CONTENT
I. Back Ground …………………………………....…1
II. Goal ……………………………………………...…2
III. Objectives ……………………………………..…...2
IV. Appointment and Accountability of Quality
Management Committee …………………………2
V. Working Procedure …………….………….………3
VI. Decision making ………………………………..….3
VII. Removal from membership ……………….………3
VIII. Duties and responsibilities of chairperson and
members ……………………………………………4
IX. Quality management committee strategies ………6
X. Amendments of the TOR …………………………6
BACK GROUND
As a key step in improving the quality of service at each public hospital, Ethiopia’s
federal ministry of health (FMOH) developed EHRIG and a hospital performance
framework with a set of key performance indicators that allow to measure hospital
performance in the areas of efficiency, effectiveness and quality. Based on this reform
guideline Nigist Eleni Mohammed memorial hospital (N/E/M/M/H) established a quality
committee (QC) to oversee all quality management functions of the hospital on 26/4/04
this data is better said to be a data of re-established because the hospital has the
committee previously but it was not functioning for a long time. Hence at this time
members were selected by the SMT and the committee became functional.
The Team is comprised of chair person who is member of hospital senior management
team (SMT) and 5 quality officers. The members are appointed from clinical,
administrative and supportive case team within the hospital.
1. Dr. Girma Lobe (Chair Person)
2. Dr. Abebe Addise
3. Dr. Lamesgnew Mose
4. Dr. Abebaw Siraw
5. Ato Tesfaye Lejeso
6. Ato Yeshanew Ayele
7. Ato Bereket Temesgen
8. Ato Alemu worku
9. Ato Gezahahn Tadios
10. W/t Seada Abirare
Where circumstance permit and depending on the size of hospital QC chair and quality
officers should be full time in their role. Since this is not possible, the members of QC
have a specified time within their regular working weeks for quality assurance activities.
The committee should act based on the concept that implies quality management. This
refers to the structure and process by which an organization
1. Ensure the continuing quality of service provided (quality control)
2. Improves the quality of services provided (Quality improvement)
3. Obtain evidence to show that services meet the given requirements (Quality
Assurance)
II. GOAL
The goal is to establish and facilitate scale up of quality management functions and
system through continuous individual and organizational performances. The quality
committee is a key vehicle in the process to achieving this goal.
III OBJECTIVE
A) Establish and revitalized quality management function at N/E/M/M/H.
B) To provide clear and uniform guidance on the role and responsibilities of quality
committee
C) To initiate hospital’s execution their quality functions based on the structure,
procedure and process entitled in ERIG
IV. APPOINTMENT AND ACCOUNTABILITY OF THE
QUALITY MANAGEMENT COMMITTEE
The QC will be reporting to hospital SMT when it is relevant. Responsible for guiding
the successful development of the quality committee functions and roll –out of an
effective and efficient service delivery at each public hospital.
The chair and members of the committee shall be appointed within a clear ground and
guidance as per EHRIG.
The committee oversees, monitor and support the implementation of quality service
delivery and attainment level against the given plan.
V. WORKING PROCEDURE
A) The committee will be lad by a chair person
B) Members may appoint a person from amongst themselves to formally act as secretary
C) The Team will meet every 2 weeks till it is organized and every one month after the
committee is organized and may conduct urgent meeting when needed.
E) The committee will communicate action points to responsible bodies, members
through the chair person within 3 days of each meeting.
F) Every effort shall be made to facilitate good member attendance. Meeting times and
dates should be agreed well in advance and members should receive relevant documents
which are useful for their roles.
VI DECISION TAKING
A) Effort should be made to reach a consensus wherever possible
B) Ordinary decisions will be taken by a simple majority (50+1)
C) The chair may use a casting vote in the event of a tied decision.
VII. REMOVAL FROM MEMBERSHIP
Membership may be withdrawn by the team at its discretion including but not limited to:
1. Poor attendance including absence from 3 consecutive meetings, or attendance of
less than 50% of the meetings in any 6 months period.
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2. Failure to declare conflicts interest
3. Disruptive or other behavior not conductive to the good reputation of the hospital
VII. DUTIES AND RESPONSIBILITIES OF CHAIR PERSON AND MEMBERS.
The chair person of the QC will be member of hospital senior management team and will.
Represent quality committee by hospital senior management team and may
participate on governing board meeting when it is relevant to share quality issues
and concerns to governing board member
Prepare and share to members and other concerned the committee meeting agenda
as appropriate and a timely manner
Chairs the regular quality committee meeting
Follow through on delivery of any action points
Ensure appropriate documentation, compilation, interpretation and dissemination
of reports,.
May establish subcommittee of QMC to undertake some of the above functions,
for eg mortality committee. Clinical Audit and Research committee, HMIS
committee. Where there are sub committees, all sub committees’ chair persons
have to be member of the hospital QMC.
Receive relevant report at all case team, departments and quality officers on
quality management activities and submit performance and other report to SMT on
monthly basis.
ROLES AND RESPONSIBILITIES OF THE QUALITY COMMITTEE
INCLUDE:
Develop the quality management strategy and present to the SMT for approval or
governing board as it is relevant.
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To develop an implementation plan for the quality management strategy and
monitor its execution.
Ensure alignment of hospital quality management plan with hospital strategic and
annual plan
Actively participate and engage in identifying the hospital focus interest areas and
develop monthly, quarterly, and/or annual improvement plan based on the interest
areas.
Coordinate all quality management activities.
To Promote and support participation of all staff in quality management activities.
To receive and analyze feedback information from patients, staffs and visitors.
To review selected hospital deaths
To conduct peer review in response to specific quality and safety concerns and to
take appropriate action and follow up when deficiencies are identified
To update hospital staffs on quality management activities and finding including
A) Comparison across time
B) Comparison between case team and departments
C) Comparison with other health facilities.
The committee will also look in to the hospital plan and performance periodically
especially in line with quality management functions; obstacles and
improvements obtained will be shared and forwarded to the ground for possible
solutions /further improvements
IX. QUALITY MANAGEMENT COMMITTEE STRATEGIES
Strategies need to address the following
1. Risk management
2. Sate surgery
3. Incident reporting
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4. Clinical effectiveness
5. Professional competence
6. Patient focused care
7. Patient and public involvement in healthcare planning and service delivery
8. Benchmarking
At the end of each meeting the committee will come up with doable action items for
identified list of problems. If there are problems that need higher level intervention, it
will be communicated through the minute to SMT and hospital governing board as it is
appropriate.
X. AMENDMENTS OF THE TOR
Any section or part of the TOP is subjected to change at any time based on the decision
or recommendation of the Quality management committee with agreement of hospital
senior management team and the approval of the Governing Boards.
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