1.2.2 Medical Care Evaluation / Performance Improvement / Patient Safety Activities a.
Actively be involved in the measurement, assessment, and improvement of activities of practitioner performance that include but are not limited to the following:
i. |
Medical assessment and treatment of patients; |
ii. |
Use of medications; |
iii. |
Use of blood and blood components; |
iv. |
Operative and other procedures; |
v. |
Education of patients and families; |
vi.
Accurate, timely, and legible completion of patients’ medical records to include the quality of medical histories and physical examinations;
vii. |
Appropriateness of clinical practice patterns; |
viii. |
Significant departures from established pattern of clinical performance; |
ix. |
Use of developed criteria for autopsies; |
x. |
Sentinel event data; |
xi. |
Patient safety data; |
xii.
Coordination of care, treatment, and services with other practitioners and Hospital personnel, as relevant to the care, treatment, and services of an individual patient; and
xiii. Findings of the assessment process relevant to individual performance.
Communicate findings, conclusions, recommendations, and actions to improve the performance of practitioners to medical staff leaders and the Board, and define in writing the responsibility for acting on recommendations for practitioner improvement.
1.2.3 Hospital Performance Improvement and Patient Safety Programs a.
Understand the medical staff’ s and administration’ s approach to and methods of performance improvement;
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