PURPOSE: To provide guidelines for supervisory staff to ...
TITLE: Quality Improvement Program
APPLICATION: All Staff
RELATED POLICIES/PROCEDURES: Clinician Peer Review Policy; Quality Improvement Annual Plan
ORIGINAL RESIDES: General policy manual
COPIES DISTRIBUTED: QuIC Manual
LAST REVISION DATE: 4/17/07
GENERAL GUIDELINES/DIRECTIONS:
General Statement:
The quality improvement program at Student Health Services (SHS) is a planned, purposeful, integrated and coordinated activity used to assess, monitor and improve the excellence of care provided to patients.
Quality of care activities undertaken by the organization address clinical, administrative, and cost-of-care issues, as well as actual patient outcomes. A system of peer review relative to quality and consistency of care and adherence to clinical standards is an integral part of this program.
Description:
The Quality Improvement Committee (QuIC) consists of three members: a Physician, Nurse Practitioner, and Associate Director, Nursing Services. The committee meets monthly and is designed to direct an active and coordinated program of quality improvement in line with the standards of AAAHC.
The committee is responsible for:
1. Assuring consistent and on-going evaluation of patient outcomes by coordinating and assisting in identification of potential issues to be evaluated. The following sources will be utilized:
a. Peer Review
b. Incident Reports (through Leadership Team)
c. Issues identified by the Health and Safety Committee
d. SHS Surveys (through Leadership Team)
e. Individual Departments - Sources for studies may include: direct observation, overutilization and underutilization. The SHS lab performs QI studies as directed through their accrediting body.
f. Outcomes of care, clinical practice patterns of health care practitioners, direct observation, staff concerns, and/or prevalent diseases shall be used as a basis for clinical studies.
g. Review of key quality of care indicators in comparison with other similar organizations and national standards.
2. Maintaining knowledge and keeping records of QI activities to assure adherence to AAAHC standards.
3. Assuring that quality improvement studies are used as a basis for improving quality of patient care.
4. Maintaining knowledge of techniques and processes available to improve quality.
5. Developing and maintaining a tracking system for quality improvement activities.
6. Assuring education to SHS staff about quality improvement: processes, studies, implementation, etc.
7. Providing an annual quality improvement summary to the Leadership Team as well as maintaining ongoing communication throughout the year.
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