Quality Assurance Committee of the Department of Surgery
Quality Assurance programs are intended to evaluate and improve the delivery of health care according to standards set by the Department, accepted by the surgical community at large, and conforming to guidelines by the State and Federal agencies. In a surgical setting, the indications for and choice of a procedure, performance with minimal risk and highest standards are basic ingredients in evaluating quality care.
Objectives
- Problem Identification. Prospective, concurrent or retrospective reviews (random or Systematic) will be used to identify problems, i.e. high-risk procedures, deviation from standard practice and unfavorable trends.
The weekly morbidity and mortality conference will be an important source in the
assessment of problems occurring in the operation room, ICU, inpatient and ambulatory units.
The records of the morbidity and mortality conference will be augmented to provide meaningful statistical information.
Problems identified by incident reports, generic quality screening, patient complaints
and reports from inspecting agencies will be assessed by the Committee to determine their
magnitude and impact on quality care.
The review process will be carried out by members of the Committee and if necessary by consultants within or outside the Department.
The Committee’s limited manpower permits only random sampling of cases in selected categories of potential maximal yield. Focused systematic reviews will be conducted after discovery of a specific untoward trend, especially among new untested procedures.
- Corrective Actions. The Committee’s role is advisory to the Department Chairman; it will formulate remedial solution(s) to problems affecting individual staff members or services within the Department. The Committee will communicate with members of the Attending or House Staffs to seek clarification of events; all correspondence will be conducted through the deliberations of the Committee will be confidential, but accessible to the Department Chairman, other Quality Assurance Committees, inspecting agencies and the Credentialing Office.
The Committee’s findings may influence reappointment, promotion or extent of privileges, at the discretion of the Department Chairman.
The Committee will coordinate and integrate its activities with other Quality Assurance bodies to avoid duplication and enhance its efficiency.
The Committee’s efforts will be strengthened by periodic reviews of the literature on issues of quality care. The results of such reviews will be communicated to the Attending and House Staffs, as part of the Committee’s educational function.
- Follow-up and Documentation. Pertinent findings derived from case reviews or tracing of untoward trends and the exchanges between the Committee and the staff member(s) involved will be documented.
If standards of care are not met, follow-up of recommended corrective actions will be
pursued until the problem(s) is eliminated or minimized.
Committee Membership
The composition of the Committee will, whenever possible, be representative of the three General Surgical Teams, Vascular, Pediatric, Plastic Surgery, ICU and the Transplant, Breast and Head and Neck Services.
Representation of House Staff, Nursing or Medical Students is optional.
Changes in membership will be proposed by the Committee, but ultimate approval will rest on the Department Chairman.
The constituency of the membership will be changed every two years.
Annual Review
The Committee will appraise its objectives annually and revise its charge and methods to adapt to changes in the provision of quality care.
Near Miss Project
Near misses are vital learning opportunities that give us the chance to find and fix problems before they harm patients. “Near misses” (or “close calls”) are situations in which one or more mistakes in care delivery are discovered and corrected before a patient suffers any injury.
The information provided goes directly to Dr. Arthur Aufses, former Chairman of the Department of Surgery. He will investigate for the purpose of informing our efforts to improve patient safety and the education of faculty and staff. All reports are confidential and complete anonymity is guaranteed for reporters. To report a near miss, visit the Executive Vice President's Office for Excellence in Patient Care Web site and select the 'Near Misses' tab.
Division Chair and Chief of General Surgery
Tel: (212) 241-5499
E-mail: celia.divino@mountsinai.org
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