When the chairperson of the governing body requests an annual report on improvements in patient care, the report should provide an overview of the quality program, with a specific focus on how these activities have impacted patient care. This approach gives the governing body a comprehensive understanding of the effectiveness of the quality initiatives and their direct influence on patient outcomes, safety, and satisfaction. It helps the leadership to assess the overall performance and supports informed decision-making for future improvements.
The names of physicians who fall below the threshold of standards of care (A): This information could lead to a punitive focus and might not be suitable for a high-level annual report.
A detailed description of all quality activities (B): While detailed information is valuable, an annual report should focus on the impact rather than every activity.
The results of peer review (D): Peer review results are typically confidential and might not be included in a high-level report to the governing body.
References
NAHQ Body of Knowledge: Quality Program Reporting and Governance
NAHQ CPHQ Exam Preparation Materials: Reporting to the Governing Body
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