Quality Assurance/Improvement

Purpose: 
The University of Arizona/UPHK Graduate Medical Education Consortium, through its Graduate Medical Education Committee (GMEC), has the responsibility for assuring compliance with efforts to provide the highest quality of safety of patient care by its resident physicians.  Such efforts are designed to protect the interests of patients, the University, through its compliance with the Essentials of Accredited Residencies for Graduate Medical Education, and the University’s affiliated institutions through their compliance with standards developed by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). 

Policy:
It is the responsibility of the Program Director to establish program specific guidelines setting out resident participation in quality assurance activities (including reviews of complications and deaths), to ensure collaborative efforts with affiliate institutions in those activities and to provide a record keeping mechanism of those activities to ensure substantial compliance with the ACGME Institutional Requirements as well as the relevant RRC Program Requirements.

In order to support the affiliate institutions in their attempts to ensure quality patient care and to comply with JCAHO requirements, GMEC shall enact a formal process for the resolution of issues of resident-related patient safety and quality care.  In furtherance of that goal, the affiliated institutions will be requested to notify the Program Director and the GME Office of resident-related patient safety and quality of care concerns raised in the course of their institution’s risk management or quality assurance activities.  In that event, the Program Director shall cooperate with and assist the risk management or quality assurance activity of the affiliated institution.  The COM recognizes that the affiliated institutions’ quality assurance activities are confidential peer review activities, and that its cooperation and assistance may be necessary from time to time to assist such institutions in conducting their protected quality assurance activities.  The COM agrees to maintain confidentiality of all privileged matters.  Furthermore, the Program Director shall investigate any such concern and initiate any remedial action as necessitated by the circumstance following established University policies and procedures.  Upon the completion of the investigation and, if needed, remediation of the resident, the Program Director shall, in writing, communicate to the Chief of Staff and the GME Office the assessment that the resident is deemed to be fit for return to the clinical area.

The affiliated institutions’ Chief of Staff or designee will on a regular basis, provide the GMEC with reports assessing the general status of residents’ performance in the areas of clinical competency and patient safety.

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