Hospital Committees – ROJoson – 2003

Hospital Committees

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Elizabeth P. Asa, MD, MHA

Rosanna Tungol, MD

Quality Council

Manila Doctors Hospital

July, 2003

Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.

These are in contrast to ad hoc committees (on as needed basis and temporary), department and unit committees.

Committees prescribed by regulatory agencies Committees prescribed by hospital administration

(MDH)

PhilHealth DOH
Pharmacy and Therapeutic Pharmacy and Therapeutic Execom
Infection Control Infection Control Mancom
Quality Assurance Quality Assurance Committee on Medical Services
Waste Management Bioethics
Medical Audit and Tissue
Tumor Board
Medical Records
Credentials
Blood Transfusion

Thus, as of July, 2003, the following 13 committees are recommended to constitute the Hospital Committees of MDH:

Execom (Executive Committee)
Mancom (Management Committee)
Committee on Medical Services
Bioethics Committee
Pharmacy and Therapeutic Committee
Infection Control Committee
Quality Council
Waste Management Committee
Medical Audit and Tissue Committee
Tumor Board
Medical Records Committee
Credentials Committee
Blood Transfusion Committee

The general functions of the MDH Hospital Committees are to formulate policies, coordinate and monitor hospital-wide activities on specified areas of responsibility.

Hospital Committee General functions:

Formulate policies

Coordinate

Monitor

Areas of responsibility
Execom (Executive Committtee) Quality services and organizational direction
Mancom (Management Committee) Quality services and operational management
Quality Council Quality services and quality management system
Committee on Medical Services Quality medical services rendered by physicians
Bioethics Committee Bioethical matters in patient care
Pharmacy and Therapeutic Committee Drug therapy
Infection Control Committee Infection control
Waste Management Committee Waste management
Medical Audit and Tissue Committee Outcome in patient care such as mortality, morbidity, and tissue review
Tumor Board Cancer management
Medical Records Committee Medical records
Credentials Committee Credentialing of physicians
Blood Transfusion Committee Blood transfusion

General functions:

Formulate policies

Coordinate

Monitor

Specific functions:

Fulfill tasks effectively and efficiently that will lead to quality outcome and excellent results with near-zero complaint from stakeholder and clients.

Policies formulation

Coordination

Monitoring

Provide training and education to promote goal achievement (as needed)

Conduct research to promote goal achievement (as needed)

Organizational chart (reporting to and supervised by whom)

General guide on selection of person/unit/officer to whom the committee should report and under whom it will be supervised:

Report to and supervised by a person/unit/office higher in rank and whose primary area of responsibility is predominantly related to that of the committee and whose vested authority can effectively and efficiently assist in the performance of the committee.

Hospital Committee Areas of responsibility Report to
Execom (Executive Committtee) Quality services and organizational direction Board of Directors
Mancom (Management Committee) Quality services and operational management Execom
Quality Council Quality services and quality management system Mancom / Hospital Director
Committee on Medical Services Quality medical services rendered by physicians Mancom / Hospital Director
Bioethics Committee Bioethical matters in patient care Medical Director
Pharmacy and Therapeutic Committee Drug therapy Medical Director
Infection Control Committee Infection control Medical Director
Waste Management Committee Waste management Operations Officer or Director
Medical Audit and Tissue Committee Outcome in patient care such as mortality, morbidity, and tissue review Medical Director
Tumor Board Cancer management Medical Director
Medical Records Committee Medical records Medical Director

(assistance most needed)

Credentials Committee Credentialing of physicians Medical Director
Blood Transfusion Committee Blood transfusion Medical Director

Members:

Types of members:

  1. Regular members
  2. Ad hoc members
  3. Ex-officio members
Function Attendance Membership Tenure Number and compensation

(to be determined by top mgt)

Regular fulfill prescribed tasks regular appointed yearly subject to renewal
Ad hoc assist As needed invited by regular members yearly subject to renewal
Ex-officio advise As needed invited or designated yearly subject to renewal

Quality objectives:

Based on area of responsibility

Expected output and quality objectives:

Hospital Committee Areas of responsibility Output expected
Execom (Executive Committtee) Quality services and organizational direction Effective and efficient governance policies, decision-making and oversight producing quality service and financial stability
Mancom (Management Committee) Quality services and operational management Effective and efficient operational strategies producing quality service and financial stability
Quality Council Quality services and quality management system Quality management system in place producing quality services
Committee on Medical Services Quality medical services rendered by physicians Quality medical services
Bioethics Committee Bioethical matters in patient care Quality management system on bioethical matters in patients care
Pharmacy and Therapeutic Committee Drug therapy Quality management system on drug therapy
Infection Control Committee Infection control Quality management system on infection control
Waste Management Committee Waste management Quality management system on waste management producing effective and efficient waste management system
Medical Audit and Tissue Committee Outcome in patient care such as mortality, morbidity, and tissue review Acceptable mortality, morbidity, and unnecessary operation rate
Tumor Board Cancer management Quality management system on cancer management
Medical Records Committee Medical records Quality management system on medical records
Credentials Committee Credentialing of physicians Quality management system in credentialing of physicians
Blood Transfusion Committee Blood transfusion Quality management system in blood transfusion

Documents and data needed:

  1. Minutes of meetings
  2. Organizational primer with quality management system manual
  3. Mid-year and annual report based on management action plan
  4. Performance reports

System of inter-office communication

Information dissemination

Management review – once a year

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