COMMITTEE TERMS OF REFERENCE

Applies To:
Name: All committee
QUALITY IMPROVEMENT & PATIENT SAFETY Members
COMMITTEE

Pages:
Sharourah General COM-003 (3) 5
Hospital Date Revised: Effective Date: Review Date:
October 20, 2013 November 20, 2013 October 20, 2015

1. Formation Replaces No:

New  Revised Reactivated
COM-003(2)
2. Team
 Standing Ad Hoc Task Force QI Team
Category
3. Authority Policy Others:
 Advisory   Implementation
Making
4. Purpose  To provide direction, coordination and oversight of the Quality
Improvement Program and the Patient Safety Program.
 To act as the Steering and Executing Force for the Total Quality
Management Initiatives.
5. Reports to: Hospital Leadership Committee
6. Activities/ 1. Act as role models, advocates and leaders in creating a hospital
Main environment of continuous quality improvement.
Functions 2. Approves all Quality Management initiatives and provides oversight
for the Quality Management program.
3. Ensures implementation of Patient Safety Program throughout the
hospital.
4. Reviews and approves the organization wide Quality Plan and Patient
Safety Plan.
5. Develops and maintains a Risk Management Program that provides a
structured framework for identification, analysis, monitoring and
evaluation of risks.
6. Set strategic directions on hospital-wide Quality Improvement and
Patient Safety as an essential integrated component of the
organization strategic plan.
7. Monitors ShGH's performance through regular collection and analysis
of data.
8. Develop educational activities that will promote knowledge
concerning the implementation of continuous quality improvement,
risk management and patient safety management processes in the
QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE CHARTER

- Original to TQM
- Copy to be provided by TQM to Chairman
- Copy to be provided by Chairman to Members
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 hospital.
9. Continually monitor and revise the quality improvement plan for
continuous quality improvement projects and initiatives.
10. To facilitate and promote the implementation of the required
standards by CBAHI or any other regulatory accreditation agency.
11. Reinforce and support all practices that reflect continuous
improvement, either directly or indirectly to ensure that performance
improvement is facilitated and sustained throughout the organization.
12. To identify Major Quality Improvement opportunities and initiate
studies as required by the Executive Committee and:
12.1 Assign priority to these matters so that those having the most
significant impact upon patient care are addressed first.
12.2 Determine how a problem area should be studied
(prospectively, concurrently or retrospectively) and by whom
(multi-disciplinary team, department or individual).
12.3 Receive reports of studies
12.4 Assess recommendations against written criteria.
12.5 Ensure that potential problem areas are monitored
periodically and that follow-up mechanisms are implemented.
13. Promote multidisciplinary approach of problem solving processes.
14. Approves all hospital wide teams that are formed to solve a particular
issue.
15. Monitor organization-wide quality improvement activities and evaluate
their outcome in accordance with the quality plan.
16. Receives reports from all teams, heads of departments, and other
members assigned quality improvement projects.
17. Provides feedback to their staff on quality improvement projects.
18. Review aggregated data and information from customer satisfaction
surveys, performance indicator monitoring, risk and safety, infection
control, and utilization issues as applicable.
19. The QIPS Council shall recommend to executive leadership high-risk,
problem-prone, and high volume processes that most directly related
to quality of care, patient safety, and safety of the environment, as
well as indicators (key measures) that allow monitoring how these
processes operate.

7. MEMBERSHIP
Chairman Hospital Director
Co- Chairman Quality Management Director
Members Medical Director
QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE CHARTER

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- Copy to be provided by TQM to Chairman
- Copy to be provided by Chairman to Members
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 Nursing Director
Patient Affairs Director
Operations & Maintenance Director
Laboratory Director
Head of Radiology
Medical Records Director/ Representative
Head of Pediatrics/NICU
Head of Medical
Head of Surgery
Head of OB GYNE
Infection Control Director
QI Continuing Education Coordinator, Pharmacy Dept
Patient Safety Officer
Risk Manager
Clinical Quality Coordinator
Invitee/Ad Hoc To be invited as needed.
Members
Scriber Administrative Secretary
8. MEETING POLICY
Meeting Frequency Weekly  Monthly Quarterly Other _________
Meeting Duration 1 hour
Quorum 90% of the membership should be present. If quorum is not met the
meeting will be re-scheduled by the chairman for the same day or the
following day.
Manner of Action Majority of voting.
Official Leave: The committee chairman or the coordinator should be notified 48 hours
in advance before and the substituted name to replace him/her.
Apology:  The committee chairman or the coordinator should be notified 48
hours in advance before the meeting.
 Members missing three consecutive meetings without previous
apology or leave will be contacted to verify intent to remain on the
Committee.
Absence: Absence without notification will direct the member to be claimed
according to the Hospital Disciplinary Procedure.
Decision Making: Decision Making will be by Majority vote (If votes are even,
Chairperson’s decision stands)
9. RECORDING AND REPORTING
Agenda Written Agenda using the approved hospital Agenda format & any
attachment if available shall be send by e-mail to each member of the
QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE CHARTER

- Original to TQM
- Copy to be provided by TQM to Chairman
- Copy to be provided by Chairman to Members
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 committee or service at least five (5) days prior to the time of the meeting.
Agenda should be signed by the chairman.
Minutes 1. Minutes of each regular and special meeting of the committee shall be
prepared and shall include a record of the attendance of members and
the vote taken as per approved hospital Minutes format
2. The minutes shall be signed by the Chairman of the committee.
3. Minutes of each committee meeting and service meeting shall be
maintained in a permanent file for 1 year effective , one year archive to
be discarded when committee annual report is produced.
4. The minutes shall be approved by the QIPS members & signed by the
chairman of the committee or the Co-Chairman.
Reports Due  Monthly meeting minutes provided to all members, hospital director-
Original minutes filed at TQM Department
 Annual Committee Report
 Quarterly Report of OVR and Performance Indicators
 Quarterly Report of Patient Safety Rounds
 Quarterly Report of Risk Management Monitoring

10. APPROVAL:

Name And Title Signature Date

Prepared by MS. MELANIE RODRIGUEZ

Clinical Quality Coordinator
Reviewed by
MR. MANA AL YAMI
QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE CHARTER

- Original to TQM
- Copy to be provided by TQM to Chairman
- Copy to be provided by Chairman to Members
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 Quality Management Director

Approved by MR. AWAD JURAIBA SAARI

Hospital Director

Stamp

QUALITY IMPROVEMENT & PATIENT SAFETY COMMITTEE CHARTER

- Original to TQM
- Copy to be provided by TQM to Chairman
- Copy to be provided by Chairman to Members
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