoc performance improvement team. This is generally a multidisciplinary team looking at ways to improve
The subcommittees of the MEC and the Integrated Performance Excellence Committee are the primary methods by which the medical staff monitor and analyze for trends all quality performance data as well as trends more specific to medical staff performance. The subcommittees, in turn, report their findings on a monthly basis to the Medical Executive Committee and to the Clinical Director for any needed action. The respective committees monitor the following indicators: Integrated Performance Excellence Committee (this is not a subcommittee of the Medical Staff but the Clinical Director serves as a member and is the primary liaison to the Medical Executive Committee). Psychiatric Emergencies Seclusion and Restraint Events Staff or Patient Injuries Priority I Incident Reports Other clinical/administrative department monitoring activity Pharmacy and Therapeutics Committee: Medication Errors Including Unapproved abbreviations Adverse Drug Reactions Pharmacy Interventions Antibiotic Monitoring Medication Use Evaluations Psychiatric Emergency process Medical Records Committee: Chart Completion Rate/Delinquencies Clinical Pertinence of Documentation of Closed Records Infection Control Committee: Infection Rates (hospital acquired and community acquired) Staff Vaccination Rates/Titers Utilization Management Committee: Admission Denials Timeliness of Discharges After Denials Peer Review and Quality Assurance Committee: Hospital-wide Core Measures and NASMHPD Data Patient Satisfaction Surveys Administrative concerns about quality Special quality improvement monitors for the current year (see also the Appendix and number 6 below). Reports from the Human Rights Committee regarding patient rights and safety issues Specific case reviews STRATEGIC PERFORMANCE EXCELLENCE 3. Performance or Process Improvement Teams: When requested by or initiated by other disciplines or by hospital administration, or when performance issues are identified by the medical staff itself during its monitoring activities, the Clinical Director will appoint a medical staff member to an ad hoc performance improvement team. This is generally a multidisciplinary team looking at ways to improve
2015Q4.docx