Terms of Reference
1.0 Purpose
The purpose of the UHN Labs Quality Management Committee (QMC) is to carry on activities for the purpose of studying, assessing or evaluating the provision of laboratory services with a view to improving or maintaining the quality of laboratory services, or the level of skill, knowledge and competence of the persons who provide laboratory services. In accordance with delegated authority from the hospital’s Quality of Care Committee the QMC established hereunder is designated a quality of care committee under the Quality of Care Information Protection Action, 2004.
The quality of care information[*] (hereinafter ‘information’) collected and/or discussed by the QMC is an activity delegated by the UHN Quality of Care Committee (QCC) and is protected under the Quality of Care Information Protection Act (QCIPA).
2.0 Responsibilities of UHN Labs QMC
The QMC will:
(i) Review and analyze matters which may give rise to significant quality of care concerns, including specifically:
a. An occurrence involving an unexpected death or serious bodily harm
b. An occurrence or series of occurrences that have the potential to result in death or serious bodily harm or harm to a number of patients and will notify, and work with, the Office of Risk Management as required
(ii) Make efforts to improve the quality of health care at UHN where appropriate by:
a. Suggesting risk prevention or control mechanisms that may be implemented.
b. Disseminating learning and recommendations that arise out of risk identification assessment and/or management
c. Evaluating the corrective action taken by or proposed by health care workers and/or groups/committees/departments
(iii) The QMC provides leadership and support to quality management activities and directs and monitors the process improvement initiatives of quality teams, and will:
a. Establish quality policy
b. Develop, maintain and monitor the quality plan
c. Monitor Environmental Health and Safety, Privacy and Licensing requirements
d. Monitor accreditation and quality assurance requirement compliance, such as proficiency testing
e. Establish quality objectives aligned with senior management priorities annually and direct and monitor their completion
f. Monitor process improvement activities of quality teams through regular updates
g. Ensure teams have set priorities and help teams develop indicators
h. Direct teams in identifying projects that require interdisciplinary teams
i. Provide a forum for communication across disciplines to ensure all members remain abreast of major process improvement issues throughout the laboratories
j. Solicit client feedback through regular meetings
k. Provide a report on quality activities to the Quality Committee of the UHN Board of Trustees and other hospitals as required
3.0 Information to the Committee
The UHN Labs QMC shall review matters referred by the Chair, by another member of the QMC, or by the Quality of Care Committee, which may give rise to significant quality of care concerns or risk management issues (see 2 (i)).
Depending on the matter to be reviewed, the Committee may seek or receive information/report from any hospital medical/privileged staff member, committee or working group and/or external person/entity.
4.0 Information Disseminated by the QMC
The QMC will forward recommendations and information pertaining to individual reviews to:
· UHN Quality of Care Committee via the Office of Risk Management
if the QMC considers that it is necessary for the purpose of:
(i) improving or maintaining the quality of health care provided at the hospital; and/or
(ii) eliminating or reducing a significant risk of bodily harm to a person or group of persons
The QMC will present as required to the UHN QCC. Please forward requests to the UHN Quality of Care Committee via the office of Risk Management.
The presentation may include, but is not limited to:
· recommendations
· information pertaining to reviews
· trends (recurring incidents and/or incidents)
· quality initiatives
· outstanding issues
· questions for/requesting advice from the UHN QCC
5.0 Membership
Chair
Dr. Sylvia Asa
Administrative Leaders
General Manager – Brad Davis
Director, Core Lab Operations – Maureen Marentette
Director, Partnership Operations and Development – Michele Henry
Medical and Scientific Leaders
Biochemistry – Dr. Eleftherios Diamandis, Dr. Jeff Tong
Haematology – Dr. Marciano Reis
Histocompatibility – Dr. Neal denHollander, Dr. Kathryn Tinckam
Microbiology – Dr. Tony Mazzulli
Pathology – Dr. Sylvia Asa
Point of Care Testing – Dr. Paul Yip
Transfusion Medicine – Dr. Jacob Pendergrast, Dr. Christine Cserti
Managers
Core Lab – Marni Lollo
Microbiology – Pauline Lo
Pathology – Laurie Mason
Client Operations/Specimen Management – Maria Amenta, Joseph Kuzma
Transfusion Medicine – Sally Balmer
Supervisors/Quality Resources
Biochemistry, Safety – Edward Kasprzak
Haematology – Fatima Cardoso
Histocompatibility – Chang-Ming Ng, Alice Van Oosterwijk
Microbiology – Suzie Ho
Pathology - Diana Booth
Point of Care Testing – Chris Cursio
Specimen Management – Jay Hockley
Transfusion Medicine – Jacquie Beal, Gisele Thorpe
Quality/Safety System – Mary Fountas
Partners
Haldimand War Memorial – Cheryl Watt
Sault Area Hospital – Kelli Ann Lemieux
Timmins Cluster – Aline Letourneau, Violet Jewitt
Shared Information Systems – Tara Amos
6.0 Accountability
The QMC reports to the Medical Director as required, who will act as the liaison between the QMC and the UHN Quality of Care Committee. The QMC reports to the UHN Board through the Quality Committee of the UHN Board of Trustees
7.0 Meeting Frequency
Monthly for one hour
8.0 Quorum
7 members consisting of at least 3 medical leaders or designates and 3 quality resources or designates, plus one; with representation from all lab areas.
9.0 Agendas and Record of Meeting
Agenda and minutes of previous meeting to be distributed within one week before the next meeting
All QMC meeting minutes and reports will reside with Quality/Safety System Manager.
February 12, 2005
Revised Jul/08 Page 1
[*] ‘quality of care information’ is defined as information collected by or prepared for a quality of care committee for the sole or primary purpose of assisting the committee in carrying out its functions; and/or information that relates solely or primarily to any activity that a quality of care committee carries on as part of its functions. It is not: a) Information contained in a patient’s chart (maintained for the purpose of providing health care); b) Information found in a record that was generated as a requirement of law; or c) factual information contained in an incident report regarding the provision of health care to a patient (unless the facts are fully recorded in the patient’s health record)