hospital committees

8/2/2019 Hospital Committees

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Hospital

Committees

Dr. Swathi K S

Assistant Professor

MIM



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.



WHY HOSPITAL COMMITTEES

Shared Decision Making

Participative style of management

Facilitate better communication &team

building

Final decision will be more rationale and

objective

Prevent centralization of power & autocracy

Periodical review of the issues and focusing

on improvements



Different Committees are:

Medical/Clinical committee

Medical audit committee

Mortality committee

Medical record committee

Safety & Infection Control Committee

Pharmacy and Therapeutic Committee

Bioethics Committee

Waste Management Committee

OT/Theatre users committee/Tissue Committee

Tumor Board



1.Safety and Infection Control

committee Safety Committee and the Infection Control

Committee take care to minimize patient andemployee risk.

Although its existence may not be widelyrecognized by patients, the Infection ControlCommittee plays an integral part in the care of every patient.

The goal of this interdisciplinary team is to bringtogether individuals with expertise in differentareas of healthcare



Importance -

Infection control is the responsibility of all

healthcare workers.

Patients and employees are only safe frominfectious processes when everyone follows

good infection control techniques



The committee acts as a central clearing

house for all infection control information

and channels that information in a manner

that will create the safest healthcare

environment

Standardize infection control proceduresthroughout the facility so that the same level

of care is provided in all departments.



Members of infection control committee

Members from multi disciplines within thehealthcare facility.

Representation may include:

Physicians

Infection control nurse

Nursing staff

Infection control practitioners,

Quality assurance personnel,

Risk management personnel

Representatives from microbiology, surgery,

environmental services, etc.



What does t he infection control

committee do? Planning

Monitoring

Evaluating

Updating

Educating



PLANNING

The Infection Control Committee is actively

involved with the planning and

implementation of new procedures that posea potential infection control risk.

For example, it may provide guidance for theset-up of an endoscopy lab or the

implementation of a new procedure.



Monitoring

Monitors infectious processes within thehealthcare facility.

When infections do occur, the committeeundertakes epidemiological investigations todetermine the cause of the problem andrecommends the necessary education orchanges in protocols



Evaluating

Constantly reviews the infection control

procedure of all the departments.

Provides input regarding procedures and

outcome.



Updating

The constant advancement of medical

technology introduces changes at all levels

within the healthcare facility, new bacterial

strains complicate and challenge olderinfection control practices, and new research

often requires re-examination of established

procedures.



Educating

The committee plays active role in educating

the staff members through continuous

training.



2.Pharmacy and Therapeutics

Committee A drugs and therapeutics committee (DTC),

also called a pharmacy and therapeutics

committee, is a committee designated to

ensure the safe and effective use of medicines

in the facility.

Formulates and reviews policies regarding the

selection, intra-hospital distribution, storage,

and safe use and administration of drugs

within the Hospital.



Responsibilities

selecting cost-effective and safe medicines

(hospital/health facilities drug formulary);

implementing and evaluating strategies toimprove medicine use (including drug use

evaluation, and liaison with antibiotic and

infection control committees);

providing on-going staff education (training

and printed materials);



controlling access to staff by the

pharmaceutical industry with its promotional

activities;

monitoring and taking action to prevent

adverse drug reactions and medication

errors;

providing advice about other drug

management issues, such as quality and

expenditure



Members may include-

Medical director/MS

Representatives from each clinicaldepartments

Intensivist

Chief Pharmacist Nursing Representatives

Quality department etc.



3.Hospital Et hics Committee

This committee is principally for the purposeof checking whether proposals submitted for

research meet established guidelines.



The committee mainly deals with:

Care of the patient in the institution

Research

Education of the staff on biomedical ethics



Who can be a member?

Comprise of members from a variety of disciplineswithin the healthcare facility. Representation mayinclude:

MD/MS/Administration

Clinicians - medical, surgical Social workers

Nurses

Rehabilitation personnel

Priests/philosophers

Lawyers

Statisticians



MEETINGS

Frequency of meetings will depend upon

the goals set for the committee.

Each member must attend 75% of the

meetings.



RESEARCH

All research proposals must conform to standardscientific and ethical guidelines.

These must be scrutinized by a designatedmember of the committee to ensure that thereis no glaring deficiency. (In case of such adeficiency, the proposal should promptly bereturned to the researcher with a note on whatis needed.)



The committee must pay special attention to:

Will the study add substantially to existingknowledge?

Is the study scientifically, statistically and ethicallyvalid?

Is it relevant?

Are the results of this study likely to prove harmful?points out that we have a moral responsibility to

desist from any inquiry as soon as it becomes clearthat it is likely to endanger mankind.

If experiments on animals form an essentialcomponent, are humane practices built into the

project?



If human subjects are involved,

special attention must be paid to how truly

informed consent is obtained, what measures have

been provided in case of complications that may

harm the subjects and how those defaulting from

the study will be followed up if a drug or implant

with medium or long term action is being used.

has summed up the requirements of truly informedconsent, listing the various kinds of information that

must be conveyed to subjects.



Care of patients

Is the institution providing the best possible medicalcare? This could be considered under the followingheads:

The art of bedside medicine

Relief of suffering

Cure of disease

Iatrogenic disease: incidence, trend over time

Cost to patient: tests, drugs, other costs. Can thesebe lowered?

Prompt attention to needs of the patient. Care of the seriously ill

The dead patient



Members may include: HOD Oncology

Surgical oncologist

Adult & pediatric oncologists Radilogist,

Histopathologist,

Radiotherapist etc.



Terms of reference include:

Setting up of protocols for managing

oncology cases Advice to treating clinicians on treatment

modalities applicable

Reviewing norms regarding staging &management



5.W ASTE MANAGEMENT COMMITTEE Deals with waste management

Framing an effective and efficient waste

management system.

Approach to waste management is based on

the rules 1998 notified under environmentprotection act by the ministry of

environment and forest Government India.



6.Mortality committee

Mortality Committees are multidisciplinary teams

whose functions are -

to analyze preventable causes of death in order to

decrease the death rate,

to contribute to the education of medical and

paramedical staff and

also to advise the hospital authorities in medical

and administrative decision-making.



Assesses the legal aspects, hospital

complications and their trend, and to take

preventive measures for avoiding unwantedcomplications.

Members may include-Medical director/MS

Representatives from each clinical/surgical

departmentsIntensivist

Representative from quality department



7.Tissue committee

A group that evaluates the justification for

surgery performed by the staff of that

hospital.

The evaluation is usually made on the basis

of the extent of agreement of the

preoperative, postoperative, and pathologicdiagnoses and on the relevance and

acceptability of the diagnostic procedures.



The committee should critically review:

(1) all instances where normal and/or notissue is removed during an operation and

(2) cases in which the preoperative andpostoperative diagnoses are in disagreement

with the pathological diagnosis - even when

diseased tissue is removed.

In its review,

the committee determines whether the

removal of the normal tissue was justified.



8.Medical /Clinical Committee

Highest technical body

Responsible for lying down code of ethics

for medical practice

Chief forum for approval of protocols

related to safe and effective delivery of

patient care services



Members:

MD/MS/Chief of medical services

Hospital administrator Quality assurance officer

Heads of various speciality divisions

Heads of radiology, laboratory, anesthesia,emergency etc.



Role & Responsibilities:

to promote clinical interests of the hospital

to bring about higher level of efficiency and

effectiveness in all the departments

Formulates plans for growth and

development of the hospital

To grant clinical privileges to individual

doctors To receive reports from various technical

committees

hospital committees

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