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Quality Committee

Chair: , MD

The Quality Committee is responsible for defining, prioritizing, overseeing and monitoring the performance improvement activities, including patient and environmental safety, within the Medical Center. The primary duties of the Quality Committee include analyzing and aggregating Institutional performance data, monitoring performance improvement efforts for effectiveness, and making recommendations to the Patient Care Council and the Clinical Staff Executive Committee for changes in clinical practice and to the Medical Center Executive Committee for changes in operations. The Quality Committee will coordinate the acquisition of performance improvement information and will interface with appropriate committees and departments/units of the Medical Center to improve organizational performance.

Chair: Senior Associate Medical Officer, Quality Members: CEO, COO, CMO, CNO, CIO, CFO, Medical Director of the ED, President of the Clinical Staff or designee, President of the Nursing Staff or designee, Department Quality Officers, GME representation and Performance Improvement Representatives, and other leaders as appointed by the President of the clinical Staff and Chief Executive Officer of the Medical Center. Membership is selected so that all elements of the Health System are represented and therefore lines of accountability for quality activities can be clarified and observed for all major performance improvement initiatives.

The Performance Improvement Program provides staff support.

Meetings: The Quality Committee shall meet monthly or as otherwise deemed necessary by the Co-Chairs, but not less than quarterly.

Duties and Responsibilities:

    • Prioritizes performance improvement efforts utilizing the strategic goals, institutional performance data and trends, and approved benchmark data.
    • Individual members accept accountability for removing barriers, assigning resources and ensuring implementation and compliance for approved recommendations resulting from performance improvement projects.
    • Collaborates with other committees and departments to facilitate performance improvement and ensure compliance with Joint Commission standards, Medicare Conditions of Participation, and other regulatory performance improvement standards.
    • Monitors aggregate data on competence patterns and trends to identify and respond to Medical Center staff learning needs.
    • Provides Institutional direction and oversight for education related to performance improvement methods and efforts.
    • Communicates performance improvement goals, activities and results via defined institutional communication processes.
    • Recognizes and celebrates successful performance improvement efforts.
    • Oversees, evaluates and revises the Quality Improvement and Patient Safety Plan.
    • Provides an annual report to the Medical Center Operating Board on the effectiveness of the Quality Improvement and Patient Safety Plan, and recommended revisions to the Plan.
    • Provides support and coordination of activities to resolve operational or service issues identified by the subcommittees. Provides quarterly updates to the Medical Center Operations Board Quality Sub Committee on institutional performance on selected benchmarks, performance improvement projects and compliance with regulatory requirements.
    • Recommends institutional policies and procedures related to quality and performance improvement initiatives.