Department of Microbiology Quality Manual / Policy QPIMI01001.09 / Page 3 of 3
Section: Process Improvement / Subject Title: Identification of Improvement Opportunity Procedure

Purpose:

To define the procedure for identifying opportunity for improvement

Responsibility:

Members of the Quality Improvement Committee.

Procedure:

1.  QI Committee members will meet quarterly to select opportunities for improvement and the appropriate indicators.

2.  Select improvement opportunities based on :

·  Client Input - QSSMI01001

·  Client Satisfaction Survey Procedure QSSMI01004

·  Staff Input - QSSMI01002

·  Staff Satisfaction Survey Procedure QSSMI01003

·  Reports from occurrence trends - QOMMI01005

·  Reports from internal assessment of the path of workflow – QASMI02000

·  Reports from internal audits of the quality system - QASMI02000

·  Reports from laboratory inspections – QASMI03000

·  Reports from proficiency testing - QPCMI07001a

·  Initiatives from literature review or practices from other organizations in order to achieve best practices.

·  Reports from TML Quality Management Committee

3.  Establish indicator for each opportunity for improvement

4.  Prioritize indicators based on:

·  Patient care impact

·  Customer satisfaction impact

·  Financial impact

·  Staff satisfaction impact

5.  Select one or more indicators per quarter.


Related Documents:

Client Input Procedure QSSMI01001 / QSSMI01001
Client Satisfaction Survey Procedure QSSMI01004 / QSSMI01004
Staff Input Procedure QSSMI01002 / QSSMI01002
Staff Satisfaction Survey Procedure QSSMI01003 / QSSMI01003
Occurrence trends / QOMMI01005
Internal assessment of the path of workflow /

QASMI02000

Internal audits of the quality system / QASMI02000
Laboratory inspections / QASMI03000
Proficiency Testing Report Summary / QPCMI07001a


Record of Edited Revisions

Manual Section Name: Identification of Improvement Opportunity Procedure

Page Number / Item / Date of Revision / Signature of Approval
Annual Review / March 05, 2004 / Dr. T. Mazzulli
Annual Review / March 20, 2005 / Dr. T. Mazzulli
Annual Review / July 31, 2006 / Dr. T. Mazzulli
Annual Review / August 13, 2007 / Dr. T. Mazzulli
Annual Review / August 13, 2008 / Dr. T. Mazzulli
Annual Review / August 15, 2009 / Dr. T. Mazzulli
Annual Review / May 31, 2011 / Dr. T. Mazzulli
Annual Review / May 31, 2012 / Dr. T. Mazzulli
Annual Review / May 31, 2013 / Dr. T. Mazzulli

UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY

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