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Opening Conference
Asked for all license agreements, contracts, regulatory correspondence, documents, etc. PI Overview
Asked very specific questions about our PI Council and its relationship to other committees and groups on the org. chart. Asked for Trustee executive session minutes, (new one for me) Asked for information on Sentinel Events, "We have had no reportable SE but we use RCA as a PI tool." Leadership
Describe the process used for your community needs assessment. Explain your new employee feedback process. Who owns the hospital? Explain in detail the Trustee self-assessment process. What changes have you made as a result? Explain the trustee appointment process and trustee qualifications of criteria for selection. Explain the process used to in your decision to close your XXXX service. Explain the public’s involvement in the decision. How does the medical staff receive PI education? Leadership team? Explain allocation of resources for PI. What information do the trustees have about individuals at the time of appointment reapp, and credentialing?
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