b'At NCH, its the Performance Improvement Plan (PI Plan)Quality Objectives: Something sought, or aimed for, related to quality (i.e., dashboards, Score cards, Key Performance Indicators (KPIs))Competence: Education, training, skills experience Interested Parties: Anyone interested or affected by the hospital operations (i.e., patient/family, employees, physicians, contractors, state/federal regulators, insurances, community, etc.) Nonconformity and corrective actionsNonconformities are a deviation from defined requirements. As defined by ISO 9000:2015, correction is an action to eliminate a detected nonconformity. Corrective action is an action to eliminate the cause of a nonconformity or to prevent its recurrence. The objectiveNCHS Management of corrective action investigation and follow-up is to analyze the source of the problem, document it, establishSystemownership for the problem, assign responsibility for its resolution, and track the results in a standardized manner. Evaluation of the need for corrective action (as opposed toDo we have a Quality Management System?just correction) should, at a minimum, cover certain areas within an organizations quality management system:Yes, we use the quality management system thatNonconformities correlating to products, services,demonstrates our commitment to the 3Cs: consistency, processes, and quality management systemcontinual improvement, and customer satisfaction within the NCHS Management System.Patient/ Family complaintsErrors and adverse events identified Our governing body who assumes full legal authority and responsibility for operations of the hospital), medical Error means the failure of a planned action to bestaff, and administrative officials are responsible and completed as intended or the use of a wrong plan toaccountable for ensuring the organization develops, achieve an aim. Errors can include problems in practice,implements, and maintains an ongoing, hospital-wide, products, procedures, and systems. Medical error meansdata driven effective quality management system (QMS) an error that occurs in the delivery of healthcare services. and integrates the Quality Assessment and Performance Improvement (QAPI) program into the QMS.Quality objectives not metSupplier/Vendor issues The QAPI program provides a mechanism to systematically examine the quality of care delivered and implementActions related to internal and external audits specific improvement projects on an ongoing basis for all Corrective action should be appropriate to the effectthe services provided by the organization. The complexity of the nonconformity encountered (i.e., the impact ofof those services shall be considered when determining the problem). Risk-based thinking should be used toquality parameters of those services. The organization support decisions for when corrective action may notshall continuously study and improve their processes be necessary. Not only will the organization need toand service delivery and take a proactive approach to determine whether corrective action is needed, but alsoimprove their performance and focus on improving patient determine if any updates to the risks and opportunitiesoutcomes and the prevention of medical errors.(see ISO 9001:2015; 6.1) are warranted based on the analysis for the corrective action.2024 Survey Readiness Guide 15'