The Quality and Risk Management Department

The Quality and Risk Management Department is made up of:

• Risk Management
• Standards Compliance
• Performance Improvement

The mission of the Quality and Risk Management Program is to support the recovery of individuals with serious mental illness by promoting a safe physical and clinical environment for patients, staff and visitors through the identification and mitigation of potential risks and hazards that may contribute to or cause injury or illness. The department also develops, directs, manages and monitors hospital-wide performance improvement activities to ensure organizational effectiveness that result in positive patient treatment outcomes. The hospital uses the Plan Do Check Act performance improvement methodology.

• Monitor unanticipated events involving patients, staff and visitors
• Analyze data for trends and key indicators of potential risk
• Conduct reviews of unanticipated events to identify system/process failures
• Collaborate with clinical and non-clinical staff in the development, implementation and monitoring the effectiveness of risk reduction strategies
• Conduct prospective risk analyses of high-risk, problem prone hospital processes
• Focus activities on assessment of processes to maximize optimal outcomes in the shortest period of time through the use of performance improvement tools
• Provide leadership for the planning, implementation and monitoring of activities that support the hospital’s continued compliance with regulatory and accreditation requirements
• Analyze information collected from various reviews, such as Root Cause Analyses, Abuse/Neglect Investigations, Performance Reviews, etc., to identify common and special causes contributing to or preventing unanticipated events

Quality and Risk Management staff are actively involved in promoting a culture that:

• Promotes and supports safety
• Recognizes that errors do happen
• Seeks to learn from unanticipated events
• Examines systems and processes for points where failures may occur; and
• Facilitates staff accountability while minimizing “blame”

Quality and Risk Management Staff

Donna McGraw, BS
Assistant Director
703-645-3169

Tamara Brown
PI Coordinator
703-207-7451

Sue Sohn
Office Assistant
703-876-6904

Ann Burke
Investigator
703-645-3166

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