RATIONALE TERMS OF REFERENCE FOR THE QUALITY COMMITTEE UNDER THE EXCELLENT CARE FOR ALL ACT. Authority

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1 RATIONALE With the intrductin f the Excellent Care fr All Act, hspital bards must nw have a quality cmmittee that reprts t the bard. The template prvides sample terms f references fr rganizatins t adapt and use fr their wn quality cmmittee under the Excellent Care fr All Act. TERMS OF REFERENCE FOR THE QUALITY COMMITTEE UNDER THE EXCELLENT CARE FOR ALL ACT Authrity The Quality Cmmittee perates under the authrity f the Bard and is the Quality Cmmittee fr the purpses f the Excellent Care fr All Act, 2010 ("ECFAA"). The Quality Cmmittee reprts t the Bard. Purpse The Quality Cmmittee is respnsible t: assist the Bard in the perfrmance f the Bard's gvernance rle fr the quality f patient care and services perfrm the functins f the Quality Cmmittee under ECFAA Duties and Respnsibilities The Quality Cmmittee shall: Excellent Care fr All Act, 2010 In accrdance with the respnsibilities in ECFAA: 1. Mnitr and reprt t the Bard n quality issues and n the verall quality f services prvided in the Hspital, with reference t apprpriate data including: perfrmance indicatrs used t measure quality f care and services and patient safety reprts received frm the Medical Advisry Cmmittee identifying and making recmmendatins with respect t systemic r recurring quality f care issues publicly reprted patient safety indicatrs 1

2 critical incident and sentinel event reprts [list ther reprts and indicatrs such as balanced scre cards r reprts frm staff quality cmmittees r patient safety fficers] 2. Cnsider and make recmmendatins t the Bard regarding quality imprvement initiatives and plicies. 3. Ensure that best practices infrmatin supprted by available scientific evidence is translated int materials that are distributed t emplyees, members f the Prfessinal Staff and persns wh prvide services within the Hspital, and subsequently mnitr the use f these materials by such persns. 4. Oversee preparatin f the Hspital's annual quality imprvement plan. 5. Perfrm such ther respnsibilities as may be prvided under regulatins under ECFAA. The fllwing items are recmmended, unlike the items abve which are required under ECFAA: Accreditatin Oversee the Hspital's plan t prepare fr accreditatin. Review accreditatin reprts and any plans required t be implemented t imprve perfrmance and crrect deficiencies. Prfessinal Staff Prcess Annually review with the Chief f Staff/Chair f the Medical Advisry Cmmittee the appintment and reappintment prcesses fr the Prfessinal Staff including: criteria fr appintment applicatin and reapplicatin frms applicatin and reapplicatin prcesses prcesses fr peridic reviews Plicy Implementatin Oversee implementatin f plicies, prcesses and prgrams t ensure quality bjectives are met and maintained. 2

3 Critical Incidents and Sentinel Events "Critical incidents" means any unintended event that ccurs when a patient receives treatment in the hspital, (a) (b) that results in death, r serius disability, injury r harm t the patient, and des nt result primarily frm the patient's underlying medical cnditin r knwn risk inherent in prviding treatment. In accrdance with Regulatin 965 under the Public Hspitals Act receive frm the Chief Executive Officer, at least twice a year, aggregate critical incident data related t critical incidents ccurring at the Hspital since the previus aggregate data was prvided t the Cmmittee. Annually review and reprt t the Bard n the Hspital s system fr ensuring that at an apprpriate time fllwing disclsure f a critical incident, there be disclsure as required by Regulatin 965 f systemic steps, if any, the Hspital is taking r has taken in rder t avid r reduce the risk f further similar critical incidents. The Quality Cmmittee shall review reprts with respect t sentinel events and versee any plans develped t address, prevent r remediate such events. Cmpliance Mnitr the Hspital's cmpliance with legal requirements and applicable plicies f funding and regulatry authrities with respect t quality f patient care and services. Financial Matters As and when requested by the Bard, prvide advice t the Bard n the implicatins f budget prpsals n the quality f care and services. Hspital Services Accuntability Agreement and Hspital Annual Planning Submissin (HAPS) As and when requested by the Bard, prvide advice t the Bard n the quality and safety implicatins f the HAPS and quality indicatrs prpsed t be included in the Hspital's Service Accuntability Agreement r in any ther funding agreement. 3

4 Risk Management Review and make recmmendatins with respect t: Hspital's standards n emergency preparedness plicies fr risk management related t quality f patient care and safety areas f unusual risk and the Hspital's plans t prtect against, prepare fr, and/r prevent such risks and services Other Perfrm such ther duties as may be assigned by the Bard frm time t time. Membership and Vting Vting Members: At least tw vting members f the Bard Chief Executive Officer Chief Nursing Executive A member f the Medical Advisry Cmmittee selected by the Medical Advisry Cmmittee A persn wh wrks in the Hspital wh is nt a member f the Cllege f Physicians and Surgens r the Cllege f Nurses Such ther persns as the Bard may frm time t time appint prvided that at least ne third f the vting members f the Quality Cmmittee shall be vting members f the Bard. Delegates: Subject t the apprval f the Bard, the members f the Quality Cmmittee referenced at paragraphs 2, 3, 4 and 5 may appint a delegate t sit as a member f the Quality Cmmittee in their stead. Chair The Chair f the Quality Cmmittee shall be appinted by the Bard frm amng the members f the Quality Cmmittee wh are vting members f the Bard. Frequency f Meetings and Number f Calls At least nine times per year at the call f Chair f the Quality Cmmittee, r as requested by the Bard. 4

5 Qurum A majrity f the vting members. Resurces [Indicate the staff wh will prvide supprt t the Quality Cmmittee] Reprting The Quality Cmmittee shall reprt t the Bard at each meeting f the Bard and shall annually prepare and prvide t the Bard a reprt that prvides an verview f the activities f the Quality Cmmittee and f the quality f care and services prvided by the Hspital ver the previus year. Privilege and Cnfidentiality Quality f care infrmatin prepared fr and reviewed by the Quality Cmmittee is prtected under the Quality f Care Infrmatin Prtectin Act, Infrmatin prvided t, r recrds prepared by, the Quality Cmmittee fr the purpse f assessing r evaluating the quality f health care and directly related prgrams and services prvided by the hspital are subject t an exemptin frm access under the Freedm f Infrmatin and Prtectin f Privacy Act. ISSUES TO CONSIDER Bards can use their current quality cmmittee f the bard as their quality cmmittee under the Excellent Care fr All Act, s lng all legal requirements under the Excellent Care fr All Act are met. Adapting the sample terms f reference fr the quality cmmittee will ensure legal cmpliance with the Excellent Care fr All Act. Cnsistent with the exclusin frm access under the Freedm f Infrmatin and Prtectin f Privacy Act, infrmatin prtected under the Quality f Care Infrmatin Prtectin Act (QCIPA) is prtected wherever it ges, including t the quality cmmittee under the Excellent Care fr All Act. There is als an exemptin fr ther nnqcipa quality assurance recrds included in Bill 173, which was given first reading n March 29, Users will need t cnfirm that this has been passed int law. 5

6 There are ther, gd gvernance practices fr quality cmmittees that are nt included in the sample terms f reference but shuld be cnsidered by the quality cmmittee. Please refer t 1.5 Recmmendatins fr an Effective Quality Cmmittee. SOURCE Ontari Hspital Assciatin (2011). Guide t Gd Gvernance: 2nd Editin. (Available in spring, 2011) 6

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