Executive Quality Committee Charter |
Published: 09/03/20 |
Charters Manual |
Page 1 of X |
This charter (the “Charter”) sets forth the duties and responsibilities, and governs the operations of, the Parkland Health & Hospital System (“Parkland”) Executive Quality Committee (the “EQC”).
STATEMENT OF PURPOSE |
This charter (the “Charter”) sets forth the duties and responsibilities, and governs the operations of, the Parkland Health & Hospital System (“Parkland”) Executive Quality Committee (the “EQC”). Purpose As a core driver of its activities and responsibilities, the EQC will promote Parkland’s dedication to:
The Board of Managers (the “Board”) of Parkland has established a Quality of Care and Patient Safety Committee (the “QBOM Committee”) to assist the Board in fulfilling its oversight responsibilities. Parkland has established a Quality and Safety Operations Division (the “QSO Division”) which is led by the Senior Vice President, Chief Quality and Safety Officer (the “CQSO”), who reports to the Chief Executive Officer and to the QBOM Committee. The EQC advises and assists the CQSO in implementing and improving Parkland’s Quality, Safety and Performance Improvement Program (the “Quality Program”). The CQSO and the EQC provide Parkland’s senior leaders with guidance regarding compliance with applicable federal and state laws and regulations, professionally recognized standards of care, advancements of the field of clinical quality and safety and Parkland’s policies and procedures (collectively, “Policies”). |
SCOPE |
The EQC’s responsibilities include:
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MEMBERS |
The EQC is chaired by the CQSO and includes the following:
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LEADERSHIP |
The EQC shall be chaired by the CQSO. The CQSO will have ultimate authority as to the composition of the EQC. Any individuals appointed as successors to these positions will serve on the EQC unless the CQSO determines otherwise. The Chair may invite to attend EQC meetings other officers, executives and employees, medical staff leaders and/or outside advisors or counsel. Any requests for additional attendees must be approved in advance by the Chair. |
REPORTS TO |
The CQSO provides a brief update on EQC meeting discussions to the QCPSC and QBOM Committees each month. (See Appendix A.) |
SUBCOMMITTEES |
The EQC may establish, reorganize, or dissolve permanent or ad hoc subcommittees or working groups, which will work at the direction of, and report on their activities to, the EQC. Subcommittees or working groups will be chaired by the CQSO or his/her designee, operate under a defined set of responsibilities, hold scheduled meetings, with such frequency as determined necessary by the subcommittee chair, and keep minutes of subcommittee/working group proceedings. The EQC will assess each subcommittee’s/working group’s effectiveness and structure at least annually. |
CRITICAL INTERFACES |
The EQC receives reports upon request from Parkland service lines and/or departments/divisions based on current issues or trends. These include:
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MEETINGS |
The EQC shall meet no less than ten (10) times annually. However, the CQSO can call special meetings as deemed necessary. At every meeting, the Chair will designate a secretary to take and maintain minutes. Meetings should be conducted in person whenever possible. All Committee members are expected to attend each meeting. A quorum representing a majority of the EQC members must be present to transact business. |
MEETING MINUTES |
Meeting minutes are taken for each meeting. Minutes are provided the following month for review and approval. |
AMENDMENTS TO THE CHARTER |
This Charter may be amended or revised only upon approval by the QBOM Committee. The CQSO shall be responsible for timely advising the QBOM Committee of any proposed amendments or revisions to this Charter. |
REFERENCES AND DEFINITIONS |
The EQC Committee fulfills the following accreditation standards as established by The Joint Commission: The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.01.03.01 (2020). The governing body is ultimately accountable for the safety and quality of care, treatment and services. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.02.01.01 (2020). The mission, vision and goals of the hospital support the safety and quality of care, treatment and services. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.01.01 (2020). Leaders create and maintain a culture of safety and quality throughout the hospital. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.02.01 (2020). The hospital uses data and the information to guide decisions and to understand variation in the performance of processes supporting safety and quality. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.03.01 (2020). Leaders use hospitalwide planning to establish structure and processes that focus on safety & quality. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.05.01 (2020). Leaders manage change to improve performance improvement. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.06.01 (2020). Those who work in the hospital are focused on improving safety and quality. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard LD.03.07.01 (2020). Leaders establish priorities for performance improvement. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard PI.01.01.01 (2020). The hospital collects data to monitor its performance. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard PI.02.01.01 (2020). The hospital compiles and analyzes data. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard PI.03.01.01 (2020). The hospital improves performance on an ongoing basis. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard IC.01.02.01 (2020). Hospital leaders allocate needed resources for the for the infection prevention and control program. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard IC.02.01.01 (2020). The hospital implements the infection prevention and control program. The Joint Commission, Comprehensive Accreditation Manual for Hospitals, Standard IC.03.01.01 (2020). The hospital evaluates the effectiveness of its infection prevention and control plan. |