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Patient Safety & Quality Committee


Co-Chairs:  and

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 learning from serious and sentinel event reporting, mortality reviews, comparative outcomes data, patient safety indicators, hospital accreditation surveys, closed litigation cases, moral distress consults, and culture survey data. The committee uses this information to identify priorities for Be Safe work and 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.

Chief Quality and Patient Safety Officer, COO, CMO, CNO, 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. 

Meetings: The Patient Safety & Quality Committee shall meet weekly or as otherwise deemed necessary by the Chairs, but not less than monthly.

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
  • Monitors the progress of the Be Safe program and enhancements needed to further lean transformation effort
  • 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.
Jeff Young, MD, Co-chair Patient Safety
Tracey Hoke, MD, Co-chair Quality & Performance Improvement
Pamela Sutton-Wallace CEO, MC Administration
William Fulkerson, MBA COO, MC Administration
Chris Ghaemmaghami, MD CMO
Jim Amato, MBA Chief, Clinical Ancillary Services
Mary Dixon, RN, MSN Interim CNO
Susan Kirk, MD Assoc Dean for GME
Melynda Zarzyski, RN, CCRN PNSO
Lily Johnston, MD GME/Surgery
Yasser El-Abd, MD GME/Radiology
John Shultz, MD GME/Medicine
Ralph Abraham, MD GME/Medicine
Evan Leitner, MD GME/Psychiatry
David Saenz, MD GME/Psychiatry
Jared Beller, MD GME/Surgery
William Chancellor, MD GME/Surgery
Scott Syverud, MD President, Clinical Staff
Karen Forsman Heart Center
John Kern, MD Surgery
Jonathan Swanson, MD Pediatrics
Diane Rozycki, MD OB/GYN
Guillermo Solórzano, MD Neurology
Jason Sheehan, MD Neurosurgery
John Voss, MD General Medicine
Paul Helgerson, MD Hospitalist Medicine
Mitch Rosner, MD Medicine
Edward Nemergut, MD Anesthesiology
Iris Welsch, RN OPSC
Robert O'Connor, MD Emergency Medicine
Reid Adams, MD Surgery
James Browne, MD Orthopedics
Jack Jackson Administrator, Musculo-Skeletal Service Line
Bobby Chhabra, MD Chair, Orthopedics
Traci Hedrick, MD Surgery/GI
Zachary Henry, MD Medicine/Gastro
Ira Helenius, MD Primary Care
Jose Oberholtzer, MD Transplant
Rob Teaster Transplant
Doris Haverstick, PhD Pathology
Arun Krishnaraj, MD Radiology & MI
Mary Shank, RN RN Quality Subcommittee
Holly Hintz, RN Nursing Governance
Costi Sifri, MD Infectious Diseases
Beth Mehring Life Support Learning Center
Bill Brady, MD Emergency Medicine
Stacy Crowell Quality & Performance Improvement
Jeffrey Lucas Director, Be Safe
Denise Barth, RN Director, Accreditation
Rebecca Hill Director, Patient Safety & Risk Management
Jackie Loach Patient Safety & Risk Management
Deb Wilmoth Patient Safety & Risk Management
Rachael Holmes Patient Safety & Risk Management
Tom Harkins Chief, Environment of Care
Rick Skinner Chief, Technology and Health Information
Rafael Saenz, PharmD Pharmacy
Jill Laird Sanders Patient Progression
Michael D. Williams, MD Surgery
Matthew Henrich MET Team
Korinne Van Keuren, DNP Director, Advanced Practice Providers