Accreditation Quality Improvement Program

Quality Improvement
Quality Improvement

The surgery center must present to the accreditation organization’s inspector the components of an active quality improvement program that is being monitored on a continuous basis; all measurements of data collection & findings must be forwarded to the Governing Body.

How strong is your quality improvement plan/policy and program?  Components of an effective program include:

Peer Review

Quality Improvement Studies

Internal & External Benchmarking

Monitoring & Surveillance of the Infection Control Program

Education In-services

Surveillance of the Physical Environment or Environment of Care

Patient Satisfaction

Credentialing & Human Resources i.e. Personnel

Safety Drills

All aspects need to be documented usually on a quarterly basis or depending on the size and frequency of patient visits.  What does your policy say?

Check your accreditation standards manual for guidance as to what they require and implement it into your policy.  Get into the habit of creating work sheets and evaluation logs to make your job easier to track the data collection.  Remember documentation is crucial for a successful survey.

Here’s to your success,



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