Board Policy CA-350: Quality and Risk Management Committee

Effective date: 2019-06-18

Policy

Terms of reference

The Client Service, Quality Management and Safety Committee (the “Committee”) is responsible to ensure that mechanisms are in place to monitor and improve the quality performance of the Network. The committee is responsible for promoting and overseeing all quality management, patient and user safety, risk and ethics activities so as to guide the Board of Directors (the “Board”) regarding its responsibilities in all aspects related to the delivery of health care services to patients.

Membership and operations

  1. The Committee is made up with three voting members of the Board, one of whom will act as Chairperson.
  2. The Committee meets at least four times and at the most five times a year according to a pre-set schedule.
  3. The Committee operates within the guidelines set out in the Board of Directors Committees Policy (CA-300).
  4. The Medical Advisory Committee and the Professional Advisory Committee chairpersons are permanent members without voting rights.

Responsibilities

  1. The Committee oversees, advises the Board, and makes the recommendations it deems appropriate on issues related to:
    1. Client service, quality management, patient and user safety, risk and ethics processes;
      1. Prioritizes quality and patient and user safety and sets the direction that the Network must follow in terms of quality;
      2. Recommends to the Board frameworks for quality and safety, risk management and ethics and follow their implementations;
      3. Reviews and recommends a multi-year quality and safety strategic plan as well as annual objectives for improvement;
      4. Ensures that effective mechanisms are established to evaluate and improve the quality of care and services and manage risks;
      5. Regularly monitors and evaluates the Network’s performance in terms of quality through its scorecard;
      6. Receives and analyzes reports from the client service, Quality Management and Safety Committee and ensures that the necessary measures are taken to address discrepancies and improve the quality of care and services;
      7. Reviews policies related to quality, patient safety, ethics and risks management;
      8. Recommends educational programs on quality and patient safety for members of the Committee and the Board;
    2. Accreditation standards related to client service, care and service quality and safety, and other processes related to the standards that are specific to a health network;
    3. Patient/client satisfaction and experience and complaint management processes;
      1. Ensures that mechanisms are established to evaluate and improve the experience of the patient/client satisfaction and deal with complaints;
    4. Processes for granting, renewing, suspending or changing medical staff privileges;
    5. Processes related to skills development and maintenance for professionals and physicians and to delegated professional and medical functions.
  2. The Committee also performs any other duties assigned by the Board.

Reporting

  1. The Committee submits a report on its activities at each meeting of the Board, including an annual quality, safety and ethics review. Regular reports include the following:
    1. Quality indicators presented in a scorecard, including performance measurements on the quality of clinical services, patient safety, and client service (on a quarterly basis);
    2. Progress in major improvements in performance and patient safety objectives (on a quarterly basis or biannually);
    3. Root-cause analysis submitted by the Network’s Client Service, Quality Management and Safety Committee;
    4. Summary of adverse events reviews (at least quarterly);
    5. Patient satisfaction/perception (quarterly and annual reports);
    6. Physician satisfaction/perception (at least every two years);
    7. Employee satisfaction/perception (at least every two years);
    8. Culture of patient safety (annual report);
    9. Accreditation (quarterly report);
    10. Verification of the credentialing and certification process (at least every two years);
    11. Report on ethics activities (quarterly and annual reports).

Committee’s work plan and annual objectives

  1. The Committee adopts a work plan and annual objectives identifying its main interests for the following year. Here are some examples:
    1. Overseeing a program to reduce medication errors;
    2. Strongly supporting and overseeing a client service improvement initiative in the Emergency Department;
    3. Overseeing projects related to a quality and safety improvement campaign;
    4. Reviewing and updating the quality scorecard and other key indicator reports pertaining to quality and patients so as to ensure that they include advanced goals established for the Network;
    5. Reviewing current national priorities in the field of quality and patient safety, such as performance-based remuneration and use of information technologies to improve quality.