The Director of Quality Improvement is responsible for coordinating quality improvement programs for patient and support services. This department is responsible for the overall coordination of both Medical Staff and institutional quality assessment and improvement activities. This includes the mechanisms for data trending. The QI Director reports directly to the Administrator regarding management functions and is also a member of key quality management committees. The scope of the activities of the department includes: quality management, support of Medical Staff quality management activities and clinical data management.
The QI Director is also responsible for: developing specific quality management and improvement plans, delineating scope of care and important aspects of care, developing clinical indicators and thresholds for evaluation, establishing mechanisms for peer and outcome review, and implementing the Quality Management and Improvement Plan, identifying and documenting: the findings, pertinent discussion, conclusions, recommendations, actions, and follow-up on the effectiveness of action developing, recommending, implementing and assessing the effectiveness of actions taken to improve care, using the results of quality improvement data, establishing specific strategic quality goals, and involving patients through survey tools and focus groups.
The Quality Improvement Department is staffed by one (1) full time Director five (5) days per week Monday through Friday from 7:30am—4:00pm.