Criterion 21: #7153

Finding: 
Compliance
Published Date: 
October 22, 2011

The framework of the institution is designed to promote quality improvement. The inclusion of multiple institutional stakeholders and departments on the performance improvement committee allows the provider to make decisions regarding the most appropriate ways to address identified quality gaps. When education is appropriate, CME stands ready to address the gap. The organization is also positioned to apply other appropriate interventions, such as technology changes and staffing modifications. In addition, performance improvement data is shared with the CME committee, which includes all specialty departments.

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