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Quality Management Division

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The Quality Management Division at WBAMC includes personnel that manage the following areas; Joint Commission compliance, Credentialing/Privileging and Medical Services, Patient Safety, Risk Management, Performance Improvement, ORYX and Medical Record review. The WBAMC Quality Management Division has established a comprehensive, integrated management plan that is in compliance with MEDCOM and current accrediting/regulatory guidance.

Joint Commission Compliance

The Joint Commission’s role in health care is to decrease or prevent healthcare errors through the application of standards and practice. The Chief, Joint Commission and Performance Improvement role is to monitor all areas of the hospital to include clinics for compliance with published TJC standards. This helps to ensure that WBAMC delivers care that meets or exceeds national and MEDCOM standards. Here at William Beaumont Army Medical Center we encourage you to report to our management any hospital patient care or safety concern that has not been addressed by the hospital. If the concerns cannot be resolved, we encourage you to contact The Joint Commission. You may submit your concern at External link icon or call 1-800-994-6610.


Before healthcare providers are permitted to practice in the hospital, the Credentialing Office must verify the person’s claimed experiences. The Credentials Office uses a process known as prime source verification of credentials in order to assess and confirm a provider’s stated education, work history, licenses and prior affiliations. Providers are reevaluated every two years and the Credentials Office maintains current licensure, required certifications and training. The Credentials Office is committed to ensuring that patients have only the most qualified providers delivering quality health care.

Risk Management

The Risk Manager coordinates quality review activities for both inpatient and outpatient care. The RM Program identifies problems or potential risk circumstances that may be eliminated or reduced to prevent accident and injury. This office insures all serious adverse events are promptly and appropriately investigated. Investigations are presented to the Risk Management Committee for a determination of the Standard of Care and developing and monitoring action plans related to those determinations.

Patient Safety

Patients that seek care at WBAMC are entitled to be treated in a safety conscious environment. It is the role of the Patient Safety Manager to monitor Patient Safety Reports on a daily basis. The reports can be entered by any staff member electronically. The Patient Safety Report can be accessed here: (Can you insert a hyperlink to the Patient Safety Report System here). The MEDCOM Quality Management Patient Safety website is: External link icon

Performance Improvement

Performance Improvement uses data analysis to identify trends, patterns and performance levels that suggest opportunities for improvement. Once these have been identified they are reported to hospital leadership where priorities are set for improvement. There are two process improvement methodologies utilized at WBAMC these are Lean Six Sigma and FOCUS PDCA. The Performance Improvement section also monitors measures selected by leadership based on setting, scopes and services that are meaningful to the hospital and addresses the needs of the patients we serve. In addition the Joint Commission has identified important processes that should always be measured because they involve risk. These are reviewed and discussed with the Executive Committee of the Medical Staff on a monthly basis during the Quality Review committee meeting.


The role of the ORYX Nurse is to facilitate and implement proven evidence based practices that improve patient outcomes. Positive outcomes are fostered via organizational education, inpatient concurrent medical record review, direct observation of clinical practice and analysis of clinical data from internal and external databases. The ORYX nurse works closely with Medical staff to assure timely implementation of best practices and quality initiatives all aimed at improving our patients lives and ability to cope with their medical diagnosis. ORYX is the “Next Evolution in Accreditation and Compliance” as it serves as the critical link between accreditation and the outcomes of patient care, allowing the Joint Commission to review data trends and patterns and to work with organizations as they use data to improve patient care.

Medical Records Reviewer

All documentation in the patient medical record is reviewed for compliance with hospital regulations and TJC standards. Trends identified during audits are reported to leadership and utilized for performace improvement.

Contact Information

Chief Quality Management Division


Chief Joint Commission and Performance Improvement


Risk Manager


Patient Safety Manager


Credentials Manager


Credentials Coordinators

742-6382 /4432 /2107 /6386 /2885 /4052

Performance Improvement Coordinator


Performance Improvement Analyst


ORYX Nurse


Medical Records Reviewer