Quality Improvement Committee in Hospitals


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.

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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