Committees in Hospital

Operating Room Committee

The Operating Room Committee is an interdisciplinary committee charged to coordinate and standardize the care of patients undergoing surgical or other invasive procedures. It is a committee of the medical staff. This Committee oversees clinical practice related to Preoperative, intraoperative and Postoperative procedure care. It has the authority to establish clinical procedure and policy within the Operating Rooms and recommend policy related to those procedures outside of the Operating Room. It works collaboratively with the quality improvement quality to monitor and improve care and ensure patient safety.

Members of the Operating Room Committee
  1. Chief or director of the department of surgery ( a surgeon) – The Chair of this Committee shall be a Physician from one of the surgical specialties or subspecialties.
  2. Director of the anesthesia department (in teaching hospitals only)
  3. Other chiefs or representatives of the specialty services
  4. OR nurse manager – shares with the OR committee, hospital administration and nursing service the responsibility for clarification, implementation and day-to-day enforcement of approved policies and procedures.
  5. OR coordinator or OR business manager
  6. Hospital administrator and director (optional)
Responsibilities and Duties
  1. Responsible for professional practice and administrative activities within their respective departments.
  2. Maintain continuing evaluation of the professional performance of all members of the medical staff.
  3. Serve as liaison representatives between the medical staff and hospital administration.
  4. Formulate policies and procedures pertaining to utilization of facilities, schedule of surgical procedures and maintenance of a safe environment. Policies and associated directives formulated and approved by the committee serve as guides for governing the actions of surgeons, anesthesiologists and the Operating Room nursing staff while in the OR suite.
  5. Utilizes evidence-based medicine to recommend changes in the clinical practice.
  6. Approves policy and procedures that are specific to the Operating Room.
  7. Provides Institutional oversight and direction for staff and faculty education related to operative and invasive procedures and care of the surgical patient.
  8. Ensures an effective process for patient and family education related to surgical care and informed consent.
  9. Works collaboratively with the quality improvement quality to monitor and improve care and ensure patient safety.
  10. Monitors adherence to policies and procedures.
  11. Recommends corrective measures to the hospital administration for efficient functioning within the OR suite.
Infection Control Committee

A health care facility has a moral duty to provide a safe environment for its patients. The infection control committee investigates hospital-acquired or nosocomial infections and seeks to prevent or control them. This committee is of the most important hospital committees which should be established in all hospitals.

Purpose of Infection Control Committee
  1. The committee’s purpose is to ratify the ideas of the infection control team and to disseminate infection control information.
  2. The committee provides the political support that empowers the infection control team to implement infection control policies.
  3. Aids the hospital in fulfilling the duty of providing a safe environment for the patients.
Infection Control Team

The infection control team is responsible for the day-to-day activities of the infection control programme. Health care establishments must have access to specialists in infection control, epidemiology, and infectious disease, including physicians and infection control practitioners. The Infection Control Committee is generally comprised of members from a variety of disciplines within the healthcare facility. Membership may vary but should include the following:

  1. Medical staff or physicians
  2. Hospital administration
  3. Nursing service
  4. Epidemiologist or the infection control coordinator – health care worker trained in the principles and practices of infection control, (e.g. a physician, microbiologist or registered nurse) as secretary.
  5. Quality assurance personnel
  6. Representatives from microbiology, surgery, central sterilization, environmental services and etc.
Responsibilities of Infection Control Committee

The role of the Infection Control Committee is very multi-faceted. It should be involved in planning, monitoring, evaluating, updating, and educating. It sets general infection control policy and provides input into specific infection control issues.

The main function of this committee is to prevent and control nosocomial infections. This goal is accomplished in a variety of ways some of which include: surveillance of nosocomial infections, product evaluation, investigation of infection outbreaks and infection clusters, development of infection control procedures for all departments, staff and patient education, medical waste management, etc.

The responsibilities of infection control committee are as follows:

  1. Approve changes necessary to eliminate hazardous practice. Included in its jurisdiction is the education of personnel so that they can provide a high standard of patient care.
  2. Carry out surveillance program.
  3. Develop and disseminate infection control policies.
  4. Monitor and manage critical incidents.
  5. Coordinate and conduct training activities.
  6. Develop an infection control manual and monitor and evaluate the performance of the infection control program.
Ethics Committee

An Ethics Committee in hospitals is an advisory group appointed by the Hospital Medical Executive Board. The multidisciplinary ethics committee represents the hospital and the community it serves. Most hospitals have an ethics committee, made up of doctors, nurses, lawyers and clergy, which can get together to help families or health care workers when difficult ethical questions arise. Family members can request an Ethics Committee consultation at many hospitals.

Representatives or Committee Members of an Ethics Committee
  1. Physicians or doctors
  2. Nurses
  3. Social workers
  4. Patient relations liaison
  5. Lawyers
  6. A chaplain
  7. Medical ethics professional (bioethicists)
  8. Lay-persons from the community
Purpose of the Committee
  1. The ethics committee reviews, on request, ethical or moral questions that may come up during a patient’s care.
  2. To educate the staff and the community regarding moral principles and processes of ethical decision making when faced with diverse issues that arise in the care of the critically and terminally patients.
  3. Provide consultation to professional staff, patients and families.
Responsibilities of the Hospital Ethics Committee
  1. Act as patient advocate on bioethical issues.
  2. Develop and recommend hospital policies and guidelines that define ethical principles for conduct within the hospital. These guidelines and policies pertain to issues such as informed consent, research protocols and advance directives.
  3. Provide advisory consultation and review in cases where ethical dilemmas are perceived by the patient or the patient’s family, surrogate, physician or medical team or other hospital or clinic staff upon request. OR nurses and surgical technologists are often confronted with social, ethical and legal decisions concerning genetic and reproductive biology, organ transplantation and death with dignity. The primary responsibility of the Ethics committee will be to encourage dialogue, educate and identify issues, offer variable options, seek supplemental resources and encourage problem resolution at the physician or patient level.
  4. To establish forums for the discussion of ethical concerns. The ethics committee can provide a forum for discussion of some issues. In these forums, the committee will educate the hospital and clinic personnel, patients and their families about the hospital policies regarding ethical issues.
Disaster Planning Committee

A disaster is a calamitous event, occurring either natural or man-made, that causes a great loss of life, damage or hardship. Hospitals and other health care facilities should have an organized for caring for mass casualties if a major disaster occurs. A disaster could either be external or internal. External disasters take place outside the health care facility. Calamitous events such as an airplane crash or an event of nature belong to this category. Internal disasters take place inside a health care facility. Fire, or an explosion belong to this category of disaster.

Disaster Planning in Health Care Facilities

A disaster planning committee serves as the planning arm and voice of the health care facility as it relates to disaster planning, preparedness, mitigation, response and recovery. The intrahospital committee plans ways and measures to prevent and deal with various disasters that might occur. This plan includes the following:

  1. Consultation with local civil authorities
  2. Consultation with representatives of other medical agencies

The planning is done by consultation to establish an effective chain of command and to make an appropriate jurisdictional provision. The result of this planning is the disaster-site triage to separate and distribute patients to ensure the most efficient use of available facilities and services.

To deal with external disasters, some health care facilities are conducting external disaster drills. These drills are conducted twice a year. The purpose of organizing and running these drills is to try out the plans developed by the committee, to seek to improve those plans and to familiarize the health care facility personnel with them.

To deal with both types of disasters, the following plans should be taken into serious consideration:

  • There should be an information center in the hospital. This facilitates a unified medical command and the movement of patients.
  • The receiving area for should follow a standard protocol that will be applied in all emergency cases. Severely wounded patients or casualties should be given emergency care depending and basing on their needs and should be sent to the operating room or to other units as indicated or transferred to another facility. Casualties or patients who are ambulatory are treated in the emergency department for slight injuries and are sent home or admitted to the hospital as indicated.
  • Special disaster medical records should accompany patients at all times.
  • There should be a plan of organization in the personnel.
  • Departmental instructions for the health care staff or personnel should be written and posted.
Quality Improvement Committee

Every hospital shall maintain a coordinated quality improvement program for the improvement of the quality of health care services rendered to patients and the identification and prevention of medical malpractice. Non-compliance of medical staff to the set of hospital rules puts a hospital or ambulatory care facility at risk of legal liability. The productive and efficient committee that will implement actions designed to eliminate real and potential problems, improving patient care and reducing financial loss is called the Quality Improvement Committee.  Because of an emphasis on cost containment, review of utilization of facilities and risk management may also be the concerns of this committee.


Quality and performance improvement is a dynamic, interdisciplinary process that strives to achieve the outcomes established annually by the hospital leadership. The Quality Improvement Committee outlines the Hospital’s goals. These goals are designed to foster a culture that supports the highest possible quality patient care. The following are the responsibilities of this committee:

  1. Monitors routine activities
  2. Evaluates clinical outcomes
  3. Reviews incident reports
  4. Conducts problem-focused studies in an effort to identify practices deemed substandard
Members of Quality Improvement Committee
  1. Representative from clinical personnel
  2. Representative from the administrative personnel
  3. Quality improvement coordinator (QI)
  4. Risk manager

The primary function of the quality improvement coordinator and / or risk manager is to ensure the implementation of committee decisions and to assess actual practices and evaluate outcomes of patient care. The quality improvement coordinator may receive and respond to complaints about patient care or environmental hazards.

Quality Improvement Subcommittee

Each hospital department and nursing unit may have its own quality improvement subcommittee. These unit-based committees perform the following tasks:

  1. Monitor performance
  2. Identify ways to constructively solve competency problems
  3. Seek opportunities for improvements in practices

This department-level committee provides nursing staff with an opportunity for leadership in the identification, implementation and dissemination of improvement projects at the unit, service and departmental level.

Other interdepartmental subcommittees may focus on specific activities or problems requiring input from several disciplines. Reports from these subcommittees are reviewed by the QI coordinator and mutual problems are shared with the hospital committee.