PROFESSIONAL/HEALTH ADVISORY COMMITTEE/BOARD

POLICY:

The Agency will establish and maintain a committee to establish and oversee standards of care.

PURPOSE:

To ensure proper professional advice, quality controls, and community input necessary to ensure patient continuity of care and Agency oversight.

REFERENCES:

10 NYCRR 766.9 (LHCSA: 5/15/2013)

Non-discoverability laws 145.61 to 145.67, pursuant to USC title 42, section 1320c-1 et seq.

DESCRIPTION:

The Professional Advisory Committee (PAC) appointed by the governing authority/designee serves as the oversight body for the Performance Management/Quality Improvement (PMQI) Committeeand Improvement initiatives. It is composed of at least one consumer and appropriate health professional persons. Committee members must be knowledgeable about the health care needs of the community.

The internal Performance Management/Quality Improvement (PMQI) Committee falls under the direction of the Professional Advisory Committee. The Performance Management/Quality Improvement Committee will meet regularly to conduct activities of the Performance Management/Quality Improvement Plan and will report quarterly to the PAC.

PROCEDURE:

  • Professional Advisory Committee members will signaconfidentiality agreement (see Confidentiality of PHI policy for form) and a conflict of interest statement annually (see attached form).
  • The Professional Advisory Committee shall meet at least quarterly and will:
  • Provide bi-directional support to the QI efforts of the department, providing consultation, feedback and evaluation of QI training and QI projects
  • Provide oversight and advise on the implementation, monitoring and evaluation of the Agency’s performance management system.
  • Provide input on Agency performance measures
  • Identify public health services in need of quality improvement and areas of focus from an outside community perspective. Review policies pertaining to the delivery of health care and services provided by the Agency and when revisions are indicated, recommend such revisionsto the governing authority for adoption. Also as necessary, the committee will review and approve new services provided by the Agency for the first time.
  • Advise the governing authority on services to be added or eliminated based on an assessment of health care resources in the community, patient’s needs, available reimbursement mechanisms, and the availability of qualified personnel.
  • Assist the agency in maintaining liaisons with other health care providers in the community.
  • Review auditfindings of both active and closed clinical records of all Agency programs(minimum of ten percent of records quarterly) to determine whether established policies are followed in furnishing services directly or under contract.
  • Review all accidents, incidents, and complaints and make recommendations as indicated.
  • Ensure collection, analysis and conclusions of customer feedback. Review the report on all patient satisfaction surveys. Ensure actions taken based on customer feedback.
  • Analyze project outcomes and make recommendations
  • Ensure completion of QI activity schedule
  • Ensure regulations regarding quality assurance are met through program audits, review of incidents, accidents and complaints, approval of policies and procedures
  • Support a culture of quality throughout the health department
  • The findings and recommendations from PAC will be made to the Performance Management/Quality Improvement Committee for further action/follow up and integrated into the Agency’s performance management and quality improvement programs as appropriate.

DOCUMENTATION:

  • Minutes summarizing the content of each meetingwill be recorded.
  • Minutes will be distributed to all committee members for approval at the subsequent meeting.
  • Minutes, including all attachments, shall be kept on file in the Agency for a period of 6 years in accordance with the NYS Retention and Disposition Schedule (CO2).
  • Minutes are considered part of the Quality Improvement Program and are therefore non-discoverable.

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DISCLOSURE OF CONFLICT OF INTEREST

No member of the Professional Advisory Committee shall derive any personalprofit or gain, directly or indirectly, by reason of his or her participation on the Professional Advisory Committee.

Each individual shall disclose to the organization any personal interest which he or she may have in any matter pending before the organization and shall refrain from participation in any decision on such matter.

Any member of the Committee who is an officer, board member, a committee member, or staff member of a client organization or vendor of the County shall identify his or her affiliation with such agency or agencies; further, in connection with any committee or board action specifically directed to that agency, s/he shall not participate in the decision affecting that agency and the decision must be made and/or ratified by the full Professional Advisory Committee.

Any member of the Professional Advisory Committee shall refrain from obtaining any list of clients for personal or private solicitation purposes at any time during the term of their affiliation.

At this time, I am a board member, committee member, or an employee of the following organizations:

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Now this is to certify that I, except as described below, am not now nor at any time during the past year have been:

1) A participant, directly or indirectly, in any arrangement, agreement, investment, or other activitywith any vendor, supplier, or other party doing business with the County Public Health Department which has resulted or could result in personal benefit to me.

2) A recipient, directly or indirectly, of any salary payments or loans or gifts of any kind or any free service or discounts or other fees from or on behalf of any person or organization engaged in anytransaction with the County Public Health Department.

Any exceptions to 1 or 2 above are stated below with a full description of the transactions and of the interest, whether direct or indirect, which I have (or have had during the past year) in the persons or organizations having transactions with the County Public Health Department.

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Date: ______Signature:______

Printed: ______

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