Clinical Quality Systems Review. The QRO shall perform a Clinical Quality Systems Review to assess the effectiveness, reliability, and thoroughness of Parkland’s quality management infrastructure and systems throughout Parkland. The QRO shall assess Parkland’s efforts to achieve compliance with its Clinical Quality Policies and Procedures described in Section III.B.2.b-c, the Medicare Conditions of Participation, and other standards designed to ensure that the delivery of patient care items or services at Parkland meet professionally recognized standards of health care and are reasonable and appropriate to the needs of Federal health care program beneficiaries. The Clinical Quality Systems Review will be undertaken at all relevant levels of the organization. The QRO shall assess, among other things, the effectiveness, reliability, and thoroughness of the following:
1. Parkland’s quality management infrastructure, including but not limited to an assessment of:
a. Parkland’s Quality of Care Dashboard required under section III.A.4.b. of this CIA;
b. The accuracy of Parkland’s internal reports, data, and assessments required by the Clinical Quality Policies and Procedures;
c. Xxxxxxxx’s ability to analyze outcome measures and other data;
d. The extent to which reviews under Parkland’s Quality, Safety, and Performance Improvement Program and other reviews are occurring to identify and address quality management issues at Parkland;
e. Parkland’s compliance with the Clinical Quality Training requirements, Clinical Quality Policies and Procedures, and performance standards of Section III.B.2.b–c & III.C.3 of the CIA;
f. The extent to which Parkland’s Clinical Quality Training program is effective, thorough, and competency-based;
g. The extent to which Parkland’s communication systems are effective and results of decisions are transmitted to the proper individuals in a timely fashion.
2. Xxxxxxxx’s response to quality of care issues, which shall include an assessment of:
a. Xxxxxxxx’s ability to identify the problem;
b. Xxxxxxxx’s ability to determine the scope of the problem (e.g., systemic or isolated);
c. Xxxxxxxx’s ability to conduct a root cause analysis;
d. Xxxxxxxx’s ability to create a corrective action plan to respond to the problem;
e. Xxxxxxxx’s ability to execute the corrective action plan;
f. Parkland’s ability to operate in a timely and effective manner; and
g. Parkland’s ability to monitor and evaluate whether the assessment, corrective action plan, and execution of that plan were ...
Clinical Quality Systems Review. The QRO shall assess the effectiveness, reliability, and thoroughness of Parkland’s quality of care and patient safety systems, as outlined in Appendix D to this CIA.
Clinical Quality Systems Review. The IRO shall assess Txxxx’x compliance with its Clinical Quality policies and procedures described in Section III.B.2.c, the Medicare Conditions of Participation and other standards designed to ensure that the delivery of patient care items or services at Txxxx hospitals meet professionally recognized standards of health care and are reasonable and appropriate to the needs of Federal health care program beneficiaries. The IRO shall assess, among other things, the following:
a. Xxxxx’x quality management infrastructure at all corporate levels, including, but not limited to, an assessment of:
(i) whether Txxxx is carrying out its functions to review, analyze, and address quality of care issues;
(ii) whether systems are in place to sufficiently promote and respond to quality of care issues;
(iii) whether systems are operating in a timely and effective manner; and
(iv) whether communication systems are effective, and results of decisions are transmitted to the proper individuals in a timely fashion.
b. Xxxxx’x response at all corporate levels to quality of care issues, which shall include an assessment of:
(i) Txxxx’x ability to identify the problem;
(ii) Txxxx’x ability to determine the scope of the problem (e.g., systemic or isolated);
(iii) Txxxx’x ability to create a corrective action plan to respond to the problem;
(iv) Txxxx’x ability to execute the corrective action plan; and
(v) Txxxx’x ability to evaluate whether the assessment, corrective action plan, and execution of that plan were effective, reliable, and thorough and maintained.
c. The accuracy of Txxxx’x internal reports, data and assessments that are required by the Clinical Quality Policies and Procedures.
d. The extent to which Txxxx’x Comprehensive Clinical Audits and other reviews are occurring to identify and address quality management issues at Txxxx hospitals.
e. Xxxxx’x compliance with the clinical quality training, Clinical Quality Policies and Procedures, and performance standards and bonuses requirements of Section III of the CIA.
Clinical Quality Systems Review. The QRO shall assess the effectiveness, reliability, and thoroughness of Providence’s quality of care and patient safety, credentialing, privileging, and peer review processes, as outlined in Appendix D to this CIA.
