Management of Substandard Quality Issues

The Chief Medical Officer and/or Associate Vice President for Clinical Programs will be notified immediately of inappropriate or substandard clinical and service quality issues and of instances in which services were lacking as identified by the quality improvement process.  Each case will be evaluated to determine if peer review, through the Credentialing Committee, is required.  Quality Improvement staff will be responsible for implementing corrective actions and follow up to monitoring activities.  Any apparent negative trends from report data will be brought to the Chief Medical Officer and/or Associate Vice President for Clinical Programs when investigation warrants.