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Quality Improvement Teams Composition

Quality improvement teams are composed of individuals with expertise in the function or process being studied. A team leader coordinates the evaluation and ensures documentation and communication. Team members represent affected departments and evaluate clinical processes. There are two types of teams: chartered teams appointed by the quality council to address specific issues, and departmental teams focused on tasks within a department. Team activities focus on improving quality, safety, reliability and other aspects of customer service. Teams may make recommendations or forward results to the quality council for action.

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30 views

Quality Improvement Teams Composition

Quality improvement teams are composed of individuals with expertise in the function or process being studied. A team leader coordinates the evaluation and ensures documentation and communication. Team members represent affected departments and evaluate clinical processes. There are two types of teams: chartered teams appointed by the quality council to address specific issues, and departmental teams focused on tasks within a department. Team activities focus on improving quality, safety, reliability and other aspects of customer service. Teams may make recommendations or forward results to the quality council for action.

Uploaded by

Lokesh Jena
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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QUALITY IMPROVEMENT TEAMS

COMPOSITION
Teams are made up of a sufficient number of individuals with expertise in the function or process being studied
to fully address the identified opportunity. Each team will have a Team Leader appointed by the Quality
Council (QC) that is assigned the responsibility of coordinating the interdisciplinary evaluation of the identified
opportunity or problems.
It is the responsibility of the Team Leader to:
 Set up the agenda and meeting time with team members.
 Participate as a team member.
 Guide the Team by allowing the free exchange of ideas and involving all team members in the process
 Ensure proper documentation of team activities including allocation of responsibilities for data
collection and minute taking.
 Guide the team to successful problem resolution through implementation and follow-up.
 Communicate with the Administrative Representative overseeing that process.
 Communicate Team’s progress to the QC.
Team Members:
Members are selected based on their familiarity with the process under review and represent those departments
or activities within departments that affect or may be affected. Medical Staff members evaluate clinical care
or processes.
It is the responsibility of Team Members to:
 Establish and adhere to the rules for team conduct.
 Offer ideas on issues addressed by the team.
 Participate in all team meetings.
 Recognize team participation as part of “the job”.
 Perform assigned tasks between meetings.
 Serve as timekeeper or recorder of minutes as requested by the Team Leader.
 Participate in evaluation of problems and determine root causes.
 Participate in setting goals and developing action plans for the team.
 Recommend agenda items for future meetings.
 Critique and offer suggestions for improving the meeting process.
 Implement recommendations of the team and monitor results.
 Assist in the preparation and presentation of documentation and reports on team activities and results
TYPES OF TEAMS:
Chartered Teams:
Teams that are appointed by the QC to address specific issues or processes. Representation on these teams is
cross-functional and represents varying levels of managers, employees and physicians. This team provides a
formal report to the QC. The area of focus will determine the composition, size, and longevity of the team.
Departmental Specific Teams:
Teams that are informal and typically designed by a Manager to work within a department on a specific task
using a team approach and problem solving tools. This team is limited in scope. Employees at all levels are
encouraged to participate. This team provides a formal report of their activities to the QC through the sub
council and Quality Improvement Department.

SCOPE OF TEAM ACTIVITIES:


Team activities should focus on issues regarding the improvement of the quality and safety of service to
customers. The Team may address organizational efficiency, cost effectiveness and the general wellbeing of
the customers. Examples are:
 Quality of service
 Patient safety
 Reliability of service
 Quality of product
 Process control and improvement
 Design of a new process/technology
 Improvement of systems
 Reducing operating costs
 Reducing re-work
 Efficiency of job performance
 Internal operations
 Improvement in communication, attitudes, and morale
 Equipment performance
 Environmental safety
 Scheduling
 Education

TEAM ACTIONS:
Depending upon the problem/process being evaluated, the Team may make direct recommendations for action
or forward the results to the QC for action.
Suggested actions based upon problems that involve system deficiencies include:
 Changing communication channels.
 Changing inventory or equipment.
 Revising job descriptions.
 Adding or revising policies and procedures.
 Designing new flow patterns.
 Re-structuring work loads.
 Developing treatment protocols.
 Implementing pilot trials/studies.

Suggested actions based upon problems in staff knowledge include:


 Modifying orientation procedures.
 Focused in-service education.
 Focused continuing education.
 Dissemination of informational material, i.e., policies.
COMMITTEE SUPPORT
Multidisciplinary committees may address Inter-Departmental Performance Improvement issues when
evaluating functions of the Medical Staff as well as hospital functions. These committees include those
specified in the Medical Staff Bylaws, Rules & Regulations.

ACTIVATING A TEAM:
Any employee or Medical Staff member may forward a request for a team to the QC. All requests for a team
should be made using the Opportunity Referral Form, (see attached). Each referral will be evaluated and
prioritized by the QC or a sub-committee assigned by the QC.

If the problem/ process involve more than one department, the QC may authorize the formation of the Team,
and assign a Team Leader. If the problem/process affects a single department, the QC will forward the referral
to a single department for intra-departmental team development. It is imperative that departmental leadership
allow staff member(s) time to participate in order for the team to be successful.

QUALITY IMPROVEMENT MODEL


Facility utilizes the IDEA Cycle (Identify – Determine – Explore – Activate) as the model for Quality Improvement.

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