(718) 963-7276
The QA-PI Division of the Regulatory Services Department, as directed by the Board of Trustees, the Medical Board, the President/CEO of Wyckoff Heights Medical Center, is responsible for supporting the Board of Trustees’ approved Plan for Improving Organizational Performance in the coordination of all quality assessment and performance improvement activities throughout the institution. In addition, the QA-PI Division reviews, analyzes, and makes recommendations and innovations concerning quality assessment and performance improvement activities based on recommendations from within the Medical Center as well as from resources and agencies outside the Medical Center, including pertinent literature.
The QA-PI Division receives and reviews departmental quality assessment and improvement activity reports from all departments and services in the hospital, both clinical and non-clinical, and maintains a file of the quarterly summaries. In addition, all Professional Staff Quality Assessment Review forms are received, reviewed, logged and tracked for each department for file reconciliation and as reminders for completion of overdue assessments.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
Minutes from the OPEC / Quality Management and Patient Safety Committee and Subcommittee meetings are maintained in the Regulatory Services Department. Periodic summary reports are prepared as needed and required.
The Regulatory Services Department ensures that each department has its own Performance Improvement Program and written plan which is consistent with, and an integral part of, the Hospitalwide Quality Management and Patient Safety Program and Improving Organizational Performance Plan, including adoption of the Medical Center’s mission. On a yearly basis, a comprehensive report is prepared and presented to the Board of Trustees and the Medical Board. Each department conducts an annual assessment of its departmental Performance Improvement Program, and its relationship to the goals and objectives of the Medical Center..