Quality Committee Structure

I. Mission Statement: Insert Program/Organization’s mission

Excellence in HIV related patient care, education and research, consistent with the medical center's mission to provide premier programs in patient care, biomedical and health sciences research and teaching that will contribute to the prevention, diagnosis, and treatment of human disease and disability.

II. Purpose

• To provide oversight and facilitation of the ______________________ quality management (QM) program.
• To provide a mechanism for the objective review, evaluation, and continuing improvement of the HIV program.

III. Goals:

A. Address goals outlined in the quality management plan:

• Develop a planning mechanism incorporating baseline data from external and internal sources (List sources) and input from department leadership, staff and patients. Clinical, operational and programmatic aspects of patient care will be reviewed.
• Emphasize design needs associated with new and existing services, patient care delivery, work flow and support systems which maximize results and satisfaction on the part of the patients and their families, physicians and staff.
• Evolve and refine measurement systems for identifying trends in care and sentinel events by regularly collecting and recording data (through a valid sampling program when appropriate) and observations relating to the provision of patient care across the continuum.
• Employ assessment procedures to determine efficacy and appropriateness and to judge how well services are delivered and whether opportunities for improvement exist.
• Focus on improving quality in all of its dimensions by implementing multidisciplinary, data driven, project teams and encouraging participatory problem solving.
• Promote communication, dialogue and informational exchange across the department and throughout the organizations reporting structure, with regard to findings, analyses, conclusions, recommendations, actions and evaluations pertaining to performance improvement.
• Strive to establish collaborative relationships with diverse community agencies for the purpose of collectively promoting the general health and welfare of the community served.
• Address QM content regarding the following major functional areas and important aspects of care: a. Clinical Primary Care, b. Clinical Research (AIDS Clinical Trials Group – ACTG), c. Patient and Staff Education, d. Continuity of Care, e. Patient Satisfaction, f. Support Services, g. Medical Record/Information Systems, and h. Utilization Review.

B. Review and update the quality plan yearly.

C. Conduct an annual evaluation of the HIV Quality Management program.

D. Prioritize quality goals and projects so the most critical areas are addressed.

E. Plan for appropriate education relating to quality improvement concepts and techniques.

F. Provide guidance for site visits.

G. Develop a program-reporting calendar to the quality committee.

IV. Committee Membership:

• Program medical directors
• Program administrator
• Quality management coordinator
• Unit Manager
• Data manager
• Pharmacist
• Social worker
• Psychiatric Nurse
• Nurse practitioner
• Family Nurse
• Peer Advocate
• Research nurse

V. Committee Meeting Schedule:

• Meet 10 times a year and as indicated

VI. Committee Reporting Structure:

• Forward committee minutes to leadership
• Provide reports to relevant individuals and groups