Charter

Committee Members:

Director: Steven Baccei, MD

Clinical Sections Quality Officers:

• Body Imaging: Sarwat Hussain, MD
• Neuro: Sathish Dundamadappa, MD
• Breast: Rebecca Hultman, MD
• MSK: Steven Baccei, MD
• Chest: Charu Desai, MD
• Nuclear Medicine: Robert Licho, MD
• VIR: Hesham Malik, MD
• NIR: Ajit Puri, MD
• Peds: Christine Wallace, MD
• Technical Lead Quality Analyst: Unfilled
• Technical Lead Patient Safety Analyst: Unfilled
• Technical Supervisor University: Stephen Beaudoin
• Technical Supervisor Memorial: Marcia Amaral
• Nursing Supervisor: Anne Morrissey
• X-Ray Dose Reduction and Monitoring:
  • Byron Chen, MD
  • Andrew Karellas, PhD
• Radiology Resident: Stacy Gagne, MD (2014-2015)
• Coding and Documentation: Penny Ellsworth                      

Structure:  Radiology Department Quality and Patient Safety Committee Meetings

Quarterly: 12pm-1pm; Second Thursday, Last Month of Quarter

Divisional Q/A meetings (coordinated by Quality Officers from each Section)
Quarterly:  Precede Departmental Quality and Patient Safety Committee Meetings.

Departmental M&M/Quality and Patient Safety Noon Conference
Quarterly: 12pm-1pm; Fourth Monday, Last Month of Quarter

Scope:  Quality and Patient Safety issues throughout Department of Radiology 

Goals:

1. Establish radiology quality and patient safety committee.
2. Establish committee member roles.
3. Review and catalogue cases relevant to radiology quality and patient safety.
4. Oversee and select cases for presentation at radiology M&M/quality and patient safety noon conference.
5. Oversee and coordinate quality and process improvement initiatives throughout the department.

Methods:

1. Clinical Sections’ Quality Officers will hold divisional quality and patient safety meetings on a quarterly basis (to precede Departmental Quality and Patient Safety Committee Meetings).  These meetings are held as part of the “Peer Review” Process.
     A. Review section specific cases/issues and determine which have potential multi-divisional or department wide impact.
     B. Catalogue these cases with brief write-up detailing specifics of the case.
     C. Forward cases to Director no less than 2 weeks prior to department committee Meetings (second Thursday, last month of quarter).

2. Director will catalogue and review cases submitted by the clinical sections’ quality officers, Technical Leads, and Nursing Leads.  These case reviews will be conducted as part of the “Peer Review” Process.
     A. Director will select 6-8 relevant cases for presentation at Departmental Quality and Patient Safety Committee Meeting.

3. Departmental Quality and Patient Safety Meetings will take place on second Thursday, last month of quarter, 12-1pm.  These meetings are conducted as part of the “Peer Review” Process.
     A. Review 6-8 relevant cases for presentation of 3-4 cases at Departmental M&M/Quality and Patient Safety Noon Conference
     B. Determine if recommendation to Radiology Chairman for Root Cause Analysis/Countermeasures implementation should be made.
     C. Oversee and coordinate quality and process improvement initiatives throughout the department.
     D. Record and catalogue relevant discussion in the form of minutes.

4.Departmental M&M/Quality and Patient Safety Noon Conference
   Quarterly: 12pm-1pm; Fourth Monday, Last Month of Quarter
   This conference is conducted as part of the “Peer Review” Process.