Improving clinical performance: a "how to" for procedures review

As part of comprehensive performance improvement for accredited hospitals, the Joint Commission on Accreditation of Healthcare Organizations requires that institutional data collection include a review of "operative, other invasive, and noninvasive procedures that place patients at risk" (JCAHO, 1998b, p. 125). To meet the standard for comprehensive procedures review, the University Hospitals and Clinics at the University of Mississippi Medical Center developed an innovative methodology to ensure Joint Commission compliance. This article describes the processes used and the outcomes realized by the performance improvement team responsible for procedures review.