The Medical Executive Committee approved revisions to the policy and procedure for “Quality Assurance Files: Medical Staff/Resident Physician”. The Quality Management Department maintains a QA file on all members of the Medical Staff during membership and for ten years after termination. Entries will no longer be given a classification, but will have a brief description. The Department Chair will review a file for trends when 3 or more incidents occur within a recredentialing cycle.
As was done previously, Medical Staff members may respond in writing to an entry and it will be placed in their QA file.