UHN Labs QUALITY MANAGEMENT COMMITTEE Revised July 2008 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 ‘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) * February 12, 2005 Revised Jul/08 Page 1 UHN Labs QUALITY MANAGEMENT COMMITTEE Revised July 2008 k. 3.0 Provide a report on quality activities to the Quality Committee of the UHN Board of Trustees and other hospitals as required 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: 5.0 recommendations information pertaining to reviews trends (recurring incidents and/or incidents) quality initiatives outstanding issues questions for/requesting advice from the UHN QCC 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 February 12, 2005 Revised Jul/08 Page 2 UHN Labs QUALITY MANAGEMENT COMMITTEE Revised July 2008 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 3