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 ;
4879-7702-4986 , v . 1 31