Quality Assurance
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Intent:
The Accreditation Council for Graduate Medical Education Institutional Requirement (I. E.) requires that institutions and residency programs participating in graduate medical education conduct formal quality assurance programs and review complications and deaths. All residents should receive instruction in and must participate in appropriate components of the institution's quality assurance and improvement program. Complications and deaths should be meaningfully reviewed and medical records should be evaluated as to their completeness and accuracy as part of this process.
Policy Statement:
The purpose of the hospital wide quality assessment improvement program is to assess and improve the quality of patient care and service at hospitals conducting Graduate Medical Education.
Description:
Quality Assurance is accomplished through the identification and effective use of opportunities to improve the overall quality of care within the institution, as well as the resolution of problems identified. This purpose may be accomplished through:
- Hospital and medical staff department participation in the development and implementation of quality assessment and improvement plans.
- The responsibility for overall coordination of quality care is usually delegated to a Quality Assurance Committee.
- Medical staff and hospital wide monitoring functions which may include: surgical case review, drug usage and evaluation, medical record review, blood usage review, infection control, safety management, risk management, patient satisfaction and complaint management. Relevant results of these monitoring activities will be incorporated in each department's monitoring and evaluation of the quality of patient care and service.
In addition, monitoring results will be used to evaluate the clinical performance of all individuals with clinical privileges as well as all others providing patient care but not permitted by the hospital to practice independently. These results (reports) should be discussed with housestaff. Housestaff should have the opportunity to serve on these committees.
Ultimately each department and program must have a process to ensure that quality improvement is part of the daily educational structure of the residency. This can be accomplished in many ways including M & M morning report, pre-operative conferences, etc.
Each program must demonstrate a commitment to quality improvement and be able to demonstrate resident participation during periodic Internal Reviews.
Last Review: Institutional Committee for Graduate Medical Education
