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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