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