Quality Management



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The Quality Management Department interacts with hospital administration, medical staff, department directors, students, and others as needed.  The department also provides services to external systems with which we have a contracted or legal obligation.

The Quality Management Department provides data management and consultative services related to the purposes of improving quality and cost-effectiveness of patient care, patient safety, risk reduction, regulatory compliance, clinical profiling, clinical benchmarking, and strategic planning.  The department also provides assistance in the research activities of hospital and medical staff and participates in the educational programs, where appropriate, for medical, nursing, and allied health students.

Performance improvement initiatives are identified based on the organization's mission, vision, and goals. Opportunities identified through benchmarking projects, regulatory requirements, risk, and leadership objectives guide development of annual PI initiatives.

The quality Performance Improvement model used by UTMC is the Plan, Measure, Analyze, Act, and Review (PMAAR) cycle. This cyclical model incorporates:

  • Defining the opportunity
  • Identify the objective
  • Collecting and measuring data
  • Analyzing performance as compared to the objective
  • Determining actions
  • Reviewing education and re-measuring

The PMAAR format should be utilized in reporting PI activities (PMAAR Template).

The Quality Management department also provides coordination of Joint Commission process. These services include:

  • Coordination of the annual Periodic Performance Review
  • Primary contact for Joint Commission
  • Coordination of the survey process
  • Providing leadership to Joint Commission Council for maintaining Joint Commission readiness
  • Coordinating response to Joint Commission complaints
  • Compiling Regulatory PI Requirements


Last Updated: 4/20/16