The Patient Safety & Quality Committee is responsible for evaluating the Medical Center’s performance with providing safe and quality care by reviewing multiple sources, including learnings from serious and sentinel event reporting, mortality reviews, comparative outcomes data, patient safety indicators, hospital accreditation surveys, closed litigation cases, moral distress consults, patient grievance data, and culture survey data. The committee uses this information to identify priorities for performance improvement activities that are needed and monitors those efforts for effectiveness. Recommendations may be made to the Patient Care Committee and Clinical Staff Executive Committee about clinical or operational changes that are needed based on learning from the aforementioned sources of information. 

Membership: Chief, Quality and Patient Safety, CEO, COO, CMO, CNO, , ACMOs, DIO, representatives from population and operational service lines, GME trainees and nursing quality. Membership is selected so that all clinical elements of the Medical Center are represented and therefore lines of accountability for patient safety and quality activities can be clarified and observed for all major performance improvement initiatives. 

The Quality and Performance Improvement Program provides staff support.

Duties and Responsibilities:

  • Individual members accept accountability for removing barriers, assigning resources and ensuring implementation and compliance for approved recommendations resulting from analysis of events, data or performance improvement project outcomes
  • Reviews the findings from the analyses of significantly adverse outcomes to approve or recommend actions designed to mitigate re-occurrence
  • Refers physician practice issues to existing peer review processes, including M&M conferences
  • Provides support and coordination of activities to resolve operational or service issues identified by the subcommittees
  • Approves institutional policies and procedures related to quality, safety, and performance improvement initiatives
  • Monitors competence patterns and trends to identify and respond to Medical Center staff learning needs.
  • Reviews analysis of aggregated, trended data related to quality and patient safety and recommends and monitors actions, including annual reports from Grievance Committee and Nutrition Committee
  • Informs Medical Center decision-making about the strategic goals based on institutional performance data and trends, and approved benchmark data
  • Communicates performance improvement goals, activities and results via defined institutional communication processes
  • Oversees, evaluates and revises the Quality Improvement and Patient Safety Plan
  • Recognizes and celebrates successful performance improvement efforts and staff actions impacting patient safety
  • Provides quarterly updates to the Health System Operating Board Quality Subcommittee on institutional performance on selected benchmarks, performance improvement projects, compliance with regulatory requirements, and sentinel events
  • Provides annual report to the Health System Operating Board on the effectiveness of the Quality Improvement and Patient Safety Plan, and recommended revisions to the Plan.