Quality and Risk Management

The daily management and oversight of all patient safety activities at Capital Health is assigned to every physician and employee at Capital Health. Capital Health follows a multidisciplinary approach by working with administration, physicians and staff to develop processes across the organization to improve clinical outcomes based on nationally recognized, evidence-based standards.

Capital Health performs retrospective, concurrent and prospective reviews of the organization to identify potential and actual risk issues and problem areas. Capital Health also promotes a patient safety culture that allows any employee to report identified risks. Once an actual or potential risk is identified, we use established methods to assess the situation, which may include intense review, surveys, assessment for application of established clinical guidelines, and on-going compliance monitoring.

When the opportunity for improvement exists, appropriate staff and physicians plan a course of action. Actions may include, but are not limited to, the following:

  • Education and/or training programs
  • Enforcement or implementation of new or revised policies and procedures
  • Staffing or support system changes
  • Equipment changes

Once an improvement plan is developed, the plan is reviewed with administration and the members of the clinical healthcare team who are most directly responsible for implementing the plan.

Once the plan is approved, the individuals and/or departments within Capital Health who are most directly related and involved will be responsible for implementing the plan. Results are monitored and continually reassessed with the department director and administrators of the involved area to ensure the plan is adequate and that staff continues to comply.

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