POLICY NAME: C. provide advice to the Board regarding any quality and safety implications of annual budget proposals.

Transcription

1 POLICY NAME: QUALITY & PATIENT SAFETY COMMITTEE TERMS OF REFERENCE APPROVING BODY: Board of Directors NUMBER: GOV-7-50 VERSION: 8.0 EFFECTIVE DATE: September 28, 2010 MANUAL: Governance LAST REVIEW DATE: August 2016 SECTION: Terms of Reference REVISION DATE: June 9, 2016 PAGES: 1 of 5 NET REVIEW DATE: August 2017 COMMITTEE OVERSIGHT: Quality & Patient Safety For the Board to operate effectively, it must have access to accurate, timely and meaningful information in order to support proper analysis and decision making. To achieve this and enable decision makers to identify explicit reasons for or against a proposed course of action, and to do that in the context of the Mission, Vision and Values all information must be presented through the use of the Decision Support Template as per the corporate Decision Making Framework. Purpose The Quality and Patient Safety Committee is a standing committee of the board of directors whose purpose is promote and oversee excellence in patient safety and quality as they relate to the achievement of the organization s vision and values and to plan for an environment of continuous improvement. The committee shall: A. recommend to the Board of Directors the priorities for quality and patient safety improvement at MAHC, establish an annual quality improvement plan with goals, specific quality indicators and strategies for achievement to be reviewed and monitored periodically by the Board and ensure the quality improvement plan is made available to the public. B. monitor ongoing improvement to the quality of the patient experience by overseeing the implementation of the patient and family centered care philosophy that fosters an atmosphere of collaboration among all parties, and working to embed the philosophy into all hospital policies, procedures and programs. C. provide advice to the Board regarding any quality and safety implications of annual budget proposals. D. oversee the impact on budget for any quality or patient safety initiatives and ongoing quality of care E. confirm that the hospital meets quality and patient safety reporting requirements as mandated by external bodies such as The Ministry of Health and Long-Term Care, North Simcoe Muskoka Local Health Integration Network and The Canadian Patient Safety Institute F. review quality and patient safety related risk management policies, processes and indicators in respect to at least, but not limited to: i. the annual quality improvement initiatives; ii. the emergency preparedness program with a thorough review conducted every three years; iii. quality care issues as identified and addressed by the Medical Advisory Committee, Quality Council and Medical Quality Assurance Committee; File Location: O:\ADMIN Mgmt\Board\Policy & Procedure\Manual\7.0 - Terms of Reference\Quality & Patient Safety Committee Terms of Reference GOV-7-50 v6.0.doc

2 iv. critical incident and sentinel event reports; v. Disclosure of Patient Safety Incidents Policy; vi. the process for appointment and re-appointment of Professional Staff; vii. publicly reported patient safety indicators; viii. recommendations resulting from any quality of care reviews (QCIPA) ix. the annual goals related to quality and safety for Support Services x. quality and safety issues arising from the HIROC self assessment process xi. quality and safety issues identified in the Enterprise Risk Management Program. G. review and report to the Board on the outcomes of stakeholder satisfaction surveys, patient relations process and patient declaration of values and any issues to be addressed. Such surveys are to be conducted in a frequency consistent with the Excellent Care for All Act, 2010 H. recommend to the Board for approval on an annual basis, a Clinical Services Resources Plan that is consistent with the strategic directions of MAHC, and has taken into account the available resources (impact analysis) at MAHC and the needs of the community. I. confirm the integrity and completeness of the appointment, reappointment and credentialing process for medical, dental and midwifery staff at least annually. J. monitor the preparation processes for MAHC s accreditation survey by Accreditation Canada and ensure implementation of relevant quality-oriented recommendations arising from the survey. K. monitor that best practice information dealing with quality of care and/or patient safety is shared with MAHC employees and physicians. L. provide oversight of the implementation of procedures to encourage potential organ donors, and to make potential donors and their families aware of the options of organ and tissue donation. The Committee shall receive a report with respect to these activities at least annually M. establish a work plan annually for approval by the Board of Directors N. perform such other tasks as outlined in the by-laws, requested by the Board or as outlined in Regulations to the Excellent Care for All Act, 2010 Membership Members will be appointed by the board annually after the annual general meeting and shall include: a) The Vice-Chair of the Board shall serve as Chair b) One-third of members must be voting members of the Board of Directors c) One physician member of the Medical Advisory Committee d) The Chief Nursing Executive e) The Chief Executive Officer f) One person who works in the hospital and who is not a physician or a nurse. This individual can be either a manager or an individual who provides direct care. This promotes inter- Policy Number: GOV-7-50 Version: 8.0 Page 2 of 5

3 professional practice and wider involvement with the committee.other members as appointed by the Board of Directors g) The Board Chair and the Chief of Medical Staff who shall be ex-officio Chair The chair is to be appointed as per the approved process. Frequency of Meetings Six meetings annually, and if required more frequently at the call of the chair. Meeting Attendance As per the Meeting Attendance Policy #GOV-5-110, all Committee members are required to attend a minimum of 80% of meetings. Committee members may participate via teleconference; however, it is strongly encouraged that participation via teleconference occur for no more than two consecutive meetings. This policy applies to all members including ex-officio directors and all non-board members of committees. Accountability The committee will develop a work plan on an annual basis and be accountable to the board for meeting the approved plan and shall submit reports of its meetings to the next regular meeting of the Board. Quorum A majority of members of the Committee which must include a minimum of two elected Directors of the Board. The Committee Chair is included in determining whether a quorum is present. The Board Chair, as an ex-officio Committee Member is not included in determining quorum. Voting All Committee members as outlined in the Membership above and appointed to the committee shall be entitled to vote. Only a member of the committee entitled to vote on the motion may move or second a motion at a committee meeting. There shall be no proxy voting. A member of a committee participating in a meeting of the committee by teleconference may vote by teleconference. or other written resolutions are not permitted. Executive Support (staff) assigned to the committee will not be voting members of the committee or included in the quorum unless the Terms of Reference of the committee otherwise provide. Term July 1 through to June 30, committee members are appointed by the Board following the Annual General Meeting. Note to archives: Prior to 2010 was Strategic Planning & Quality Assurance Committee Policy Number: GOV-7-50 Version: 8.0 Page 3 of 5

4 Quality & Patient Safety Committee Deliverables Matrix Terms of Tool Frequency Responsible Reference Aug Oct Dec Jan Feb Apr Deliverables A MAC Report Every meeting J. Goossens B Patient Stories Every Meeting K. Fleming A Quality Council Updates Every meeting J. Goossens F.iii. Quality Council Updates Every meeting J. Goossens N Strategic Initiative - Physician Recruitment Every Meeting J. Goossens B Strategic Initiative Dashboard Patient & Family Every Meeting K. Fleming Centered Care A Strategic Initiative Dashboard Quality Care & Safety Every Meeting K. Fleming A Balanced Scorecard Quarterly K. Fleming (Q1) (Q2) (Q3) B Patient Experience Interview Summary Quarterly K. Fleming E Patient Safety Indicator Report Quarterly K. Fleming E Alternate Level of Care Updates Quarterly K. Fleming F.i. Balanced Scorecard Quarterly K. Fleming F.vii. Indicator Report Quarterly K. Fleming G Patient Satisfaction Survey Results Quarterly K. Fleming G Patient Relations Report Quarterly N. Bubela L Trillium Gift of Life Network Reports Quarterly J. Goossens N Ethics Program Updates Quarterly K. Fleming (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) (Q1) (Q2) (Q3) N Clinical Research Report Annually N. Bubela F.vi. Credentialing process review Annually J. Goossens F.ix. Department Specific Report Every Meeting K. Fleming F.xi. Enterprise Risk Management Program. (November) Annually K. Fleming File Location: O:\ADMIN Mgmt\Board\Policy & Procedure\Manual\7.0 - Terms of Reference\Quality & Patient Safety Committee Terms of Reference GOV-7-50 v6.0.doc

5 Terms of Tool Frequency Responsible Reference Deliverables Aug Oct Dec Jan Feb Apr H Medical Human Resources Plan Annually J. Goossens A Medical Quality Assurance Terms of Reference Review Annually J. Goossens G Patient Relations Process Review Annually N. Bubela I Credentialing Process review Annually J. Goossens A Quality Council Work Plan Annually J. Goossens C Annual budget Annually K. Fleming A Quality Improvement Plan Annual approval K. Fleming M Committee Work Plan Twice per year Committee Chair F.iv. Critical Incident Report Twice per year K. Fleming F.viii. QCIPA Review Recommendation Twice Per Year K. Fleming (combine with critical incident) D Budget implication for initiatives - as applicable, to be As Applicable added to reports K Best Practice Information Sharing - Varied As required As applicable F.x. HIROC Self Assessment Every three K. Fleming 2013 G Patient Declaration of Values Every three K. Fleming in 2012 F.v. Disclosure Policy review Every three K. Fleming in 2014 I Credentialing Policy Review Every three years, last J. Goossens reviewed 2016 F.ii. Code Review Results Every three years, last reviewed in 2014 J Accreditation Specific Work Plans Every four years, next Accreditation in 2018 K. Fleming K. Fleming Policy Number: GOV-7-50 Version: 8.0 Page 5 of 5