Healthcare Compliance Forms and Tools

Executive Quality Committee Charter

Published: [DATE]

Charters Manual

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Statement of Purpose

As a core driver of its activities and responsibilities, the EQC will promote the hospital’s dedication to:

• Delivery of safe, high-quality healthcare across the system to the patients and community that the Company serves;

• Full compliance with applicable federal, state, and county laws and regulations, and adherence to professionally recognized standards of care; and

• An enterprise-wide culture of safety and just behavior.

The Board of Managers of the hospital has established a Quality of Care and Patient Safety Committee (QBOM Committee) to assist it in fulfilling its oversight responsibilities.

The hospital has established a Quality and Safety Operations Division, which is led by the senior vice president, chief quality and safety officer (CQSO), who reports to the CEO and to the QBOM Committee. The EQC advises and assists the CQSO in implementing and improving the hospital’s Quality, Safety, and Performance Improvement Program (Quality Program). The CQSO and the EQC provide the hospital’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 the hospital’s policies and procedures (Policies).

Scope

The EQC’s responsibilities include:

• Promoting a systemwide organizational culture focused on safety and just behavior, including nonretaliation;

• In support of the CQSO, overseeing and evaluating the structure, operations. And effectiveness of the Quality Program

  • As part of this assessment, evaluating ongoing relevance of enterprise-wide quality committees (e.g., mislabeled specimens, two-patient identification).

  • On a periodic basis, reviewing and analyzing safety event data for trends and other areas of focus;

• Maintaining oversight of survey readiness, including staying abreast of significant developments relating to regulatory requirements and standards and expectations of accrediting bodies;

• Performing an annual review of the systemwide quality assurance and process improvement plan;

• Providing direction and reviewing, on an annual basis, the clinical quality training plan;

• Reviewing and approving, on an annual basis, the Quality and Safety Operations Division risk assessment and associated work plan, including auditing and monitoring initiatives;

• Reviewing auditing and monitoring activities conducted as part of the Quality Program and any audits or reviews conducted by internal or external resources, as well as ensuring that management develops and timely implements appropriate corrective actions in response to the findings;

• Ensuring sustainability of changes implemented during the systems improvement agreement with the Centers for Medicare & Medicaid Services and the corporate integrity agreement with the Department of Health & Human Services’ Office of Inspector General;

• Performing, at least annually, a review and approval of the quality-of-care dashboard’s metrics and benchmarks;

• At least annually, reviewing and revising, as appropriate, the Charter;

• At least biannually, reviewing certain Policies as deemed appropriate by the CQSO; and

• Periodically, and no less than annually, assessing the EQC’s oversight of the Quality Program as evidenced by its operation in conformance with all Charter requirements and reporting such to the QBOM Committee.

Members

The EQC is chaired by the CQSO and includes the following:

• Executive vice president & chief clinical officer;

• Executive vice president & chief nursing executive;

• Executive vice president & chief financial officer;

• Executive vice president & general counsel or their designee;

• Executive vice president & chief operating officer;

• Executive vice president & chief talent officer;

• Senior vice president & chief medical officer

• Senior vice president & chief compliance officer;

• Senior vice president & chief information officer;

• Vice president, senior medical director, ambulatory and population health;

• Senior vice president and chief nursing officer;

• Vice president, safety & clinical risk management;

• Vice president, quality & clinical effectiveness;

• Chief medical information officer;

• Chief of infection prevention; and

• President of the medical executive committee or their designee.

  • Chief executive officer (optional)

  • Vice president, chief governance officer (optional)

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, 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 their 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 the Company’s service lines and/or departments/divisions based on current issues or trends. These include:

• Research: RSIC/CRAW updates

• Contracts Oversight Committee

• Enterprise performance improvement projects

• Infection Prevention and Control Committee

• Clinical informatics

• Emergency department throughput

• Global patient access data review

• IT clinical system performance review

• Nursing quality indicators (e.g., falls, wounds)

• Company’s nursing home facilities quality report

• Quality-Based Purchasing Governance Committee

• Clinical risk management (RCA/ACA Trends, Safety Center Trends, DHSH Reportable Events)

• Clinical quality training

• Education Governance Committee

• Regulatory and accreditation department (ICM/survey readiness, mock surveys)

• QSO and IP program assessments, risk assessments, and work plans

• QSO dashboard metrics: quality of care, performance improvement operations

Meetings

The EQC shall meet no less than 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 hospital-wide planning to establish structure and processes that focus on safety and 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.