Formatting departmental quality assurance minutes to meet internal and external needs

This article presents a method that is helpful in achieving compliance with the JCAHO medical staff monitoring standards. Since the QA activity of the medical staff is of great importance to the institution, it is imperative that monitoring activities are clearly documented and easily evaluated. Through the use of a standardized departmental minutes format, each clinical department is prompted to address the monthly activity relating to each of the basic quality assurance functions. These minutes can be "scored" using an evaluation tool suitable for review by the Medical Executive Committee. This enables the committee to track the status of each department's use of the "Ten Step Process." This method has successfully met the challenge of a recent JCAHO accreditation visit. The use of the standardized departmental minutes format and the evaluation tool provide a method to successfully meet the JCAHO medical staff quality assurance standards.