May 7, 2008

Dear MUHA Leaders:

As many of you are aware, the quality reporting structure has changed. With this change, we have eliminated the Quality Council and in its place now have a twice a month meeting at Hospital Operations Committee (HOC) dedicated to quality issues. This change is due to the increasing number of measures and activities to report in the quality arena.

The other major change is the method of reporting. All sentinal events, quality monitoring, and performance measures will be reviewed by a subcommittee in the weeks leading up the quality/HOC meeting. Additionally, we are going to limit informational items coming to quality/HOC. Instead, we will focus on evidence based analysis and action plans. This change will require presentees to modify their presentations and adhere to new deadlines:

1. All presentees will be reminded 4-6 weeks prior to the meeting about your presentation.
2. All data to be reviewed at quality/HOC must be presubmited to the subcommittee 2-3 weeks prior.
3. Data must be submitted in a template provided by the Quality Department.
4. The subcommittee will provide feedback and may require revision of the data/presentation.
5. If you have any questions about this, do not hesitate to contact Chris Rees or myself about the process.

Patrick J Cawley, MD
Executive Medical Director