General Surgery Practice Quality Assurance Plan Template

1. Quality Management Structure

1.1 Quality Committee

• Chair: Chief of Surgery or designated lead surgeon
• Members:
  • Surgical staff representatives
  • OR nursing leadership
  • Anesthesiology representative
  • Quality/risk management coordinator

1.2 Meeting Schedule

• Monthly quality committee meetings
• Quarterly comprehensive reviews
• Annual program evaluation

2. Quality Metrics Monitoring

2.1 Surgical Outcomes

• Surgical site infection rates
• 30-day mortality rates
• Unplanned return to OR
• Length of stay metrics
• Readmission rates

2.2 Patient Safety Indicators

• Wrong-site surgery prevention compliance
• Surgical time-out adherence
• Medication error rates
• Equipment malfunction incidents

3. Performance Improvement Processes

3.1 Data Collection

• Standardized outcome reporting forms
• Electronic health record data extraction
• Patient satisfaction surveys
• Peer review documentation

3.2 Analysis Methods

• Statistical process control charts
• Benchmark comparisons
• Root cause analysis for adverse events
• Trend analysis

4. Quality Assessment Activities

4.1 Clinical Review

• Monthly surgical case reviews
• Morbidity and mortality conferences
• Peer review sessions
• Chart audits

4.2 Safety Protocols

• WHO Surgical Safety Checklist compliance
• Pre-operative verification process
• Post-operative handoff procedures

5. Continuous Improvement Implementation

5.1 Action Plans

• PDSA cycle implementation
• Clear accountability assignment
• Timeline establishment
• Resource allocation

5.2 Education and Training

• Staff competency assessments
• Regular safety training sessions
• New protocol implementation training

6. Documentation Requirements

6.1 Required Records

• Meeting minutes
• Quality metric reports
• Action plan progress
• Audit results
• Training completion records

7. Annual Review Process

7.1 Program Evaluation

• Annual goals review
• Performance metric analysis
• Program effectiveness assessment
• Strategic planning for upcoming year