TERMS OF REFERENCE

for
AND QUALITY IMPROVEMENT
UNIT (QIU)

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ABBREVIATIONS
 CRC: Compassionate, Respectful and Careful Professional
 GB: Governing Board
 EHAQ: Ethiopian Hospitals Alliance for Quality
 HDA: Hospital Development Army
 HSTQ: Health Sector Transformation in Quality
 QC: Quality Committee /Quality Control
 QI: Quality Improvement
 QU: Quality Unit
 WHO: World Health Organization

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SHORT TITLE

This document shall be referred to as “TERMS OF REFERENCE FOR QUALITY

IMPROVEMENT UNIT OF SECHA HEALTH CENTER.” It is prepared to guide the activities
of the unit.

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INTRODUCTION

Successful implementation of QI activities need appropriate structures at all levels. The roles,
responsibilities and linkages of the structures within the organization must be clearly defined.
These help to identify the monitoring and supervisory systems that are required to support the QI
programs. Effective leadership and management commitment at all levels is also the key to the
sustainability and success of QI programs.

QI activities should be an integral part of service delivery and applies to preventive, curative,
rehabilitative and support services at all levels. It must involve every department and every
health worker. Quality structures at all levels should drive from existing structures for effective
implementation.

Each health centers should establish a Quality Improvement Unit to oversee all quality
management functions of the health centers. The Unit should comprise a chair person (head) who
is among senior health professional within the health centers the quality improvement Unit
should be multidisciplinary with member appointed from different professionals mix up within
the health centers.

The Unit should act based on the concept that implies, Quality Management refers to the
structure and process by which, Ensure the continuing quality of service provided(Quality
Control) , Improves the quality of services provided(Quality Improvement ) & Obtain evidence
to show that services meet the given requirements (Quality Assurance).

Goal
 The goal is to establish and facilitate scale up of quality management functions
and system, through continuous individual and organizational performances. The
Clinical Governance and quality improvement Unit is a key vehicle in the process
towards achieving this goal.

Objectives:
General objective:

 To establish and revitalized quality management functions at each Case team and
provide clear and uniform guidance on the role and responsibilities of quality
improvement unit which initiates health center’s execution quality functions
based on the structure, procedure and process entitled in current EHCRIG and
HSTQ guideline.

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 Specific objectives:
 To make case teams, clinics and non-clinical case teams facilitate to improved
health provision system based on ,EHCRIG,& HSTQ guideline
 To give mandates to members of quality committee and develop sense of
ownership
 To monitor and evaluate our health centers care provision on regular basis
 To follow quality of purchasing materials activities and involve in checking
quality of materials before they are purchased
 To encourage best performers of our health centers case teams
 To create conducive service delivery areas for each client of guest visiting our
health centers

Roles and responsibilities of Quality Improvement Unit (QIU)

Roles of the QI Unit include:
a) Develop the quality management strategy and present to the health centers Management
Team for approval,
b) Develop an implementation plan for the quality management strategy and monitor its
execution,
c) Ensure that QI activities relate to the vision and mission of the health centers, and are
aligned with the health centers strategic and annual plans,
d) Co-ordinate all quality management activities,
e) Promote and support the participation of all staff in QI activities,
f) Receive and analyse feedback information from patients, staff and visitors,
g) Review selected health centers deaths in collaboration with the clinical quality improvement
committee.

h) Work very closely with the HMIS Focal Officer/Unit in monitoring HMIS performance
i) Conduct peer review in response to specific quality and safety concerns and to take
appropriate action and follow-up when deficiencies are identified, and
j) Build the capacity of, and to update hospital staff on quality improvement activities and
findings including:
a) Comparisons across time

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 b) Comparisons between Case Teams/Departments
c) Comparisons with other health facilities.

This unit should work closely with the Chief Clinical Director of the hospital as most of the
activities are closely related. (EHSTG chap 19. Section 3.2)

Generally, an effective clinical governance and quality improvement program is underpinned by

a cycle of activities involving assessment and problem identification, planning, implementation
of an intervention and evaluation. (EHSTG chap 19. Section 3.3)
The CG&QIU provides leadership, support, tools and services to all parts of the hospital to
enable them to:
 Provide high quality services to their patients.
 Develop and innovate.
 Meet governmental agencies’ (Regional and Federal) requirements.

Our CG&QIU supports front line staff and managers in four ways:
1. Routine support, ensuring good quality service delivery.
2. Support to ensure compliance with national, regional and hospital level
performance targets.
3. Tools and facilitation to support improvement and innovation.
4. Horizon scanning to know what’s new and considers how we respond. (EHSTG
chap 19, p36, topic: The Clinical Governance and Quality Improvement Unit
[CG&QIU])

The following are the ten (10) major pillars or scopes of activity for clinical governance and
quality improvement unit.

Serial National Guideline Remarks

Number
1. EHSTG Ethiopian Hospital Service Transformation 20
Guidelines chapters

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 2. HSTQ Hospital Service Transformation in Quality 10
chapters
3. SaLTS Saving Lives Through Safe Surgery
4. CRC Compassionate, Respectful and Caring health
professional
5. EHAQ Ethiopian Hospitals Alliance for
Quality /የኢትዮጵያ ሆስፒታሎች ጥምረት ለጥራት/
6. IPPS Infection Prevention and Patient Safety /Clean
/CASH Attractive and Safe Hospital
7. HDA Health Development Army/Technology
development army
8. HEP Health Education and Promotion
9. KPI Key Performance Indicators
10. HPMI Health Performance Monitoring and
Improvement

The above eight scopes of activity are the main focus areas (the eight pillars) of the clinical
governance and quality improvement unit (CGQIU) of the hospital.

Clinical governance is the system through which hospitals are accountable for continuously
improving the quality of their services and safeguarding high standards of care, by creating an
environment in which clinical excellence can flourish. It is essentially a quality control system
that helps hospitals monitor the quality of care they deliver.

The QC would be reporting to hospital chief executive committee (CEC) when it is relevant.

The Chief Executive Committee, CEC /or Executive Management Team, EMT/ is responsible
for guiding the successful development and functions of the clinical governance and quality
improvement unit and roll –out of an effective and efficient service delivery at each service area/
unit.

The unit (CGQIU) oversees monitors and supports the implementation of quality service delivery
and attainment level according to the given plan.

The first dimension of quality is to ensure that no harm is done to patients. Researches from
America, Australia and the United Kingdom indicates that around 10% of patient contacts result
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in harm to patients or staff and that half of these harmful or adverse incidents are preventable.
The physical and emotional consequences of an incident can be significant for patients, staff and
caregivers. Adverse incidents also increase costs for additional treatment, claims and litigation.
Hospital Clinical Governance and Quality improvement focuses not only on the quality and
safety of healthcare but also the means to achieve this. Hospital Clinical Governance and quality
improvement Unit, Chief Executive Management and the Governing Board should ensure that
clinical governance systems are in place and should monitor their effectiveness. All staff should
participate in clinical governance and quality improvement activities specific to their area of
work.

Clinical Governance and Quality improvement Unit mainly focus on quality of services being
delivered to our customers either clinical or non-clinical aspects, so that Clinical effectiveness is
to the extent which specific clinical interventions do what they are intended to do, i.e. maintain
and improve the health of patients securing the greatest possible health gain from the available
resources. Clinical effectiveness can be described as the right person doing: the right
thing( evidence based practice), in the right way ( skills and competence), at the right time
( providing treatment/ services when the patient needs them), in the right place (location of
treatment/services) and with the write result( clinical effectiveness/ maximizing health gain)

STRATEGIES, PROCEDURES AND PROCESSES FOR QUALITY MANAGEMENT

The clinical governance and quality improvement unit should develop a quality management
strategy that addresses the key components of quality management including:
1. Risk management: involves assessing the environment for potential risk to patients; then
taking action to minimize any risks identified. The process of risk management seeks to
answer four step related questions:

How bad?

What can go Is there a need for

wrong? action?
How often?

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Risk assessment looks at:
 Hazards: which are situations with the potential to cause harm; and
 Risks: which are defined as the probability that a specific adverse event will occur in a
specific time period or as a result of a specific situation
A “Safe-walk-round” is another approach to risk management. It’s done where a group of
clinical governance and quality improvement unit members and other staff visit areas of the
hospital and ask frontline staff about specific events, contributing factors, near misses, potential
problems and possible solutions.
2. Safe Surgery: to ensure safe surgical care, the hospital should implement the WHO
surgical safety checklist.1
3. Incident Reporting: the hospital should establish a system to report, analyze and learn
from adverse events and service failures that involve risk to patients and/or staff. All staff
should be encouraged to report incidents, errors and near misses. An incident officer will
be assigned to receive and investigate all incident reports. He/she should investigate all
reports received, ideally in collaboration with the relevant case team or department head.
The clinical quality improvement committee should receive regular summary reports of
all incidents reported.
4. Clinical effectiveness: can be described as the right person doing the right thing, in the
right way, at the right time, in the right place and with the right result. It depends on
adequate manpower and resources. It also requires that health professionals have up-to-
date knowledge of the most effective diagnostic tests, treatments and procedures. It also
requires the collection and dissemination of evidence.
5. Professional competence: to ensure that clinicians are able to access the most up-to-date
information deriving from research, hospitals must have a systematic approach to attain
continuous professional development.
6. Patient Focused Care: it involves planning and delivering quality care as a partnership
between staff, patients and care givers. A statement of patients’ rights and responsibilities
will be adopted by the hospital and be visibly posted in all clinical service areas.
7. Patient and public involvement in healthcare planning and service delivery: this helps to
improve service quality and the experience of patients who receive care in the hospital.
Patient forums should be conducted in the college at least once every quarter.
8. Benchmarking: sharing experience and learning from the experience of other regional
and national hospitals. It can be achieved through participating in different meetings of
hospitals in region and sharing site visits to other hospitals in the region and at national
levels.

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EHSTG volume 2, Chapter 13, page 13-10

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IMPLEMENTATION GUIDANCE

Plan, Do, Study, Act (PDSA) Cycle

PLAN DO

ACT
STUDY

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Table 1: Description of PDSA model
Plan Diagnose the situation

 Define problem and overall objective

 Conduct a root cause(s) analysis
 Generate alternative interventions; decide
how to treat the problem
 Conduct a comparative analysis and pick
the best solution
 Create an implementation plan
Do Treat the problem- implement the plan

Study Evaluate your success- did the solution have the

desired effect?

Act Revise your treatment based on the evaluation;

update or change your plan for treatment as
needed

 The CG&QIU supports all case teams to develop and test quality improvement projects.
The level of support provided by CG&QIU can be:
o Full project management – which includes project planning, tool design, data
entry and analysis, and report and the provision of a template for action planning
which will be monitored through the clinical audit and service evaluation.
o Partial project management – which includes the provision of advice, production
of data collection tool and scanned data entry. Teams will be expected to
undertake their own analysis and report, with advice from CG&QIU.
o Consultancy only – which includes advice surgeries at each stage of the project.
Individuals and teams will be expected to undertake the project themselves.
(EHSTG chap 19, p 41)

ACCOUNTABILITY OF THE QUALITY MANAGEMENT UNIT

 The Clinical governance and quality improvement unit will be accountable to the chief
executive management. It will report regularly /monthly/ to the hospital CEM and GB
when it is relevant. It is responsible for guiding the successful development of the quality
functions and roll-out of an effective and efficient service delivery at each service units of

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the hospital. The unit will oversee, monitor and support the implementation of quality
service delivery and attainment level of the hospital against Quality Improvement Plan.

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 WSU CHSMQUALITY ENHANCEMENT AND ASSURANCE DIRECTOR ORGANOGRAM

CHIEF EXECUTIVE DIRECTOR

CHIEF ACADEMIC AND RESEARCH QUALITY ENHANCEMENT AND ASSURANCE CHIEF CLINICAL DIRECTOR
DIRECTOR DIRECTOR

ACADEMIC QUALITY COORDINATOR CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT

UNIT (HEAD AND QUALITY OFFICERS)

8 DEPARTMENTS &
SCHOOLS QUALITY
COMMITTEES
CLINICAL QUALITY MAJOR INCIDENT CRC COMMITTEE
IMPROVEMENT COMMITTEE (MIC)
STUDENTS’ QUALITY
COMMITTEE
COMMITTEE
COMPLAINT HANDLING HEALTH ETHICS IPPS-CASH
COMMITTEE COMMITTEE COMMITTEE
CURRICULUM & 20 DEPARTMENTAL
QUALITY ASSURANCE QUALITY
STANDING IMPROVEMENT SUB-
COMMITTEE TEAMS (QITs)

Note: Solid arrows indicate line of accountability

Broken arrows indicate line of communication

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Departmental Quality Improvement Sub-Teams (QITs)
 All staff should participate in clinical governance activities specific to their area of work.
(EHSTG chap 19, p 19-1)
 Each clinical department should establish its own QI team which functions incorporating
the various CG&QI activities. Department heads are responsible to ensure that quality
activities take place within the different case teams of the department and are responsible
to report these activities to the CG&QI Unit. Each clinical department should perform
regular auditing of its own performance. (EHSTG chap 19, section 3, implementation
guidance)
 Each department should establish a QI team which will work on improving the quality of
services provided in the unit. Department heads should lead the QI team. (EHSTG chap
19, section 3, implementation guidance)
 Irrespective of the workload, the hospital should establish a departmental/case team level
QI team to undertake some of the above functions if the hospital has sufficient number of
staff. Each departmental QI team should be chaired by the department director and they
should provide regular update reports to the CG&QIU. (EHSTG chap 19, section 3.2, last
paragraph)

Roles and responsibilities of Departmental Quality Improvement

teams (QITs)

 Roles and responsibilities of Departmental Quality Improvement teams (QITs) include the
following:
o Attend regular and prompt meetings called by the chair or delegate of the QIT (at
least weekly or every two weeks)
o All meetings must be documented with minutes and the agenda should be relevant
to quality improvement activities, clinical audit, action plan, implementation,
challenges, re-audit to close gaps identified in previous audits etc.
o Receive tools and materials from the chair or delegate of the QIT
o Discuss on overall quality improvement activities and challenges in their service
unit

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 o incorporate the various CG&QI activities to their service area
o work on improving the quality of services provided in their service area
o Department heads should lead the QI team
o QI team is said to be functional when:
 They have developed and signed TOR,2
 They have developed Annual operational plan and communicated it to the
CGQIU,
 They have a quarterly and annual performance report as per the plan,
 Have done continuous EHSTG/HSTQ chapter assessment monthly,
 Have done regular monthly clinical audit and re-audit
 Regular meeting as per their specific TOR, that is weekly or every two
weeks
 have active QI project to solve identified problems
 develop at least one QI project quarterly
RECOMMENDED DEPARTMENTAL QUALITY IMPROVEMENT SUB-TEAMS (QIT)
ESTABLISHMENT FRAME

S. Chairperson Deputy chair Secretary Members Remarks

No
.
1. OPD QIT (OPD director/ (OPD focal or (OPD nurse) 1. (ART focal)
coordinator) pinpoint) 2. (TB focal)

2. Medical (HIT/HMIS (MR head) (KPI focal) 1. (MR staff)

Records + head) 2. (MR staff)
HMIS QIT 3. (MR staff)

3. Inpatient (IPD director) (Matron) (IPD pinpoint 1. (medical

Department or focal) IPD)
QIT 2. (surgical
IPD)
3. (pediatric
IPD)
4. (Gyn Obs
IPD)
4. MNCH (Gyne Obs (GPs (labor ward 1. (OB ward
(Gyne Obs) department head)
2
TOR: Terms of Reference

15
 QIT head) coordinator) head) 2. (Gyne OR
head)
3. (NICU head)
5. Pediatrics (Pediatrics (GPs (Pedi ward 1. (Pediatric
QIT department coordinator) head) EMOPD
head) head)
2. (NICU staff)
3. (Pediatrics
staff)
6. SaLTS QIT (OR director) (anesthesia) (Surgical OR 1. (Gyne OR
pinpoint) pinpoint)
2. (Ophtha OR
pinpoint)
3. (Orthopedics
OR pinpoint)
4. (surgical
ward head)
7. Medical Biomedical (Lab (anesthesia) 1. (store man)
equipment Engineer technologist) 2. (OR
mgt QIT pinpoint)
3. (Asset mgt
officer)
8. Facility (General (General (Maintenance 1. (Cleaner)
Management Service head) Service deputy or workshop 2. (Guard)
QIT head or officer) officer) 3. (Gardener)
4. (Laundry)
5. (Kitchen)
6. (Porter)
7. (Runner)
9. Laboratory (Lab head) (Lab quality (Lab safety (Lab
QIT officer) officer) technologist)

10. Pharmacy (Pharmacy (Pharmacy (Pharmacist) (Pharmacist)

QIT clinical head) coordinator,
focal, or
pinpoint)
11. Radiology (Radiology (Radiology (Radiology (Radiology staff)
QIT head) coordinator, staff)
focal, or
pinpoint)
12. CRC and CRC (A member of (A member of (A member of
Patient ambassador CRC CRC CRC committee)

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 Centered /focal committee) committee)
Care QIT

13. Emergency (Emergency (Emergency (Emergency (Emergency

services QIT director) coordinator, staff) staff)
focal, or
pinpoint)
14. IPPS and (Environmental (Environmenta (Laboratory 1. (Cleaner)
CASH QIT health l health staff) 2. (Gardener)
professional) professional) 3. (Laundry)

15. HRM QIT (HRM head) (HRM quality (HRM officer) (HRM officer)
officer)

16. Finance, (Finance head) (Procurement (Finance 1. (Procuremen

procurement and asset mgt quality t & asset mgt
and asset head) officer) quality
management officer)
QIT 2. (Finance
officer)
17. Liaison, (Liaison head) (Social service (Reception 1. (Liaison
referral, head) officer) officer)
reception & 2. (Social
social service service
QIT officer)

18. Nursing & (Nursing (Matron) (pinpoint (nursing staff)

midwifery director) nurses)
service QIT

19. Rehabilitative (Rehabilitative (Rehabilitative (Rehabilitative (ICU staff)

and palliative and palliative and palliative and palliative
care QIT care head) care care staff)
coordinator,
focal, pinpoint)
20. TB-HIV QIT (OPD director) (ART focal) (TB focal) 1. (CDC focal)
2. (PMTCT
focal)
3. (HTC focal)
4. (ART clinic
staff)
5. (TB clinic
staff)

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 ወላይታ ሶዶ ዩኒቨርሲቲ ጤና ሳይንስና ህክምና ኮሌጅ

Wolaita Sodo University College of Health Sciences and Medicine

የ ___________________ ክሊኒካል ጥራት ማሻሻያ ንዑስ ኮሚቴ

መተዳደሪያ ደንብ

TERMS OF REFERENCE FOR

___________________ QUALITY IMPROVEMENT
SUB-TEAM (QIT)

Team name: _____________Clinical Quality Improvement Sub-Team (QIT)

(የ___________________ ክሊኒካል ጥራት ማሻሻያ ንዑስ ኮሚቴ)

Responsible to: Clinical Governance and Quality Improvement Unit (CGQIU)

(የክሊኒካል ጥራት ማሻሻያና ማረጋገጫ ዩኒት)

Members of ___________________ QIT

Serial Full Name Status Role Signature Contact Phone Remarks
Number
1 Department Chairperson
Head/director
2 GPs coordinator Deputy
chair
3 Coordinator Secretary
4 Focal/pinpoint Member
5 Staff Member

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የንዑስ ኮሚቴው የሥራ ኃላፊነት (Responsibilities of the QIT)

1) የንዑስ ኮሚቴው አባላትን ስም ለዋናው የክሊኒካል ጥራት ማጎልበቻና ማረጋገጫ ዩኒት

ማሳወቅ
2) በክፍሉ የሚሰጠው የጤና አገልግሎት ጥራት እና ደረጃውን የጠበቀ መሆኑን መከታተል
3) በክፍሉ የሚያስፈልጉ ቁሳቁስ እንዲሁም መመሪያዎች እና ፕሮቶኮሎች የተሟሉ
መሆናቸውን መከታተል እና ማሟላት
4) በየሁለት ሳምንቱ በጥራት ጉዳዮች ስብሰባ እና ውይይት ማድረግ
5) ሁሉም ስብሰባዎች በቃለ ጉባኤ መዝገብ መያዛቸውን ማረጋገጥ፤
6) የተሰበሰቡበትን ቃለ ጉባኤ በየሁለት ሳምንቱ ለዋናው የክሊኒካል ጥራት ማጎልበቻና
ማረጋገጫ ዩኒት በጽሑፍ መላክ፤
7) ለክፍሉ የጥራት ማሻሻያ ዕቅድ /Quality Improvement Plan/ ማዘጋጀት
8) ክፍሉን የሚመለከቱ ስታንዳርዶች /EHSTG, HSTQ, EHAQ, SaLTS, IPPS/CASH, CRC,
HDA/ የተሟሉ እንዲሆኑ ተግቶ መስራት
9) በክፍሉ በየወሩ ክሊኒካል ኦዲት ማካሄድ እና የጎደሉ ስታንዳርዶችን መለየት፤
10) በክፍሉ የጎደሉ ስታንዳርዶችን ለማሟላት የድርጊት ዕቅድ /አክሽን ፕላን/ ማውጣት
11) የወጣውን አክሽን ፕላን ተግባራዊ ማድረግና መከታተል
12) በየወሩ የአፈጻጸም ሪፖርት ለዋናው የክሊኒካል ጥራት ማሻሻያና ማረጋገጫ ዩኒት
ማቅረብ /ሪፖርት ማድረጊያ ቅጹን በመጠቀም/
13) ከጎደሉ ስታንዳርዶች መካከል መቅደም ያለበትን ችግር በማስቀደም ያን ለመፍታት
የሚያስችል የጥራት ማሻሻያ ፕሮጀክት /Quality Improvement Project/ ማዘጋጀት
14) በክፍሉ አስተያየት መስጫ መዝገብ እና እስክብሪቶ ምንጊዜም በግልጽ ስፍራ መኖሩን
ማረጋገጥ

19
 /ተገልጋዮች አስተያየት መስጠት ሲፈልጉ ወረቀት በኪሳቸው ላይኖር ስለሚችል
የአስተያየት ሳጥን ሳይሆን የአስተያየት መዝገብ መሆን አለበት፡፡ ተገልጋዮች እስክብሪቶ
በኪሳቸው ላይኖር ስለሚችል በአስተያየት መስጫ መዝገቡ አጠገብ ሁሌም እስክብሪቶ
መኖር አለበት፡፡ ያለው የአስተያየት መስጫ ሳጥን ከሆነ ግን ተገልጋዮች ቀድደው
የሚጠቀሙት ወረቀት እና እስክብሪቶ በሳጥኑ አጠገብ ምንጊዜም በግልጽ ስፍራ መቀመጥ
አለበት፡፡/
15) በአስተያየት መስጫ መዝገብ ላይ ተገልጋዮች ያሰፈሩትን ሀሳብ በየሳምንቱ በ 1 ለ 5 ስብሰባ
ላይ መወያየት፣ በየሁለት ሳምንቱ በጥራት ማሻሻያ ንዑስ ኮሚቴ ስብሰባ ላይ መወያየት እና
በአስተያየቱ መሠረት የአገልግሎት ጥራትን ለማሻሻል የድርጊት ዕቅድ /አክሽን ፕላን/
ማውጣት፤ የወጣውን አክሽን ፕላን ተግባራዊ ማድረግና መከታተል
16) በሥራ ክፍላቸው የኮሌጁን ኦርጋኖግራም (Organogram) መለጠፍ ይኖርባቸዋል፡፡ ጎን ለጎን
ደግሞ የራሳቸውን የስራ ክፍል ኦርጋኖግራም (Organogram) አዘጋጅተው መለጠፍ
ይኖርባቸዋል፡፡

የክሊኒካል ጥራት ማሻሻያ ንዑስ ኮሚቴ አባልነት

1) የክሊኒካል ጥራት ማሻሻያና ማረጋገጫ ንዑስ ኮሚቴ አባላት የሚሆኑት በክፍሉ

የሚሠሩ ዳይረክተሮች፣ ኃላፊዎች፣ አስተባባሪዎች፣ ፎካሎች፣ ፒን-ፖይንቶች
ሲሆኑ እንዲሁም ሌሎች ስታፎችም አባል ሊሆኑ ይችላሉ፡፡
2) የአባላት ብዛት በትንሹ 3 (chairperson, secretary and member) እና ከዚያ በላይ መሆን
አለበት፡፡ ቢበዛ ደግሞ ከ 6-7 መሆን ይችላል፡፡
3) የክሊኒካል ጥራት ማሻሻያ ንዑስ ኮሚቴ አባላት በቅርበት የሚገናኙ እና የሚግባቡ
መሆን ይጠበቅባቸዋል፡፡ በየሁለት ሳምንቱ እየተገናኙ በጥልቀት የሚወያዩ መሆን
ይጠበቅባቸዋል፡፡

20
 4) የክፍሉ ዳይረክተር፣ ኃላፊ ወይም አስተባባሪ የኮሚቴው ሰብሳቢ /Chairperson/
በመሆን ቡድኑን ይመራል፡፡
5) ኮሚቴው ምክትል ሰብሳቢ /Vice Chairperson/ ሊኖረው ይገባል፡፡ ይህም ዋና
ሰብሳቢው በማይኖርበት ጊዜ እርሱን በመወከል ይሠራል፡፡
6) ኮሚቴው ጸሐፊ /secretary/ ይኖረዋል፤ ይህም ቃለጉባኤ የሚይዝ ይሆናል፡፡
7) ከዚህ በተጨማሪ ኮሚቴው አባል /member/ ወይም አባላት /members/ ይኖሩታል፡፡
አንድ የጥራት ማሻሻያ ንዑስ ኮሚቴ በአግባቡ እየተንቀሳቀሰ ነው ለማለት ማሟላት
የሚጠበቅበት መስፈርት

1) ኮሚቴው አመታዊ ዕቅድ ሲኖረው

2) በዕቅዱ መሠረት ሲንቀሳቀስ
3) ወርሃዊ፣ የሩብ አመት እና አመታዊ ሪፖርት ሲያቀርብ
4) ኮሚቴው በቋሚነት በየሁለት ሳምንቱ እየተሰበሰበ ሲሆን
5) ተሰብስቦ የሚወያይበት አጀንዳ ከጥራት ጋር /EHSTG, HSTQ, EHAQ, SaLTS,
IPPS/CASH, CRC, HDA/ የተያያዘ ሲሆን
6) ኮሚቴው ያለማቋረጥ በየወሩ ለዋናው ጥራት ማሻሻያና ማረጋገጫ ዩኒት በየወሩ
የአፈጻጸም ሪፖርት በጽሁፍ ሲያቀርብ
7) የአባላት መተዳደርያ ደንብ /Terms of Reference/ በጽሁፍ አዘጋጅቶ ከአባላቱ ጋር
የተፈራረመ ሲሆን
8) ቃለጉባኤ መዝገብ ያለው ሲሆን እና
9) በቃለጉባኤ መዝገቡ ላይ በትክክል በየሁለት ሳምንቱ ያደረጉት ስብሰባ ተመዝግቦ ሲገኝ
ነው፡፡

QI team is said to be functional when:

1. They have TOR,3
2. Annual operational plan,
3. Performance report as per the plan,
4. Continuous EHSTG chapter assessment,
5. Regular meeting as per their specific TOR,
6. And have active QI project to solve identified problems.

3
TOR: Terms of Reference

21
Guidelines /Etiquette for Effective Committees and Meetings4

When a new committee/group is established it is important to:

1) Determine group membership:
 Consider which departments /people are most involved and should be on the team.
 Include all points of view, including conflicting ones.

2) Assign a Chairperson and Secretary (and a vice chairperson if necessary)

3) Establish Terms of Reference (TOR) for the group including:

 Function /duties of the committee
 Description of outputs expected
 Realistic timeline for completion of project (if relevant)
 Statement of who the group /committee is accountable to (if relevant)
 Frequency of meetings: when the group shall meet and discuss

4) Set schedule for meetings, ideally at a fixed frequency, day and time. (For example, the first
Monday of every month at 4 pm; or every Wednesday at 3 pm). A fixed schedule makes it
easier for committee members to plan their schedule and remember to attend the meetings.

For each meeting:

5) The Secretary and Chairperson should circulate the agendas (topics of discussion), the
minutes of the previous meeting, and papers for discussion in advance of the meeting. These
should be circulated to all committee members in advance (ideally one week before the
meeting).

6) All committee members should review the agenda, minutes and items for discussion
BEFORE the meeting so that they have full information for discussion at the meeting. If the
meeting is spent reviewing items for the first time then much time will be wasted and the
meeting will be unproductive.

7) Begin and end the meeting ON TIME. Do not wait more than a few minutes for members
who are late.

4
Source: Federal Democratic Republic of Ethiopia, Ministry of Health, Ethiopian Hospital Services Transformation
Guidelines (EHSTG) Volume 1, September 2016, Ethiopian Hospital Management Initiative, Version 1.0, chapter 1,
Appendix E

22
8) Be concise and stay on topic. If the agenda is long, a time limit should be set for each agenda
item.

9) Begin the meeting by reviewing the minutes of the previous meeting and obtaining an update
report on any action points that were assigned from the previous meeting.

10) For each item on the agenda agree any action points that need to be followed up after the
meeting. For each action assign a specific individual to complete the task and a deadline for
completion (for example prior to next meeting, within one week, within one month etc.)

11) Prepare minutes of each meeting. These should include a summary of discussions; and all
action points should be clearly stated with the name of the responsible individual.

Terms of Reference for any team/committee should be defined including the following:

1. a description of the membership of the team/committee,

2. the roles and responsibilities of the team/committee,
3. the roles and responsibilities of the chairperson, secretary and member
4. frequency of meetings,
5. voting rules and
6. a statement of confidentiality.
7. Each team/committee member should sign a copy of the TOR indicating his/her
acceptance.

23
RESOURCES FOR CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT
UNIT

Effective quality management requires both human and financial resources. Clinical quality
officers should have their duties clearly described and should have sufficient time allocated in
their working schedule to undertake quality management activities. Resources such as
computers, printers, lap tops, photocopy machines, internet access, stationeries (paper) etc.
should be available in plenty amount to support quality management activities. The costs of
implementing the quality management strategy should be calculated and should be included
within the hospital annual budget plan.

WORKING HOURS OF CGQIU

Working day and hours of clinical governance and quality improvement unit officer shall be
sixteen (16) hours per day from Monday to Friday and twelve (12) hours per day from Saturday
to Sunday.

However when there is high work load and any need arise, quality officers should stay actively
working regardless of working day and time. The institution shall arrange adequate
compensation and benefit packages for their committed engagement and extra times of working.

TRAINING AND BENCH MARKING

As it is well known, quality improvement is a continuous process and it is not a single time
action. In order to cop up with continuously developing technology, it is necessary to update
work force which enables sustainability of quality improvement. So, to build working capacity
of the unit, the college should facilitate trainings and bench marking process.

FREQUENCY OF MEETING

 The Clinical Governance and Quality Improvement Unit will conduct meeting with its
own members/Quality Officers at least once every two weeks accompanied by minute
documents.
 The Clinical Governance and Quality Improvement Unit will conduct meeting with
clinical quality committee at least once in a month.

24
  The Clinical Governance and Quality Improvement Unit will conduct meeting with the
college management council at least once every two weeks.
 Departmental quality improvement teams (QITs) shall meet at least once every two
weeks. Departmental quality improvement teams (QITs) are chaired by the
head/coordinator of the unit/department.

MINUTE DOCUMENTS

 All meetings shall be accompanied by minute documents

25
 Clinical Governance and Quality Improvement Unit conducts Regular Quality
Improvement Meeting with its own members/Quality Officers every Two Weeks

Tentative Schedule

Every Two weeks

Year 2011 E.C

S. Date Day Month Year Remarks

No.
1. 25/11/2010 Wednesday July 2010 E.C. Conducted
2. 30/11/2010 Monday July 2010 E.C. Conducted
3. 02/12/2010 Wednesday August 2010 E.C. Conducted
4. 21/12/2010 Monday August 2010 E.C. Conducted
5. 23/12/2010 Wednesday August 2010 E.C. Conducted
6. 03/01/2011 Thursday September 2011 E.C. Conducted
7. 18/01/2011 Friday September 2011 E.C.
8. 02/02/2011 Friday October 2011 E.C.
9. 16/02/2011 Friday October 2011 E.C.
10. 30/02/2011 Friday October 2011 E.C.
11. 07/03/2011 Friday November 2011 E.C.
12. 21/03/2011 Friday November 2011 E.C.
13. 05/04/2011 Friday December 2011 E.C.
14. 19/04/2011 Friday December 2011 E.C.
15. 03/05/2011 Friday January 2011 E.C.
16. 17/05/2011 Friday January 2011 E.C.
17. 01/06/2011 Friday February 2011 E.C.
18. 15/06/2011 Friday February 2011 E.C.
19. 29/06/2011 Friday February 2011 E.C.
20. 13/07/2011 Friday March 2011 E.C.
21. 27/07/2011 Friday March 2011 E.C.
22. 11/08/2011 Friday April 2011 E.C.

26
23. 25/08/2011 Friday April 2011 E.C.
24. 09/09/2011 Friday April 2011 E.C.
25. 23/09/2011 Friday May 2011 E.C.
26. 07/10/2011 Friday June 2011 E.C.
27. 21/10/2011 Friday June 2011 E.C.

28. 05/11/2011 Friday July 2011 E.C.

29. 19/11/2011 Friday July 2011 E.C.
30. 03/12/2011 Friday August 2011 E.C.
31. 17/12/2011 Friday August 2011 E.C.
32. 01/13/2011 Friday Leap year 2010 E.C.
33. 09/01/2012 Friday September 2012 E.C.

27
YEARLY SCHEDULE FOR CLINICAL QUALITY IMPROVEMENT
COMMITTEE REGULAR MONTHLY MEETING 2011 E.C

 (Venue: Clinical Governance and Quality Improvement Unit Office)

Serial Date Day TIME Month Year Main Remarks

number (E.C.) agendas
1 17/11/2010 Tuesday 9:30 LT Hamle 2010 Discussion
(July) E.C. on ISS
feedback
2 15/12/2010 Tuesday 9:30 LT Nehase 2010
points,
(August) E.C.
Discussion
3 22/01/2011 Tuesday 9:30 LT Meskerem 2011
on
(September) E.C.
identified
4 13/02/2011 Tuesday 9:30 LT Tikimt 2011 quality gaps
(October) E.C.
5 18/03/2011 Tuesday 9:30 LT Hidar 2011
(November) E.C.
6 16/04/2011 Tuesday 9:30 LT Tahisas 2011
(December) E.C.
7 14/05/2011 Tuesday 9:30 LT Tir 2011
(January) E.C.
8 19/06/2011 Friday 9:30 LT Yekatit 2011
(February) E.C.
9 17/07/2011 Tuesday 9:30 LT Megabit 2011
(March) E.C.
10 15/08/2011 Tuesday 9:30 LT Miazia 2011
(April) E.C.
11 13/09/2011 Tuesday 9:30 LT Ginbot 2011
(May) E.C.
12 11/10/2011 Tuesday 9:30 LT Sene (June) 2011
E.C.

28
1 16/11/2011 Tuesday 9:30 LT Hamle 2011
(July) E.C.
2 14/12/2011 Tuesday 9:30 LT Nehase 2011
(August) E.C.
3 20/01/2012 Tuesday 9:30 LT Meskerem 2012
(September) E.C.
4 18/02/2012 Tuesday 9:30 LT Tikimt 2012
(October) E.C.

29
 Quality Improvement Meeting with College Management Council

Tentative Schedule

Every Two weeks

Year 2011 E.C.

S. Date Day Month Remarks

No.
34. 04/01/2011 Friday September Conducted
35. 16/01/2011 Wednesday September
36. 30/01/2011 Wednesday September
37. 14/02/2011 Wednesday October
38. 28/02/2011 Wednesday October
39. 12/03/2011 Wednesday November
40. 26/03/2011 Wednesday November
41. 10/04/2011 Wednesday December
42. 24/04/2011 Wednesday December
43. 08/05/2011 Wednesday January
44. 22/05/2011 Wednesday January
45. 06/06/2011 Wednesday February
46. 20/06/2011 Wednesday February
47. 04/07/2011 Wednesday March
48. 18/07/2011 Wednesday March
49. 02/08/2011 Wednesday April
50. 16/08/2011 Wednesday April
51. 30/08/2011 Wednesday April
52. 14/09/2011 Wednesday May
53. 28/09/2011 Wednesday May
54. 12/10/2011 Wednesday June
55. 26/10/2011 Wednesday June

56. 10/11/2011 Wednesday July

57. 24/11/2011 Wednesday July
58. 08/12/2011 Wednesday August
59. 22/12/2011 Wednesday August
60. 07/01/2012 Wednesday September

30
Departmental quality improvement teams (QITs) shall meet at least once every two weeks
Tentative Schedule

Every Two weeks

Year 2011 E.C

S. Date Day Month Year Remarks

No.
61. 06/11/2010 Friday July 2010 E.C.
62. 20/11/2010 Friday July 2010 E.C.
63. 04/12/2010 Friday August 2010 E.C.
64. 18/12/2010 Friday August 2010 E.C.
65. 02/13/2010 Friday Leap year 2010 E.C.
66. 04/01/2011 Friday September 2011 E.C.
67. 18/01/2011 Friday September 2011 E.C.
68. 02/02/2011 Friday October 2011 E.C.
69. 16/02/2011 Friday October 2011 E.C.
70. 30/02/2011 Friday October 2011 E.C.
71. 07/03/2011 Friday November 2011 E.C.
72. 21/03/2011 Friday November 2011 E.C.
73. 05/04/2011 Friday December 2011 E.C.
74. 19/04/2011 Friday December 2011 E.C.
75. 03/05/2011 Friday January 2011 E.C.
76. 17/05/2011 Friday January 2011 E.C.
77. 01/06/2011 Friday February 2011 E.C.
78. 15/06/2011 Friday February 2011 E.C.
79. 29/06/2011 Friday February 2011 E.C.
80. 13/07/2011 Friday March 2011 E.C.
81. 27/07/2011 Friday March 2011 E.C.
82. 11/08/2011 Friday April 2011 E.C.

31
83. 25/08/2011 Friday April 2011 E.C.
84. 09/09/2011 Friday April 2011 E.C.
85. 23/09/2011 Friday May 2011 E.C.
86. 07/10/2011 Friday June 2011 E.C.
87. 21/10/2011 Friday June 2011 E.C.

88. 05/11/2011 Friday July 2011 E.C.

89. 19/11/2011 Friday July 2011 E.C.
90. 03/12/2011 Friday August 2011 E.C.
91. 17/12/2011 Friday August 2011 E.C.
92. 01/13/2011 Friday Leap year 2010 E.C.
93. 09/01/2012 Friday September 2012 E.C.

REVISION OF THIS TOR

This TOR shall be revised at least annually or can be modified any time needed depending on the
institution’s demand. Generally it shall be revised every June of the year.

32