It is important to provide a clear picture of how the department assesses and controls quality, including examples of problems, sentinel events, improvement strategies and policies that have been adopted for the surveyors to evaluate in order to avoid a more intense review later in the survey process. Leadership Interviews - addresses the collaboration of leaders in the performance improvement process. This session is designed to make sure that problems are routinely brought to the attention of leadership and resolved as part of the overall strategic planning of the hospital. Visits to Patient Care Settings - these include the operating room, anesthetizing locations and recovery areas. Surveyors are especially sensitive to patient privacy, control of medications, the preoperative process, re-evaluation of the patient's status before induction, infection control and compliance with the other regulations set forth above.
Unresolved issues are likely to surface here.
Leadership Exit Conference - surveyors meet with leadership to review and discuss findings, including any potential accreditation issues, including presentation of a preliminary report. Performance measurement systems were solicited by the Joint Commission and then reviewed, and those meeting the criteria have been listed as acceptable for accreditation. The cost of ORYX will be assessed to the performance measurement systems, and it is expected that most of these costs will be passed back to enrolling health care organizations. The 1998 ORYX requirements for the hospital accreditation program have been established. The minimum number of clinical measures that may be selected is two.