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TYPES OF COMMITTEES GOVERNING HOSPITALS
Presented by:- Dr. Mahboob Khan Phd
AIMS AND OBJECTIVES Emphasis on primary care. Primary care should be the cornerstone of a people-centered health
system. objective is to keep the number of deaths below 77.5 per 1,000 among
patients reporting to the emergency department with a diagnosis of heart attack.
The underlying goals committees are:a. to promote the rights of patients;b. to promote shared decision making between patients and their
cliniciansc. to promote fair policies and procedures that maximize the likelihood
of achieving good, patient-centered outcomes; andd. to enhance the ethical tenor of health care professionals and health
care institutions.
WHAT IS COMMITTEE? A group of persons convened for the
accomplishment of some specific purpose, typically with formal protocols; a guardian; someone in charge of another person deemed to be unable to look after himself or herself.
A committee is generally a formal working group within a larger organization, often formed by election, often having authority or legitimacy of some specific kind.
Committees prescribed by regulatory agencies
Committees prescribed by hospital administration
Phil Health
Pharmacy and Therapeutic
Pharmacy and Therapeutic
Execom
Infection Control Infection Control MancomQuality Assurance Quality Assurance Committee on
Medical ServicesWaste Management
Bioethics
Medical Audit and TissueTumor BoardMedical RecordsCredentialsBlood Transfusion
• Hospital CommitteesHospital 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, department and unit committees.
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
Thus, as of July, 2016, the following 13 committees are recommended to constitute the Hospital Committees :
Governig Board
President
Medical director/me
dical superintend
ent
Administrative officer
Commitees of board
Medical staff organisation
Chief executive officer
AccountingBusiness officeCredits &collectscashierAdmitting
FINANCIAL NURSING
Nursing education
IPD Units
OPD units Operating rooms
Ttrannies Emergency rooms
committees
Medical support
Medicine
House staff
Surgery Gyn&Obs
Pediatrics
Others
AdministrativeEnvironmental
Maintenance
Housekeeping
Plant operations
Laundry
Patients
Dietary
Social services
CHIEF EXECUTIVE OFFICER
ANCILLARY
HOSPITAL INFORMATION SYSTEM
HUMAL RESOURCE MANAGEMENT
RADIOLOGY CLINICAL LABSANAESTHESIA PHYSIAL THERAPYRESPIRATORY THERAPY ELECTROCARDIOGRAPHYPHARMACY ELECTROENCEPHALOGRAPHY
• ADVANTAGES • DISADVANTAGES
•Exchange of views and information.•To bring collective wisdom,group deliberation,judgements on subjects•Solution of problems in hospital•Recommend action.•Generate ideas.Discuss pros n cons.•To perform at high level of cooperation and commitment.•To make decision collectively
•Waste of time•“if you want a kill an idea,Appoint a committee”•Intrerference of external members•Dominance of overbearing and aggressive members.•Committee members can use their position to further their self interest
*Medical Executive Committee* Typically composed of elected officers of the medical staff, the immediate past president
of the medical staff, the chairpersons of the various medical departments, and physicians on the Board of Directors.The president of the hospital,vice president of medical affairs,metron and director of quality care/assurance/utilization review/risk management
The duties of this committee usually include: • Accounting to the Board of Directors for patient/resident care. • Acting on reports and recommendations offered by other committees. • Coordinating the activities of the medical staff. • Making recommendations on medical issues. • Recommending appointment, reappointment,and corrective action of medical
staff. * Ethics Committee* Ethics Committee is an advisory group appointed by the University Hospital Medical
Executive Board. It reviews, on request, ethical or moral questions that may come up during a patient's care. Committee members include doctors, nurses, social workers, an attorney, a chaplain etc..
Responsibilities of the Hospital Ethics Committee To act as patient advocate on bioethical issues.. Develop and recommend hospital and other clinical policies and guidelines that define
ethical principles for conduct within the hospital. The committee will provide advisory consultation and review in cases where ethical
dilemmas are perceived by the patient/patient's family.the physician/medical team, or other hospital or clinic staff. The primary responsibility will be to encourage dialogue, educate, identify issues offer viable options,
The committee will educate hospital and clinic personnel, patients, and their families about hospital policies regarding ethical issues.
The Pharmacy and Therapeutics CommitteeThe Pharmacy and Therapeutics (P & T) Committee is an important medical staff advisory group. As the primary, formal communication link between the pharmacy and medical staff, the P & T Committee is of particular importance to the department of pharmacy services. All matters of use of medications within the institution, including pharmacy programs, must be reviewed and approved through the committee. Medication formulary data is reviewed through the committee and recommendations are offered to the medical staff. An active involvement in the committee by the department of pharmacy services is vital in order to develop a contemporary and progressive institutional pharmacy program.
The Infection Control Committee Every healthcare facility uses interdisciplinary task forces such as the Safety Committee and the Infection Control Committee to minimize patient and employee risk Representation may include: physicians, nursing staff, infection control practitioners, quality assurance personnel, risk management personnel as well as representatives from microbiology, surgery, central sterilization, environmental services, etc.
.The duties of this committee typically include:• Monitoring equipment currently in use.• Evaluating new products being considered or already ordered.• Providing information about equipment and products to involved employees.
Safety Committee/ Employee Health CommitteeTypically composed of representatives from the occupational health unit, safety manager, humanresources, and employees from the various departments. The duties of this committee usuallyinclude:• Developing and reviewing policies and procedures for safe and healthy work conditionsfor employees.• Developing and evaluating all safety and health programs, including implementation ofthe Exposure Control Plan for Bloodborne Pathogens.• Establishing and implementing procedures for workplace safety inspections.• Establishing procedures for investigating and recording all workplace accidents, illnesses
Hospital acquired infection, transfusion transmitted diseases, rising incidence of Hepatitis B, and HIV, increasing land and water pollution lead to increasing possibility of catching many diseasesThis usually include
Hospital waste management
1. Segregation of waste2. Collection of bio-medical
waste3. Transportation4. Treatment of hospital waste5. Safety measures6. Measures for waste
minimization
Budget/Finance and Audit CommitteeTypically composed of representatives from the Board of Directors, chief executive officer, chieffinancial officer, and various departmental directors. The duties of this committee usuallyinclude:• Monitoring the financial status of the health care facility.• Advising the Board of Directors concerning financial policies.• Reporting to the Board of Directors on the effectiveness of resource allocations.
URGENT CARE The CMO should regularly participate in Advanced
Cardiac Life Support and Advanced Trauma Life Support programmes and disaster drills conducted by the hospital from time to time. The hospital administration should have a dedicated person to look after the casualty.
Nursing staff is the backbone of the casualty and the department should have dedicated nurses who may be rotated through the critical care areas of the hospital to improve their skills and response time, as the casualty is also an acute care area, which caters to critically ill patients.
TUMOUR BOARD BLOOD BANK COMMITTEE
The Role of the Tumor Board In a Community&Objectives:
1. To formulate integrated, coordinated, and comprehensive hospital-wide policies on the management of patients with cancer in the hospital.
2. To monitor and continually improve the quality of care to patients with cancers.
3. To conduct educational and training programs for concerned staff so as to facilitate implementation of hospital policies on management of cancer patients.
4. To promote research on oncology that will continually improve the quality of care for cancer patients.
Need for Blood Bank As a blood transfusion service deals with
different functions related to donors and patients, it is imperative to keep in mind the safety of both donors and recipients. The blood transfusion service has to be planned and organized in such a way that it fulfils its ideal aims and objectives i.e.
Recruitment of blood donors - voluntary & replacement
Care of donor, donated unit and the recipient
Maintain adequate blood stock Provide clinically effective blood
components Optimal use of available blood
BUDGET/FINANCE AND AUDIT COMMITTEE
INFORMATION SYSTEMS COMMITTEE
Typically composed of representatives from the Board of Directors, chief executive officer, chief
financial officer, and various departmental directors. The duties of this committee usually
include: • Monitoring the financial status of
the health care facility. • Advising the Board of Directors
concerning financial policies. • Reporting to the Board of Directors
on the effectiveness of resource allocations.
Typically composed of the director of information systems and representatives from the various
This committee usually include: • Evaluating and
recommending clinical computer systems.
• Providing training on clinical computer systems.
• Responding to requests for assistance with computer applications
MEDICAL RECORD COMMITEEIn most of the hospitals,the quality review of the midical
record is done by a medical record committee.Functions:1) Reviewing the medical records for timely Complition. Clinical relevance Adequacy of the file for use in quality review activities
and medico-legal documents The whole course of treatment2)Reviewing the security and integrity of MRD3)Checking the retrivel system of department for easy and
quick retrival.Role of MRD :-to maintain records of hospital To ensure completeness, be self regulating,to avoid any deficiencies
and errors in future.
Hospital Committee General functions:Formulate policiesCoordinateMonitor
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 managementMedical Records Committee Medical records
Credentials Committee Credentialing of physicians
Blood Transfusion Committee Blood transfusion
The general functions of the MDH Hospital Committees are to formulate policies, coordinate and monitor hospital-wide activities on specified areas of responsibility.
Report to
Board of Directors
Execom
Hospital Director
Hospital Director
Medical Director
Medical Director
Medical Director
Operations Officer or Director
Medical Director
Medical Director(assistance most needed)
SSCOMMITTEE
STRENGTH
ENERGY/ EFFORTS
SPIRIT
COURAGEVALUES/ STANDARDS
INTELLIGENCE