Committees Term of Reference

1. CME and Patient Education Committee (Terms of Reference)

2. Code Blue Committee (Terms of Reference)

3. Governance Board (Terms Of Reference)

4. Infection Control Committee (Terms of Reference)

5. IT - Health Information Management Committee (Terms of Reference)

6. Medical Records Review Committee (Terms of Reference)

7. Mortality & Morbidity Committee (Terms Of Reference)

8. Nursing Leaders Committee (Terms Of Reference)

9. OR Committee_(Terms Of Reference)

10. Performance and Blood Utilization Review Committee (Terms Of Reference)

11. PURCHASING, STOCK CONTROL & PHYSICAL COUNT COMMITTEE (Terms Of reference)

12. QUALITY COUNCIL (Terms of Reference)

13. Safety & Risk Management Committee (Terms of Reference)

14. SENIOR MANAGEMENT COMMITTEE & Big SMC (Terms of Reference)

15. Antibiotic Committee-Pharmacy Therapeutics Committee (term of Reference)

16. Pharmacy & Therapeutics Committee (term of Reference)

17. Human Resources & Staff affairs Committee (TERMS OF REFERENCE)

18. Learning & Development Committee

19. Ethics Committee (Terms of Reference)

20. Renal Transplantation committee

21. Clinical Team Committee (Terms Of Reference)

22. Clinical Team Committee consolidated report

23. JCI reaccreditation preparation steering committee (Terms of reference)

QQMD (CME & PATIENT EDUCATION COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/CME & PATIENT EDUCATION COMMITTEE/TOR

Page 1 of 2

QQMD/CME & PATIENT EDUCATION COMMITTEE/TOR

Report to: MEDICAL BOARD COMMITTEE

CHAIR: ………………

MEMBERS: Voting:

MEMBERS: Voting:

Medical Staff Representative

Nursing Staff Representative

Quality management Representative

Pharmacy services Representative

Physiotherapy Representative

Clinical Nutrition Representative

Others as appointed by Chair

QUORUM:

50% of members excluding the Chair

MEETINGS: The Patient/Family Education Task Force Committee shall meet monthly but no

less than ten times a year. Special meetings to handle urgent decisions will be called at the

discretion of chair.

Minutes shall be maintained for all meetings. The minute format shall be reporting by exception

with responsibility and recommended action documented.

The minutes shall be forwarded to MEDICAL BOARD COMMITTEE for action and or

approval.

The agenda shall be sent to all members at least one week prior to the meeting unless the meeting

is for urgent matters.

Additional Information:

PURPOSE:

The Patient/Family Education Committee is a multi-disciplinary team acting on behalf of the

Medical Staff to examine the hospital system for patient/family learning and for building and

maintaining an effective patient/family education system.

The purpose of the Patient/Family Education Task Force Committee is to set standard and goals

aimed at developing the staff performance and services directly related to the patients’ education

to increase patient/family awareness and participation in health maintenance and improvement.

TERMS OF REFERENCE:

1. Establish a hospital-wide patient/family education system

2. Standardise patient/family education processes

3. Prepare patient/Family Education Materials

4. Approve all patient /family education materials used in the Hospital

QQMD (CODE BLUE COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/CODE BLUE COMMITTEE/TOR

Page 1 of 2

QQMD/CODE BLUE COMMITTEE/TOR

Pag

e1

Reports to: MEDICAL BOARD Committee

CHAIR: MEDICAL DIRECTORS OF ICUs.

MEMBERS: Voting:

Medical Director.

ER Manager.

NNICU Manager.

Director of Nursing Department.

Quality Manager

Specialists Physicians Manager

Others as appointed by Chair

QUORUM:

50% of members excluding the Chair

MEETINGS:

The Code Blue Committee shall meet monthly but no less than ten times a year. Special meetings to

handle urgent decisions will be called at the discretion of chair.

Minutes shall be maintained for all meetings.

The minute format shall be reporting by exception with responsibility and recommended action

documented.

The minutes shall be forwarded to the MEDICAL Board Committee for action and or approval.

The agenda shall be sent to all members at least one week prior to the meeting unless the meeting is for

urgent matters.

Additional Information:

PURPOSE:

The CODE BLUE Committee is a multi-disciplinary advisory body acting on behalf of the Medical

Staff to formulate policies on the administration of artificial heart and lung action in the event of cardiac

and/or respiratory arrest; and closed-chest cardiac massage.

The purpose of the CODE BLUE Committee is to promote high standards of patient care through

monitoring and evaluating of the quality and appropriateness of all major components of cardio-

pulmonary resuscitation functions.

TERMS OF REFERENCE:

1. Review CPR policies and procedures.

2. Develop standards and indicators for monitoring effectiveness of CPR.

3. Develop a system to record and evaluate every resuscitation incident.

4. Plan and support training courses by certified trainers for medical and nursing staff.

5. Developing a planned training program by certified trainers for the related staff.

QQMD (GOVERNANCE BOARD COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/MEDICAL BOARDCOMMITTEE/TOR

Page 3 of 3

QQMD/MEDICAL BOARDCOMMITTEE/TOR

17. Is responsible for identifying and planning for the types of clinical services required to meet the

goals of the patients served.

18. Provide oversight of contracts for clinical or management services.

19. Ensure that there are uniform programs for recruitment, retention, development and continuing

education of all staff.

20. Assure that one or more qualified individuals provide direction for each department or service in

the organization and that the direction includes identifying in writing the services to be provided,

that the services are coordinated and integrated within the department or service with other

departments or services, recommend space, equipment, staffing and other resources needed by the

department or service, recommend criteria for selecting the department or service’s professional

staff and choose or recommend individuals who meet those criteria, provide orientation and

training to all staff of the department or service appropriate to their responsibilities, monitor the

department’s or service’s performance as well as staff performance.

21. Establish a framework for ethical management that ensures that patient care is provided within

business, financial, ethical, and legal norms and that protects patients and their rights which

includes marketing, admissions, transfer and discharge, and disclosure of ownership and any

business and professional conflicts that may not be in the patient’s best interests. These

framework’s goals are to support ethical decision making in clinical care.

BASELINE AGENDA REQUIREMENTS:

I. Call to order

II. Approval/Revision of previous minutes

1. Guest Relation Feedback- GRM- 30 minutes

2. Feedback from Nursing and Operations- DON/Nursing Rep; GMO- 15 minutes

3. Night Shift Feedback-NDM- 30 minutes

4. Quality Report- QM – 30 minutes

5. Sales Report - SM- 30 minutes

6. Cash Patient analysis- OFA -30 minutes

7. Revenue Report- ACFO – 30 minutes

8. Accounts Receivables status & Collection Forecast-MOM-30 minutes

9. P&L statement and Cash Flow Report- ACFO- 30 minutes

III. Other Business : Any of the HODs called as per top management request

IV. Adjournment

QQMD (INFECTION CONTROL COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/IC COMMITTEE/TOR

Page 2 of 3

QQMD/IC COMMITTEE/TOR

4. Review hospital infection related statistics prepared on a monthly basis and recommend specific

actions to be taken by the infection control team, various departments and wards, and specific

staff.

5. Educate through lectures, symposia, workshops and seminars medical, nursing and ancillary staff,

patients and their attendants regarding infection control issues.

6. Ensure that notifiable diseases are adequately reported and communicated to the appropriate

authorities.

7. Recommend regular supply of appropriate equipment, consumables and drugs required to prevent

and manage nosocomial infections.

8. Ensure that the various hospital contractors (e.g.: cleaning, catering, pest control, laundry, etc.)

abide by the terms of their contracts in aspects related to control of infections, use of detergents

and disinfectants, and general hygiene of the hospital.

9. Review all environmental contracts affecting the management of infection control prior to their

approval.

BASELINE AGENDA REQUIREMENTS: Suggest

I. Call to Order

a. Review of Minutes of Previous Meeting

b. Revisions/Approval of Minutes

II. Committee Reports

a. Statistical Reports (TRENDED) Based on per 1000 patient days.

i. Infection Rate (# total infections/patient days X 1000)

ii. Nosocomial Rate (#nosocomial infections/patient days X 1000)

1. broken down by unit/location

2. broken down by

a. urinary tract catheter/non catheter

b. respiratory

c. decubitus ulcer

d. surgical site

e. other

iii. Community Acquired Infection Rate (#community Acquired/patient days X

1000)

iv. Multi-drug Resistant Infection (MDRI) Rate (# MDRI’s /patient days X 1000)

1. broken down by type

a. TB

b. MRSA

c. MDRI, non MRSA

v. Nosocomial Sepsis Rate (#Nosocomial Sepsis/patient days X 1000)

vi. Death from Nosocomial Infection Rate(# of deaths determined to be secondary to

nosocomial infections/patient days X 1000)

vii. Employee Health Report

1. Food Poisoning

2. Diarrhea

QQMD (INFECTION CONTROL COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/IC COMMITTEE/TOR

Page 3 of 3

QQMD/IC COMMITTEE/TOR

viii. Needle sticks

III. Policy and Procedure Review

a. Annual policy review. (bring 1/12th to each meeting)

b. New Policy review

IV. Reports of In service Education(Database % staff educated, reporting issues)

a. In services (Target groups, plan, etc.)

b. Education boards/brochures

c. Special seminars

V. Other Business

a. National and International Infection Concerns

b. Risk Reporting, i.e. SARS, Ebola, etc.

c. Review of cleaning chemicals—Annually and as proposing changes

i. Does Chemical Meet Infection Control needs

ii. Plans for educating cleaning staff on proper use

iii. Environmental impact

QQMD (Information Technology COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/IT COMMITTEE/TOR

Page 1 of 2

QQMD/IT COMMITTEE/TOR

Reports to: Senior Management Committee

CHAIR: IT Department Manager

MEMBERS: Voting:

GMO

Ward Secretary Manager

Purchasing department Representative

Admission & Billing Manager

Pharmacy Representative

Finance Department Representative

Others as appointed by Chair

QUORUM:

50% of members excluding the Chair

MEETINGS: The Health Information Management Committee shall meet monthly but no less than ten

times a year. Special meetings to handle urgent decisions will be called at the discretion of chair.

Minutes shall be maintained for all meetings. The minute format shall be reporting by exception with

responsibility and recommended action documented.

The minutes shall be forwarded to the Hospital Senior Management Committee for action and / or

approval.

The agenda shall be sent to all members at least one week prior to the meeting unless the meeting is for

urgent matters.

Additional Information:

PURPOSE:

The Health Information Management Committee is a multi-disciplinary advisory body acting on behalf of

the SM Committee to oversight the acquisition, implementation, and use of information technology and

management services regarding improving the overall quality of patient care at the hospital.

The purpose of the Health Information Management Committee is to identify important health

information management and technology issues and develop plans and actions to address these concerns.

TERMS OF REFERENCE:

1. Developing and updating the Hospital Information Management Plan.

2. Evaluating the process of computerizing health information at the hospital.

3. Ensuring that the hospital implements information security policies and control procedures.

4. Developing a planned training program by certified trainers for the related staff.

QQMD (SENIOR MANAGEMENT COMMITTEE)

(TERM OF REFRENCES)

Document #: QQMD/SMC COMMITTEE/TOR

Page 3 of 3

QQMD/SMC COMMITTEE/TOR

BASELINE AGENDA REQUIREMENTS:

I. Call to order

II. Approval/Revision of previous minutes

Departments called for meeting set in the approved order for SMC meeting

Regular SMC meeting:

Departments shall report:

a- KPIs results: measures that appear in department dashboard

b- Department statistics: measures of core services that are not included in the

dashboard

c- Complaints / Incident Reports: that are raised from the department stating the

action needed and departments which are requested for cooperation to solve

d- Inquiries From Other Departments : inquiries Requested from other department

“stated” to follow up during coming week and reported in the coming sector

e- Follow up of Pending Issues/Complaints: Follow up of issues raised against the

department in Previous SMC

f- Improvement Projects / Business Process Improvement: either an existing project

or any OFI “an Opportunity for Improvement” shall be reported for follow up

g- Others: for other valuable information, the coming updates on the system will

depend on the frequency of new information reported in this sector

All pending issues shall be documented by relevant HOD and action taken for all pending issues

reported in the next SMC except for strategic decisions, which will be followed up on monthly

basis “Big SMC” meeting

Big SMC meeting

a- Deteriorated KPIs follow-up: compared to previous month with primitive data

collection on probable causes and recommended actions

b- Follow-up of still Pending Issues/Complaints: to take action for each.

c- Committees & meetings attended by the department and follow up of actions taken.

d- Improvement Projects / Business Process Improvement still hunting any OFI.

III. Other Business

IV. Adjournment

Committees Master

Decisions Follow up Sheet

Committee Date Decisions Sent date Received date Status

Nursing leadership 00/00/20Nursing Director asked IT Manager that all

items to be bar coded and stickers asap.00/00/20 00/00/20 ongoing

Nursing leadership 00/00/20Rule and responsibility of

the Head Nurse should be activated 00/00/20 00/00/20 Done

Nursing leadership 00/00/20

Part time only will be 3 months and will

pay full insurance but the cancellation will

be discussed with HR.

00/00/20 00/00/20 Done

Nursing leadership 00/00/20

Charge Supplies,Nursing Director

asked from Head Nurses to not stop

the charge supply training for all the

staff nurses.

00/00/20 00/00/20 Done

Nursing leadership 00/00/20Instrument collection/Humidifier

check.00/00/20 00/00/20 Done

Nursing leadership 00/00/20 Pharmacy instructions “discussion” 00/00/20 00/00/20 Done

Nursing leadership 00/00/20 Standardize of auditing 00/00/20 00/00/20 Done

Nursing leadership 00/00/20 Teaching Program 00/00/20 00/00/20 ongoing

Nursing leadership 00/00/20customer feedback To be

reduce it as much as possible 00/00/20 00/00/20 Done

Nursing leadership 00/00/20 decrease Medication Error 00/00/20 00/00/20 Pending

Nursing leadership 00/00/20 decrease Customer feedback 00/00/20 00/00/20 Pending

Decisions taken in Committees from (Month) 20-- to (Month) 20--Decision Follow up Cycle

Minutes Demonstrations

Page 1 of 3 QQMD-QMD-FRM-021

Issue No.: 0 Issue Date: 0/0/20

Revision No.:0

Meeting Title: Code Blue Committee

MINUTES

[MEETING DATE] 30/ 07 /2011

[MEETING TIME] 14:00 PM- 15:30 PM

[MEETING LOCATION] TRAINING ROOM

MEETING CALLED BY Dr. Mohamed Khalil

TYPE OF MEETING Monthly

FACILITATOR Mr. ……………………….

NOTE TAKER Mr. ……………………….

TIMEKEEPER Dr ………………………….

ATTENDEES

Dr. ………………….; Dr. ………………….; Dr. ………………….; Dr. …………………., Ms. …………………., Ms. …………………., Mr. …………………. , Ms. …………………., Ms. …………………., Ms…………………..

Agenda topics This Meeting represent July

[TIME ALLOTTED] ONE HOUR

Matters arising from minutes of previous meeting

DISCUSSION

Briefing of the previous code blue committee minutes was done by Dr. Mohamed Khalil. The list of ACLS trained and certified physicians were sent to Dr. Adel Omran. The code blue events for the current month were revised and the documentation was satisfactory with minimal comments on the medications. The AHA dolls are in the purchase and every thing was done from our clinical side, it needs a financial approval and support. Two cricothyroidotomy set are requested by Dr. Mohamed Ali to be available in the E.R Crash Cart, it will be followed up by the E.R manager. Portable suction not resolved and bending, Mr.fathy needs E-Mail to fasten the process.

Page 3 of 3 QQMD-QMD-FRM-021

Issue No.: 0 Issue Date: 0/0/20

Revision No.:0

Code Blue cases during July

Thank You

No Name & MRN Age Consultant Date& area of

code event

Outcome of code

1

Abdel Hamid Ali Elsaid

MRN 210739

71

years

Dr. Hussam

Salah

26/07/2011

ER Unsuccessful

2 3 4 5

Page 1 of 3 QQMD-QMD-FRM-021

Issue No.: 0 Issue Date: 0/0/20

Revision No.:0

Quality council committee

DATE: 22/11/2012 TIME: 10:00 AM LOCATION: TRAINING ROOM

MEETING CALLED BY Quality Department

TYPE OF MEETING Quality council committee

FACILITATOR Dr. Mohamed ameen

NOTE TAKER Dr. …………………

INVITED MEMBERS HODs

TOPIC NAME: BLS & ACLS

DISCUSSION BLS & ACLS

Dr. Mohamed ameen explained the demonstration of new electronic recertification of BLS for the consultants. The site starts with video explains the BLS to the consultants. After reviewing the video the consultant will answer MCQ questions and. Pass score will be 8/10.the certificate will be submitted to HR Dr. Mohamed ameen requested Medical director to provide valid BLS exam and its model answer.

CONCLUSIONS

Demonstration of new electronic recertification of BLS for the consultants had been explained

A slip containing the link, password and the name will be sent to the consultant to register in the website. A clip will be opened explaining the BLS. Then an application will be opened containing 10questions.

The result will be sent to HR data base including the consultant code, result and the expire date

training department will be responsible to archive the certificates and the names

Code blue committee will be responsible to provide the baseline or current status of the BLS, the plan and to provide the quality department weekly with the ratio of BLS certified number.

ACTION ITEMS PERSON RESPONSIBLE DEADLINE

Provide the approved BLS Video, questions and its model answer Code blue committee

Certificates archiving training department

To provide the following:

Baseline of BLS (current status) Certification and recertification plan of BLS

Weekly report of the BLS ratio (KPI)

Official approval of the “RESUSCITATION TECHNIQUE TRAINING “policy which modified by quality department

Code blue committee

TOPIC NAME: PRIVILAGE AND CREDENTIAL

DISCUSSION

Dr. Mohamed ameen repeated the what had been discussed that Nurses have to know how to access to the doctors privilege

The attending physician is the responsible person to check the privilege according to the patient’s plan of care. If there is any problem regarding the privilege. She/he has to report to the specialist physician manager

The specialist physician manger is responsible to monitor the process

The specialist physician manger and the medical director are responsible to update the privilege of consultants and specialist physicians.

Page 1 of 3 QQMD-QMD-FRM-021

Issue No.: 0 Issue Date: 0/0/20

Revision No.:0

Meeting Title: Safety Committee MINUTES

[MEETING DATE] 31ST OCTOBER 2012

[MEETING TIME] 12:00 PM

[MEETING LOCATION] TRAINING HALL

MEETING CALLED BY HSE Department

TYPE OF MEETING Safety committee

FACILITATOR Mr. Ali Mohamed

NOTE TAKER Mr…………………..

TIMEKEEPER Ms.------------------

ATTENDEES

Ms. …………., Dr. …………….., Ms. ……………., Mr. ……………, Eng. …………, Ms. ------------------, Mr. ………..….., Mr. …………………, Ms. ………………, Dr. ………………., Mr. …………………., Mr. ………………….., Mr. ……………, Mr. ……………, Eng. ……………………, Mr. ……………..

Agenda topics PREVIOUS TOPICS

[TIME ALLOTTED] [AGENDA TOPIC] HSE ISSUES [PRESENTER] MR. ALI

MOHAMED

DISCUSSION HSE Progress within the last 10 Months

ACTION ITEMS PERSON RESPONSIBLE DEADLINE

Proper HSE Manual is Prepared HSE Dept. Done

Waiting for the HSE uniform Procurement Dept. ASAP

Waiting for the HSE staff recruitment till now HR ASAP

Need to Complete the remaining Staff Training HSE Dept. ASAP

Need to Start Implementing Fire Marshals and Safety Warden HSE Dept. ASAP

[TIME ALLOTTED] INCIDENT INVESTIGATION REPORT -IIR P&P + RIDDOR

[PRESENTER] MR. ALI

MOHAMED

DISCUSSION

No Type Date Event Action taken Owner

1

20-10-2012

Maintenance struck by fallen break

Maintenance workers to abide by the safety regulation and have a work permit before working in hazardous work

Maint.

2 23-10-2012 Water Pipe Broken inside Kitchen Store Room

Maintenance dept. have to check all infrastructure (preventive maintenance

Broken water pipe is replaced

Maint.

3 24-10-2012 Struck by falling Glass Sheet from 0 th Floor

The contractor must work with safety net under the designated roof company

4 25-10-2012

Electrical Arc-Blast - Neuro-ICU Patient’s Bed Cable - Patient Room 000

Cable was replaced Preventive Maintenance Program to check all patients room wirings and cables.

Maint.

CONCLUSIONS Highest rate of Incidents since the Year started, due to renovations works. A Safety Net must be installed ASAP to prevent falling objects and reduce the risk.

ACTION ITEMS PERSON RESPONSIBLE DEADLINE

SEE TABLE

[TIME ALLOTTED] [AGENDA TOPIC] PERMIT-TO-WORK [PRESENTER] MR. ALI

MOHAMED

DISCUSSION • The Importance of Issuing a Permit-To-Work

CONCLUSIONS • Never to work on height without signed work permit • A work permit should be issued before any welding operation

Committees Templates

TITLE OF MEETING

Subject: Date: 00/00/20

Facilitator: Location :

Page 1 of 1 QQMD-QMD-FRM-026

Issue No.: 0 Issue Date: 0/0/20

Revision No.:0

SR

Invitee Signature Designation Department Sign in

Time

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

LEAN COMMITTEES QQMD

Lean Committees

2 | P a g e

INTRODUCTION

Committees follow up shows that there is a lot of defects & waste in QQMD committees, that’s why Quality

Management Department (QMD) chosen the lean approach to improve committee

function in QQMD.

The project was done following the lean thinking 5 principles:

Principle 1 - Specify value

Principle 2 - Identify and visualize value stream

Principle 3 - Making the value steps flow through identifying waste

Principle 4 - Pulling committee cycle instead of pushing

Principle 5 - Perfection

PRINCIPLE 1 - SPECIFY VALUE

The first step in lean committees is to identify Committee stakeholder & their value perspectives, this was done through:

1. Observations of QQMD committees.

2. Reviewing QQMD committees meeting minutes.

3. Conducting Focus group with HODs.

4. Conducting HODs “Committees questionnaire”.

We reached the following conclusions from collecting stakeholder voices & views regarding QQMD committees’

function, which helps to identify demand from committees.

Customers Voice of the customer

HODs - Participation in decision making - Too much time spent in committee

Top management - Decision making - HOD commitment to Attendance

Quality Management Department (QMD)

- Updated TORs - Committees follow TORs - Follow up of decisions - Follow schedule/ no overlap - Covers JCI requirements

PRINCIPLE 2 - IDENTIFY AND VISUALIZE VALUE STREAM

The second stage is drawing, understanding & analyzing committee consequences & events, which to enable committee

stakeholder:

1. To visualize the current committee meetings practices and activities.

2. Highlight the non-value added steps & waiting time (delay) in committee process.

3. To Identify QQMD committees waste.

This was done by:

1. DRAWING A DETAILED FLOW CHART : SEE FIGURE 1

Lean Committees

3 | P a g e

FIGURE 1: COMMITTEES VALUE STREAM MAP SHOWING VALUE ADDED, NON-VALUE ADDED & WAITING TIME

Lean Committees

4 | P a g e

From the value stream map (the above figure), we can classify committee process steps to:

1. Process steps that definitely create value: Discussion

New decisions

Members execute decisions 2. Process steps that create no value but are

necessary, due to current state of the system:

Review approve TORs

members preparing reports

Writing & sending meeting minutes

QMD decisions follow up cycle

archiving meeting minutes 3. Process steps that create no value and

can be eliminated: sending notification, invitations & agenda

meeting room reservation

meeting room coordination with QMD

reporting in a committee

2. DRAWING COMMITTEE TIMELINE; SEE FIGURE 2

FIGURE 2: COMMITTEES TIMELINE SHOWING TIME SPENT IN EACH COMMITTEE

Committee’s timeline shows that:

Only 30 minutes of a 120 minutes spend in a single committee is value added time, which is the

time of members discussing a topic & reaching a final decision after going through pros & cons of

every possible suggestion for a decision, which is the ultimate goal of a committee.

Lean Committees

10 | P a g e

PRINCIPLE 5 - PERFECTION

Committee item Changes after lean

Schedule All committees to be held on Thursdays from 12:00 PM to 2:00 PM

Duration 45 minutes

frequency Committee Frequency

SMC, CTC, Infection control, safety, code blue, morbidity & mortality, Pharmacy , medical records

Monthly committee

QC, Team A meeting weekly committees

Governance board Biannual

* HR, Nursing, blood utilization, purchase, IT committees can be departmental committees, organized coordinated & controlled by the related department & committee chairmen. *Kidney, liver transplantations, Ethics, patient education, credentials & privilege, continuous medical education committees can be organized coordinated & controlled by clinical team leaders.

Session

2 committees shall be held in the same session as follows:

1st week Big SMC

2nd week Infection Control - Safety

3rd week Code Blue - Morbidity & Mortality

4h week Pharmacy – medical records

Logistics Annual Training room reservation to be done according to committees’ schedule

Purpose/Content Minimize time spent in reporting & displaying results, statistics or KPIs, discussions should be directed to decision making.

Major changes in TORs

Committee Major changes

Governance board

To be held biannual

1st half of the year, the purpose of GB is to review annual budget, financial plan for the next year, departmental objectives.

By the end of the year, a second GB is held for the final approvals of policies & procedures, hospital plans, organization chart.

Quality circle Incident reporting review, corrective action is to be added to QC quarterly.

SMC Weekly SMC is cancelled as its mainly reporting, yet