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 and employee risk.

Although its existence may not be widely recognized by patients, the Infection Control Committee plays an integral part in the care of every patient. The goal of this interdisciplinary team is to bring together individuals with expertise in different areas of healthcare

Importance Infection control is the responsibility of all healthcare workers.

Patients and employees are only safe from infectious 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 procedures throughout the facility so that the same level of care is provided in all departments.

Members of infection control committee

Members from multi disciplines within the healthcare 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 the 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 pose a potential infection control risk. For example, it may provide guidance for the set-up of an endoscopy lab or the implementation of a new procedure.

Monitoring
Monitors infectious processes within the healthcare facility.

When infections do occur, the committee undertakes epidemiological investigations to determine the cause of the problem and recommends the necessary education or changes 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 older infection 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 to improve 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 clinical departments Intensivist Chief Pharmacist Nursing Representatives Quality department etc.

3. Hospital Ethics Committee

This committee is principally for the purpose of 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 disciplines within the healthcare facility. Representation may include: 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 standard scientific and ethical guidelines. These must be scrutinized by a designated member of the committee to ensure that there is no glaring deficiency. (In case of such a deficiency, the proposal should promptly be returned to the researcher with a note on what is needed.)

The committee must pay special attention to: Will the study add substantially to existing knowledge? Is the study scientifically, statistically and ethically valid? 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 clear that it is likely to endanger mankind. If experiments on animals form an essential component, 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 informed consent, listing the various kinds of information that must be conveyed to subjects.

Care of patients
Is the institution providing the best possible medical care? This could be considered under the following heads: 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 these be lowered? Prompt attention to needs of the patient. Care of the seriously ill The dead patient

4. Tumor board
Can be seen in hospitals with full-fledged Oncology department where all cases are discussed and joint decisions on the best line of management are taken A team of renowned experts from Surgical, Radiation and Medical Oncology, and related disciplines come together

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.WASTE 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 environment protection 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 unwanted complications. Members may includeMedical director/MS Representatives from each clinical/surgical departments Intensivist 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 pathologic diagnoses and on the relevance and acceptability of the diagnostic procedures.

The committee should critically review: (1) all instances where normal and/or no tissue is removed during an operation and (2) cases in which the preoperative and postoperative 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