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Western Kentucky University

WKUHS AAAHC Accreditation : Quality Management Improvement

I.D. Chapter Evidence Notes

5

Subchapter 1 -Peer Review

 

 

5.A 

Quality Management & Improvement

Peer Review 

 

 5.B

Quality Management & Improvement

Peer Review

WKUHS's Peer Review program is under the direction of the Medical Director

 5.B.1

Quality Management & Improvement

Peer Review

 

5.C 

Quality Management & Improvement 

Peer Review

 

5.D 

Quality Management & Improvement 

Peer Review

 

5.E 

 Quality Management & Improvement

Peer Review

 

5.F 

Quality Management & Improvement 

Peer Review

 

 5.G

Quality Management & Improvement 

Peer Review

Provider:Credential/Privilege

 

5.H 

Quality Management & Improvement 

 Peer Review

WKUHS provides access to educational articles and information via internet access,  CME/CEU's,conferences and trainings. 

5.H.1 

Quality Management & Improvement 

Peer Review

See 5.H 

5.H.2 

Quality Management & Improvement 

Peer Review

See 5.H 

 5.I

Quality Management & Improvement 

Provider:Credential/Privilege

Ancillary:Credential/Privilege

The Medical Director and Clinical  Nurse Manager maintain certification and licensure files for clinical staff to ensure that credentials are up to date.

5

Subchapter 2 -Quality Improvement Program 

 

 

 5.A

Quality Management & Improvement 

Quality Improvement Program 

The  focus areas of WKUHS's quality improvement program include: Appropriateness, Effectiveness, Patient Focus, Prevention & Education and Timeliness.

5.A.1 

Quality Management & Improvement 

Quality Improvement Program

 

 5.A.2

Quality Management & Improvement 

Quality Improvement Program

WKUHS's Quality Committee oversees  quality improvement activities and reports to the Governing Body.

5.A.3 

Quality Management & Improvement 

 Quality Improvement Program

 

5.A.4 

Quality Management & Improvement 

Quality Improvement Program 

 

5.A.5 

Quality Management & Improvement 

Quality Improvement Program

 

5.A.6 

Quality Management & Improvement 

 Quality Improvement Program

 

 5.A.7

Quality Management & Improvement 

Quality Improvement Program

When indicated, action items derived from the results of QI and Peer Review studies are used for learning opportunities, in the privileging & credentialing process and during the risk management planning process. 

5.A.8 

Quality Management & Improvement 

Quality Improvement Program 

 

 5.A.9

Quality Management & Improvement 

Quality Improvement Program 

 See 5.A.2

5.B 

Quality Management & Improvement 

Quality Improvement Program

QI Study Template

Proposals for QI studies are presented to the Quality Committee and approved before being completed. Most study results are presented on a quarterly basis.

 5.B.1

Quality Management & Improvement 

 QI Study Template

 See 5.B

 5.B.2

Quality Management & Improvement 

QI Study Template

 See 5.B

5.B.3 

Quality Management & Improvement 

QI Study Template

See 5.B 

 5.B.4

Quality Management & Improvement 

QI Study Template

 See 5.B

5.B.5 

Quality Management & Improvement 

QI Study Template 

See 5.B 

5.B.6 

Quality Management & Improvement 

 QI Study Template

See 5.B 

 5.B.7

Quality Management & Improvement 

QI Study Template 

See 5.B 

 5.B.8

 Quality Management & Improvement

QI Study Template 

See 5.B 

 5.B.9

Quality Management & Improvement 

QI Study Template 

 See 5.B

5.B.10 

Quality Management & Improvement 

QI Study Template 

See 5.B 

 5.C

Quality Management & Improvement 

Quality Improvement Program 

WKUHS has participated in external benchmarking from ACHA, AHRQ and others. Information from external sources is  used to create goals and for comparison purposes during educational activities provided to students.   

 5.C.1

Quality Management & Improvement 

Quality Improvement Program 

 See 5.C

5.C.1.a 

Quality Management & Improvement 

Quality Improvement Program 

See 5.C 

 5.C.1.b

Quality Management & Improvement 

 Quality Improvement Program

 See 5.C

 5.C.1.c

Quality Management & Improvement 

 Quality Improvement Program

 See 5.C

 5.C.1.d

Quality Management & Improvement 

Quality Improvement Program 

See 5.C 

5.C.1.e 

Quality Management & Improvement 

Quality Improvement Program 

See 5.C 

 5.C.1.f

Quality Management & Improvement 

Quality Improvement Program 

See 5.C 

 5.C.2

Quality Management & Improvement 

 Quality Improvement Program

 

 5.C.3

Quality Management & Improvement 

Quality Improvement Program 

Results from benchmarking studies are reported to the Quality Committee and Governing Body. 

 5

Subchapter 3 -Risk Management 

   

 5.A

Quality Management & Improvement 

 Risk Management Plan

Implementation and oversight of the Risk Management Program is managed through the Governing Body.

5.B

Quality Management & Improvement 

Risk Management Plan 

See 5.A

5.C

Quality Management & Improvement 

Risk Management Plan 

 

5.C.1

Quality Management & Improvement 

Risk Management Plan 

 

5.C.2

Quality Management & Improvement 

Risk Management Plan 

Patient Dismissal

Patient dismissal is used only as a last resort.

 5.C.3

Quality Management & Improvement 

Risk Management Plan 

 Incident Reporting

The Incident Review Committee monitors and creates action plans when incidents occur. 

5.C.4

Quality Management & Improvement 

 Risk Management Plan

Incident Reporting

 See 5.C.3

 5.C.5

Quality Management & Improvement 

Risk Management Plan 

Incident Reporting

See 5.C.3 

 5.C.6

Quality Management & Improvement 

Risk Management Plan 

Incident Reporting

 See 5.C.3

 5.C.7

Quality Management & Improvement 

 Risk Management Plan

Incident Reporting

 See 5.C.3

 5.C.8

Quality Management & Improvement 

Risk Management Plan 

 

 5.C.9

Quality Management & Improvement 

Risk Management Plan 

Impaired Professionals

WKUHS employees are expected to refrain from activities that cause impairment while working and to report and/or assist in the event a professional becomes incapacitated at work. 

 5.C.10

Quality Management & Improvement 

Risk Management Plan 

Impaired Professionals

See 5.C.9

5.C.11

Quality Management & Improvement 

Risk Management Plan 

After Hours Care

WKUHS designates a late provider for coverage while there are patients being treated in the facility. When WKUHS is closed, information is available for after hours care.

5.C.12

Quality Management & Improvement 

Risk Management Plan 

Prescription pads are kept under lock and key when not in use. 

5.C.13

Quality Management & Improvement 

Risk Management Plan 

Time Out Procedure

 

 5.C.14

Quality Management & Improvement 

 Risk Management Plan

Infection Prevention

 

 5.D

Quality Management & Improvement 

 Risk Management Plan

 

 5.E

Quality Management & Improvement 

Risk Management Plan 

Visitor Policy

 

 5.F

Quality Management & Improvement 

Risk Management Plan 

Peer Review

 

 5.G

Quality Management & Improvement 

 Risk Management Plan

 

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 Last Modified 9/24/14