Witalis LLC

Purpose

The Quality & Safety Committee assists the board in fulfilling its governance responsibilities for quality, patient safety, clinical effectiveness, patient experience, and medical staff credentialing and oversight. The committee provides direction, oversight, and accountability for organizational quality and safety, and for continuous improvement.

Committee Membership

The committee has at least five members, including:

• Three board members, including at least one physician board member
• At least two of the following executives: CEO, CMO, CNO, or Chief of Medical Staff

The committee chair is appointed by the board chair.

Meetings

• Meets at least six times each year.
• A majority of committee members constitutes a quorum.
• The chair reports committee actions and recommendations to the full board after each meeting.

Primary Duties

• Oversee that quality assurance and improvement processes are in place and operating.
• Enhance quality across the patient care, technical, and operational areas of the organization, including the interface and experience between patients, families, and the community, and coordination and alignment within the organization.
• Assure continual learning and skills development for risk surveillance, prevention, and continuous improvement. The committee examines activities against the Institute of Medicine’s Six Aims for Improvement: safe, effective, patient/family-centered, efficient, timely, and equitable.

Specific Responsibilities

• Develop and oversee an annual quality improvement plan.
• Establish and monitor performance goals, targets, and metrics related to quality, patient safety, patient experience, and clinical outcomes.
• Oversee the organization’s Quality Assessment and Performance Improvement (QAPI) program.
• Review CMS, Joint Commission, state survey, and accreditation findings.
• Oversee serious safety events, infections, medication safety, mortality, readmissions, and other high-risk indicators; develop and monitor corrective actions as needed.
• Review, oversee, and monitor accreditation surveys, regulatory findings, and corrective action plans.
• Monitor enterprise quality risks and strategic quality initiatives.
• Ensure quality priorities align with the strategic plan.
• Align investments with those that improve quality, safety, and experience for patients and staff.

Credentialing and Privileging

• Review and approve Medical Executive Committee recommendations for appointments, reappointments, privileges, and professional practice evaluations.
• Ensure credentialing activities comply with medical staff bylaws, rules, and regulations.
• Review credentialing matters in closed session when appropriate and recommend board action.
• Review medical staff corrective actions and physician leadership development.
• Monitor physician relations.

Reporting to the Board

The committee chair reports out at each regular board meeting, and provides the full board an annual summary of the strategic plan’s status, including any assumptions that have changed and any resulting recommendations.

Reporting

The committee establishes and oversees a board-level quality dashboard, including performance measures, trends, and national benchmarks relating to:

• CMS Star Rating and domain performance
• Patient safety and experience scores
• Infection prevention
• Regulatory and accreditation status
• Performance improvement initiatives
• Quality risk mitigation
• Credentialing audit (at least every two years)

Standard Duties for All Committees

• Develop and recommend to the board, for approval, a charter that supports the organization’s mission and values; review and refine the charter as needed.
• Review and reassess the adequacy of this charter at least annually and recommend any proposed changes to the board for approval.
• Identify issues requiring full board deliberation and develop materials to inform board discussion and decision-making.
• Maintain expertise on the committee sufficient to execute its purpose, duties, and functions.
• Carry out responsibilities delegated by the board.
• Periodically review its own performance against the requirements of this charter.
• Maintain agendas and minutes documenting meeting date and time, attendees, significant discussion items, and any actions taken.

Charter Review

At least annually.