Medical Staff Bylaws - Arkansas Children's Hospital

functions of the ACH clinical enterprise. As such, deliberations and findings of the Committee areprotected under Arkansas statues.Through its deliberations and activities, the committee will:e. Affirm proper service recovery was done in case of adverse events in patients.f. Provide enterprise-wide accountability for regular review and follow-up of:1) Opportunities for improvement or corrective actions identified throughservice- and section-based morbidity and mortality (M&M) conferences.2) Findings and action plans developed as a result of Root Cause Analyses(RCAs).3) Summary and relevant details of all adverse events.4) General Counsel open file issues related to patient care and safety.5) Other issues as identified by or referred to the Committee.g. Refer as appropriate issues for specific actions and follow up to the respectivesenior leader. For example,1) Quality improvement and risk management – Chief Quality Officer2) Credentialing of Physicians and other Independent Practitioners – Chief ofStaff3) Operations – Chief Operating Officer4) Medical Staff – Chief Medical Officer5) Patient Care Services and Nursing – Chief Nursing Officer6) Hospital information technology – Chief Medical Information Officerh. The Committee shall regularly report its findings to the Board Services andQuality Committee and the Medical Staff Executive Committee.3. Meetings: The Risk Management/Peer Review Committee will meet at least sixtimes per year.13.9.8 Quality and Patient Safety Committee1. Composition: The Quality and Patient Safety Committee will consist of at leastthe following: the Chief Quality Officer, the Chief of Staff, the Medical Director, the Chief OperatingOfficer, the Chief Nursing Officer, the Chief Finance Officer, Vice President, Ambulatory Services, theChief Medical Information Officer, the Chief Nursing Information Officer, the Chair of the IntensiveCare Committee, the Chair of the Escalation of Care Committee, a Pediatric Chief Resident, anEmergency Department physician representative, a Surgery physician representative, an Anesthesiaphysician representative, an Infection Control representative, a Safety Office representative, a QualityImprovement physician representative, an NICU Quality Improvement physician representative, the Vice85