Critical Quality Functions: A Guide for Hospital Leaders During Quality Leadership Turnover

The OHA Council on Quality & Patient Safety has developed a guide for hospital leadership related to critical quality functions within a hospital. The purpose of the guide is to assist the CEO and other hospital leadership in assuring the maintenance of required quality and reporting functions in the event of turnover in the quality management position.

This resource guides hospital leadership in assessing the current status of four important functional components that are usually related to the responsibilities of quality management. These areas are: quality and infection prevention data collection and reporting, regulatory/accreditation compliance, credentialing, and meaningful use. Upon answering the assessment questions, hospital leadership will learn whether or not critical functions are being performed, especially during times of personnel loss.

While the guide does list resources, it is not intended to be an orientation or educational tool. Nor is it exhaustive of every responsibility the quality leadership position may have.

To view or download the complete guide,  click here.

Hospital Quality Data Reporting

To meet the requirements of Oklahoma licensure, Medicare Conditions of Participation and other accrediting bodies, hospitals must continually assess their performance and act to implement processes to improve the quality of care they provide. To monitor the quality of care in a hospital, Medicare recommends, and the State of Oklahoma (through the Oklahoma State Department of Health) requires that hospitals report certain quality "indicators." These indicators include information about certain patient diagnosis and conditions, patient safety events and patient satisfaction scores.

For a complete list of indicators, click here. To view the hospital scores reported to Medicare go to:

OHA Quality Data Reports

1. Value Based Purchasing (or pay for performance) reports: using the actual formulas that will be used for VBP payment determinations, these reports demonstrate how a hospital will fare financially in the pay for performance system. An Excel format is provided to allow hospitals to input more recent data to gain an understanding of how current performance affects their VBP outcome. It can also be used to identify areas in which to focus improvement efforts. 

2. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) results of your hospital's HCAHPS scores compared to National and Oklahoma averages.

For more information, contact Mitzi McCullock, [email protected], or LaWanna Halstead, [email protected]