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 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 hospital wide processes. Currently the following performance improvement teams involving medical staff are in existence or have recently completed their reviews: Review of treatment plans Lower Saco Unit 4. Miscellaneous Performance Improvement Activities: In addition to the formal monitoring and peer review activities described above, the Clinical Director is vigilant for methods to improve the delivery of clinical care in the hospital from interactions with, and feedback from, other discipline chiefs, from patients or from their complaints and grievances, and from community practitioners who interact with hospital medical staff. These interactions may result in reports to the Medical Executive Committee, in the creation of performance improvement teams, performance of a root-cause analysis, or counseling of individual practitioners. 5. Reports of Practitioner-specific Data to Individual Practitioners: The office of the Clinical Director will provide confidential outcomes of data to each medical staff member within 30 days of the end of the fiscal year. This information will be available without the necessity of the practitioner requesting it. It will be placed in the confidential section of the practitioner’s medical staff file and freely accessible during normal business hours. The office of the Clinical Director will notify all medical staff members when the data is available for review. Each medical staff member may discuss the data with the Clinical Director at any time. 6. Process to amend the quality improvement plan, including adding or deleting any monitors or processes:
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 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 hospital wide processes. Currently the following performance improvement teams involving medical staff are in existence or have recently completed their reviews: Review of treatment plans Lower Saco Unit 4. Miscellaneous Performance Improvement Activities: In addition to the formal monitoring and peer review activities described above, the Clinical Director is vigilant for methods to improve the delivery of clinical care in the hospital from interactions with, and feedback from, other discipline chiefs, from patients or from their complaints and grievances, and from community practitioners who interact with hospital medical staff. These interactions may result in reports to the Medical Executive Committee, in the creation of performance improvement teams, performance of a root-cause analysis, or counseling of individual practitioners. 5. Reports of Practitioner-specific Data to Individual Practitioners: The office of the Clinical Director will provide confidential outcomes of data to each medical staff member within 30 days of the end of the fiscal year. This information will be available without the necessity of the practitioner requesting it. It will be placed in the confidential section of the practitioner’s medical staff file and freely accessible during normal business hours. The office of the Clinical Director will notify all medical staff members when the data is available for review. Each medical staff member may discuss the data with the Clinical Director at any time. 6. Process to amend the quality improvement plan, including adding or deleting any monitors or processes:
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