The organized medical staff leads and participates in organizationwide performance improvemen...

(1)

The organized medical staff provides leadership for measuring, assessing, and improving processes that primarily depend on the activities of one or more physicians or other licensed practitioners credentialed and privileged through the medical staff process.

(2)

Information used as part of the performance improvement mechanisms, measurement, or assessment includes sentinel event data and patient safety data.

(3)

The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following: - Participating in the establishment of protocols and quality metrics - Reviewing performance improvement data

(4)

The organized medical staff completes patient medical records accurately, timely, and legibly.

(5)

The organized medical staff participates in the following performance improvement activities: - Review of findings of the assessment process that are relevant to an individual’s performance. The organized medical staff is responsible for determining the use of this information in the ongoing evaluation of a physician's or other licensed practitioner’s competence. - Communication of findings, conclusions, recommendations, and actions to improve performance to appropriate staff members and the governing body.