AAAHC:QualityMgmtImprove

Rights of Patients
Governance
Administration
Quality of Care Provided
Quality Management Improvement
Clinical Records and Health Information
Infection Prevention and Control and Safety
Facilities and Environment
Anesthesia Services
Surgical & Related Services
Pharmaceutical Services
Pathology & Medical Laboratory Services
Diagnostic & Other Imaging Services
Other Professional & Technical Services
Health Education and Health Promotion

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

WKUHS AAAHC Accreditation : Quality Management Improvement