6818 Fort Hamilton Parkway

Brooklyn, NY 11219

718.375.1100 phone

718.745.6735 fax

PURPOSE: To demonstrate a commitment to providing quality patient care within the scope of available resources and the goals of this facility. 

GOALS: The goal of the Quality Improvement (QI) Program is to monitor the appropriateness  and quality of patient care. Monitoring will be accomplished by activities that:

1. Are planned, systematic, and ongoing

2. Are comprehensive

3. Are based on objective criteria that reflect current medical knowledge and clinical experiences

4. Are accomplished by the routine collection and periodic evaluation of data

5. Result in appropriate actions to resolve identified problems

6. Are updated to assure sustained improvements in care and performance

7. Are coordinated in such a way that the information derived is shared among the appropriate staff of this facility

SCOPE: The scope of the QI Program is comprehensive and problem oriented. It includes all departments and services within Global United Medical Supplies. The topics to be reviewed are:

1. The quality and appropriateness of client teaching procedures

2. The quality, content, and timeliness of repairs and/or replacements of medical equipment

3. Client/staff complaints

4. The infection control

5. Patient satisfaction

QI unit is be responsible for identifying the important aspects of the patient care provided, for indicating quality and appropriateness of the important aspects of care, and for the establishment of thresholds that will be used to evaluate the indicators. All personnel are expected to participate in the QI activities.

AUTHORITY AND RESPONSIBILITY

    Governing Body

a. The governing body  shall have the responsibility of assuring the public of the goal of optimal quality of all care delivered within Global United Medical Supplies.

b. The governing body shall make the commitment to provide the financial support necessary for Global United Medical Supplies in order to provide services that are required (e.g., resources, equipment and personnel).

c. The governing body will receive reports from the appropriate parties according to the organizational plan on the findings of the Quality Improvement (QI) activities. The governing body will respond definitively, if necessary, to fulfill their responsibility of adherence to the QI program.

d. The governing body delegates the authority and accountability for the QI program.

e. The governing body stipulates that all departments within Global United Medical Supplies will work together in a cooperative manner to create and maintain an effective program.

f.  The governing body stipulates that the Safety/Infection Control Unit and Quality Improvement Coordinator and Committee will create a unified program of Quality Improvement.

g. The President of Global United Medical Supplies shall represent the governing body.

RESPONSIBILITIES AND COMPOSITION OF THE QI COMMITTEE

A. The Quality improvement Committee shall be combined with the Safety unit and the Infection Control unit to form the Safety/Infection Control/Quality Improvement Committee. The President of Global United Medical Supplies shall appoint the members of QI committee to review QI activities. The committee will consist of at least three members. The President, on an annual basis, will review committee membership and the program coordinator position.

B. The committee shall meet quarterly.

The duties of the committee are:

A. To identify and coordinate all QI activities

B. To conduct routine appraisals of QI unit and to make recommendations regarding QI activities

C. To promote and assist, where needed, in developing standards of care within QI unit

D. To evaluate and coordinate the reports of QI units

E. To identify problems and set priorities for their resolution, if needed

F. To insure that all available data sources are utilized in implementing the QI  program

G. To insure the appropriate utilization of all available methods of studying, assessing, and resolving perceived problems, both within the SICQI Committee and within the individual QI units

H. To reappraise the QI plan at least annually for

Unity of organization and function

Comprehensiveness

Effectiveness in solving problems

RESPONSIBILITIES OF THE QUALITY IMPROVEMENT COORDINATOR:

A. The President appoints the QI Coordinator, and on an annual basis, reviews this appointment.

B. The duties of the QI Coordinator include the following:

To maintains copies of all QI committee minutes and all reports routinely obtained from the

QI unit. A copy of all quarterly meeting minutes will be sent to the President of Global United Medical Supplies for approval.

To maintain a master file of all QI activities.

To attends staff meetings, or sends a representative, when monitoring functions or QI activities are to be discussed.

To assists the QI unit in developing written indicators and thresholds used to assess problems as needed.

To provide references and/or indicators and thresholds developed by QI committee.

To promote concepts of QI through New Employee Orientation.

To prepare data to review/evaluate professional staff of Global United Medical Supplies as deemed necessary.

To promote consistency in QI activities by developing a glossary of terminology used to describe studies or methods employed.

To facilitate quarterly reports by the QI unit to the QI committee.

To collaborate with the QI committee in preparing quarterly reports to be submitted to the President of Global United Medical Supplies.

To provide the President with a yearly rating of each employee regarding the employee’s compliance with the QI program/plan. This rating will be incorporated into the official yearly performance evaluation of each employee.

EVALUATION OF THE QI PROGRAM

The President of Global United Medical Supplies evaluates the program at least annually and direct the committee and its Coordinator as to components that need to be instituted, altered or deleted.

CONFIDENTIALITY

Confidentiality of the QI activity records will be honored. All reports and communications regarding QI activities will be filed in the Coordinator’s office. These records will only be available to the Director, the QI committee, and any other persons authorized by the President of Global United Medical Supplies.

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