Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services. These are in contrast to ad hoc committees, department and unit committees.

1. TYPES OF COMMITTEES
GOVERNING HOSPITALS
Presented by:- Dr. Mahboob Khan Phd

2. AIMS AND OBJECTIVES
 Emphasis on primary care.
 Primary care should be the cornerstone of a people-centered health
system.
 objective is to keep the number of deaths below 77.5 per 1,000 among
patients reporting to the emergency department with a diagnosis of
heart attack.
 The underlying goals committees are:
a. to promote the rights of patients;
b. to promote shared decision making between patients and their clinicians
c. to promote fair policies and procedures that maximize the likelihood of
achieving good, patient-centered outcomes; and
d. to enhance the ethical tenor of health care professionals and health care
institutions.

3. WHAT IS COMMITTEE?
 A group of persons convened for the accomplishment of
some specific purpose, typically with formal protocols; a
guardian; someone in charge of another person deemed to
be unable to look after himself or herself.
 A committee is generally a formal working group within a
larger organization, often formed by election, often having
authority or legitimacy of some specific kind.

4. Committees prescribed by regulatory
agencies
Committees
prescribed by hospital
administrationPhil Health
Pharmacy and
Therapeutic
Pharmacy and
Therapeutic
Execom
Infection Control Infection Control Mancom
Quality Assurance Quality Assurance Committee on
Medical Services
Waste Management Bioethics
Medical Audit and
Tissue
Tumor Board
Medical Records
Credentials
Blood Transfusion
•Hospital Committees
Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed
necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities
that are considered critical in the delivery of quality health care services.
These are in contrast to ad hoc committees, department and unit committees.

5. Execom (Executive Committee)
Mancom (Management Committee)
Committee on Medical Services
Bioethics Committee
Pharmacy and Therapeutic Committee
Infection Control Committee
Quality Council
Waste Management Committee
Medical Audit and Tissue Committee
Tumor Board
Medical Records Committee
Credentials Committee
Blood Transfusion Committee
Thus, as of July, 2016, the following 13 committees are
recommended to constitute the Hospital Committees :

6. Governig Board
President
Medical
director/medical
superintendent
Administrative
officer

7. Commitees of
board
Medical staff organisation
Chief executive
officer
Accountin
g
Business
office
Credits
&collects
cashier
Admitting
FINANCIAL NURSING
Nursing
education
IPD
Units
OPD units Operati
ng
rooms
Ttrannies Emerg
ency
rooms
committees
Medical support
Medicin
e
House
staff
Surgery Gyn&Ob
s
Pediatrics Others
Administrative
Environment
al
Maintenanc
e
Housekeeping
Plant
operations
Laundry
Patients
DietarySocial
services

8. CHIEF EXECUTIVE OFFICER
ANCILLARY HOSPITAL INFORMATION
SYSTEM
HUMAL RESOURCE
MANAGEMENT
RADIOLOGY CLINICAL LABS
ANAESTHESIA PHYSIAL THERAPY
RESPIRATORY THERAPY ELECTROCARDIOGRAPHY
PHARMACY ELECTROENCEPHALOGRAPHY

9. • ADVANTAGES • DISADVANTAGES
•Exchange of views and information.
•To bring collective wisdom,group
deliberation,judgements on subjects
•Solution of problems in hospital
•Recommend action.
•Generate ideas.Discuss pros n cons.
•To perform at high level of cooperation
and commitment.
•To make decision collectively
•Waste of time
•“if you want a kill an idea,Appoint a
committee”
•Intrerference of external members
•Dominance of overbearing and aggressive
members.
•Committee members can use their position
to further their self interest

10. *Medical Executive Committee*
 Typically composed of elected officers of the medical staff, the immediate past
president of the medical staff, the chairpersons of the various medical
departments, and physicians on the Board of Directors.The president of the
hospital,vice president of medical affairs,metron and director of quality
care/assurance/utilization review/risk management
The duties of this committee usually include:
 • Accounting to the Board of Directors for patient/resident care.
 • Acting on reports and recommendations offered by other committees.
 • Coordinating the activities of the medical staff.
 • Making recommendations on medical issues.
 • Recommending appointment, reappointment,and corrective action of medical
staff.
 * Ethics Committee*
 Ethics Committee is an advisory group appointed by the University Hospital
Medical Executive Board. It reviews, on request, ethical or moral questions that
may come up during a patient's care. Committee members include doctors,
nurses, social workers, an attorney, a chaplain etc..
Responsibilities of the Hospital Ethics Committee
 To act as patient advocate on bioethical issues..
 Develop and recommend hospital and other clinical policies and guidelines
that define ethical principles for conduct within the hospital.
 The committee will provide advisory consultation and review in cases where
ethical dilemmas are perceived by the patient/patient's family.the
physician/medical team, or other hospital or clinic staff. The primary responsibility
will be to encourage dialogue, educate, identify issues offer viable options,
 The committee will educate hospital and clinic personnel, patients, and their
families about hospital policies regarding ethical issues.

11. The Pharmacy and Therapeutics Committee
The Pharmacy and Therapeutics (P & T) Committee is an important medical staff
advisory group. As the primary, formal communication link between the pharmacy and
medical staff, the P & T Committee is of particular importance to the department of
pharmacy services.
All matters of use of medications within the institution, including pharmacy programs,
must be reviewed and approved through the committee.
Medication formulary data is reviewed through the committee and recommendations are
offered to the medical staff.
An active involvement in the committee by the department of pharmacy services is vital
in order to develop a contemporary and progressive institutional pharmacy program.
The Infection Control Committee
Every healthcare facility uses interdisciplinary task forces such as the Safety
Committee and the Infection Control Committee to minimize patient and employee risk
Representation may include: physicians, nursing staff, infection control practitioners,
quality assurance personnel, risk management personnel as well as representatives
from microbiology, surgery, central sterilization, environmental services, etc.
.The duties of this committee typically include:
• Monitoring equipment currently in use.
• Evaluating new products being considered or already ordered.
• Providing information about equipment and products to involved employees.

12. Safety Committee/ Employee
Health Committee
Typically composed of representatives
from the occupational health unit,
safety manager, human
resources, and employees from the
various departments.
The duties of this committee usually
include:
• Developing and reviewing policies and
procedures for safe and healthy work
conditions
for employees.
• Developing and evaluating all safety and
health programs, including implementation of
the Exposure Control Plan for Bloodborne
Pathogens.
• Establishing and implementing procedures
for workplace safety inspections.
• Establishing procedures for investigating
and recording all workplace accidents,
illnesses
Hospital acquired infection, transfusion
transmitted diseases, rising incidence of
Hepatitis B, and HIV, increasing land and
water pollution lead to increasing possibility
of catching many diseases
This usually include
Hospital waste management
1. Segregation of waste
2. Collection of bio-medical waste
3. Transportation
4. Treatment of hospital waste
5. Safety measures
6. Measures for waste minimization

13. Budget/Finance and Audit Committee
Typically composed of representatives from the Board of Directors, chief executive officer,
chief
financial officer, and various departmental directors. The duties of this committee usually
include:
• Monitoring the financial status of the health care facility.
• Advising the Board of Directors concerning financial policies.
• Reporting to the Board of Directors on the effectiveness of resource allocations.

14. URGENT CARE
 The CMO should regularly participate in Advanced
Cardiac Life Support and Advanced Trauma Life
Support programmes and disaster drills conducted by
the hospital from time to time. The hospital
administration should have a dedicated person to look
after the casualty.
 Nursing staff is the backbone of the casualty and the
department should have dedicated nurses who may be
rotated through the critical care areas of the hospital to
improve their skills and response time, as the casualty
is also an acute care area, which caters to critically ill
patients.

15. TUMOUR BOARD BLOOD BANK COMMITTEE
 The Role of the Tumor Board In a
Community&Objectives:
 1. To formulate integrated,
coordinated, and comprehensive
hospital-wide policies on the
management of patients with
cancer in the hospital.
 2. To monitor and continually
improve the quality of care to
patients with cancers.
 3. To conduct educational and
training programs for concerned
staff so as to facilitate
implementation of hospital policies
on management of cancer patients.
 4. To promote research on
oncology that will continually
improve the quality of care for
cancer patients.
 Need for Blood Bank
 As a blood transfusion service
deals with different functions
related to donors and patients, it is
imperative to keep in mind the
safety of both donors and
recipients. The blood transfusion
service has to be planned and
organized in such a way that it
fulfils its ideal aims and objectives
i.e.
 Recruitment of blood donors -
voluntary & replacement
 Care of donor, donated unit and the
recipient
 Maintain adequate blood stock
 Provide clinically effective blood
components
 Optimal use of available blood

16. BUDGET/FINANCE AND AUDIT
COMMITTEE
INFORMATION SYSTEMS COMMITTEE
 Typically composed of
representatives from the Board of
Directors, chief executive officer,
chief
 financial officer, and various
departmental directors. The duties
of this committee usually
 include:
 • Monitoring the financial status of
the health care facility.
 • Advising the Board of Directors
concerning financial policies.
 • Reporting to the Board of
Directors on the effectiveness of
resource allocations.
 Typically composed of the director
of information systems and
representatives from the various
 This committee usually include:
 • Evaluating and recommending
clinical computer systems.
 • Providing training on clinical
computer systems.
 • Responding to requests for
assistance with computer
applications

17. MEDICAL RECORD COMMITEE
In most of the hospitals,the quality review of the midical
record is done by a medical record committee.
Functions:
1) Reviewing the medical records for timely
Complition.
Clinical relevance
Adequacy of the file for use in quality review activities and
medico-legal documents
The whole course of treatment
2)Reviewing the security and integrity of MRD
3)Checking the retrivel system of department for easy and
quick retrival.
Role of MRD :-to maintain records of hospital
To ensure completeness,
be self regulating,to avoid any deficiencies
and errors in future.

18. Hospital Committee General functions:
Formulate policies
Coordinate
Monitor
Areas of responsibility
Execom (Executive
Committtee)
Quality services and
organizational direction
Mancom (Management
Committee)
Quality services and
operational management
Quality Council Quality services and quality
management system
Committee on Medical
Services
Quality medical services
rendered by physicians
Bioethics Committee Bioethical matters in patient
care
Pharmacy and Therapeutic
Committee
Drug therapy
Infection Control Committee Infection control
Waste Management
Committee
Waste management
Medical Audit and Tissue
Committee
Outcome in patient care such
as mortality, morbidity, and
tissue review
Tumor Board Cancer management
Medical Records Committee Medical records
Credentials Committee Credentialing of physicians
Blood Transfusion Committee Blood transfusion
The general functions of the MDH Hospital Committees are to formulate policies, coordinate and
monitor hospital-wide activities on specified areas of responsibility.
Report to
Board of Directors
Execom
Hospital Director
Hospital Director
Medical Director
Medical Director
Medical Director
Operations Officer or
Director
Medical Director
Medical Director
(assistance most
needed)

19. SSCOMMITTEE
STRENGTH
ENERGY/
EFFORTS
SPIRIT
COURAGE
VALUES/
STANDARDS
INTELLIGENCE