This approach is used by some small hospitals whose board and board committee meetings are open to the public. In these hospitals, a QI committee typically includes department heads and medical staff representatives and is the point of coordination for quality indicators and performance improvement efforts. If a problem is identified but not addressed, the committee is supposed to act. As the ultimate guarantor of hospital quality, the board reviews its reports. Having a trustee on the QI committee demonstrates the board's commitment to quality and ensures that problems not resolved by the committee are reported to the board.
However, a QI committee gets into nitty-gritty issues. The trustee needs to work at a policy level and not get involved in operations. The trustee might be given a job description as follows:
If the committee determines the medical staff is not addressing a quality issue, the trustee should communicate the board's expectation that the medical staff will meet accreditation requirements and perform peer review. If they cannot do so objectively, the trustee should explain that the board will do what's needed to protect patient safety, such as authorizing an outside peer review or taking disciplinary action.