2. What is a Committee?
A Group of people appointed for a specific
function by larger group and typically consisting of
members of that group.
A person or group of persons elected or appointed
to perform some service or function so as to
investigate, report on, act upon a particular matter.
3. Hospital Committees
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
delivery of quality health care services.
4. Types of Committee
Execom (Executive Committee)
Mancom (Management Committee)
Committee of Medical Services
Bioethics Committee
Pharmacy and Therapeutic Committee
Infection Control Committee
5. Quality Council
Waste Management Committee
Medical Audit and Tissue Committee
Tumour Board
Medical Records Committee
Credentials committee
Blood Transfusion Committee
6. Function of Committees
Fulfil tasks effectively and efficiently that will lead to quality
outcome and excellent results with near-zero complaint from
internal as well as external customers
Provide training and education to promote goal achievement
Conduct research to promote goal achievement
Policy formulation
Coordination
Monitoring
8. Function Attendance Membership Tenure
Regular
Fullfil
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
9. Execom Committee
Area of responsibility: Quality services and
organisational direction
Report to: Board of Directors
Output: Effective and efficient governance
policies, decision-making and oversight producing
quality service and financial stability
10. Mancom Committee
Area of responsibility: Quality services and
operational management
Report to: Execom
Output: Effective and efficient operational
strategies producing quality service and financial
stability
11. Quality Council
Area of responsibility: Quality services and
quality management system
Report to: Mancom/ Hospital Director
Output: Quality management system in place
producing quality services
12. Committee on Medical
Services
Area of responsibility: Quality medical services
rendered by physicians
Report to: Mancom/ Hospital Directors
Output: Quality medical services
13. Bioethics Committee
Area of responsibility: Bioethical matters in
patient care
Report to: Medical Director
Output: Quality management system on bioethical
matters in patient care
15. Infection Control
Committee
Area of responsibility: Infection control
Report to: Medical Director
Output: Quality management system on infection
control
16. Waste Management
Committee
Area of responsibility: Waste Management
Report to: Operations Officer or Director
Output: Quality management system on waste
management, producing efficient and effective
waste management system
17. Medical Audit and Tissue
Committee
Area of responsibility: Outcome in patient care
such as mortality, morbidity and tissue review
Report to: Medical Director
Output: Acceptable mortality, morbidity and
unnecessary operation rate
18. Tumour Board
Area of responsibility: Cancer management
Report to: Medical Director
Output: Quality management system on cancer
management
19. Medical Records
Committee
Area of responsibility: Medical records
Report to: Medical Director (assistance most
needed)
Output: Quality management system on medical
record keeping/ management
20. Credentials Committee
Area of responsibility: Credentialing of physicians
Report to: Medical Director
Output: Quality management system in
credentialing of physicians
21. Blood Transfusion
Committee
Area of responsibility: Blood transfusion
Report to: Medical Director
Output: Quality management system in blood
transfusion
22. Quality Management
System
A Quality Management System (QMS) is set of
policies, process and procedures required for
planning and execution (production/ development/
Service) in the core business area of an organization.
(i.e. areas that can impact the organisation’s ability
to meet customer requirements.)
23. System of Functioning
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
