System Board Quality Committee Guidelines

Quality Committee

The Hospital System Board of Trustees Quality Committee shall meet quarterly in order to provide:

Visibility and focus for the organization’s commitment to the delivery of high quality medical care;

Oversight of quality and performance improvement initiatives across the Hospital System, as demonstrated by:

  1. Approval of an annual Quality and Performance Improvement Plan which is supportive of the system’s strategic goals, and which will include specific core performance improvement indicators in the areas of clinical quality, accreditation compliance, patient safety, and customer satisfaction (patient, physician, and employee), to be measured at all care sites;
  2. Approval of annual performance targets for those indicators;
  3. Quarterly monitoring of measurements of those core indicators;
  4.  Feedback to care sites of desired performance improvement in specific areas;

Recommendation of appropriate allocation of resources to support performance improvement.Review of external peer review and other agency reports which describe quality, accreditation, patient satisfaction, or safety performance.

Similar review and monitoring of the following site-specific quality/performance improvement activities:

  1. Regular reports of the professional review activities of each medical staff;
  2. Regular reports of the quality assurance activities of all non-medical staff departments at all facilities;
  3. Assessment of site-specific clinical, accreditation, patient satisfaction, and safety issues, in order to drive needed improvements for each facility within the System.
  4. Assessment of risk management issues across the System.

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