Objective

To define policy and protocols on carrying out clinical audit with an aim to improve the quality inpatient care and suggests changes as required based on the audit findings.

Scope

Applicable to all the members in the clinical audit committee.

Constitution of committee

1. HOD of Surgical Oncology – Chairperson
2. Surgical oncologist
3. Anaesthestists
4. Radiation oncologists
5. Medical oncologists
6. PET-CT & nuclear medicine HOD
7. Radiology Department HOD
8. Pathology department HOD
9. Nursing department HOD
10. Manager – Quality department
11. Executive – Medical Services – Secretary

The chairman shall have the authority to invite any non member to attend the meeting, if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.

Quorum

The minimum quorum for passing any resolution in the committee should be 50% of the members present in the committee with chairperson being mandatory.

Frequency of meeting

Members of the committee meet once in three months

Selection of members

1. Chairperson – Selected by the chairman of Apex Committee
2. Secretary – Selected by the chair person, he or she is also a member of the committee
3. Members – Selected by the chair person

Responsibilities

• To scrutinize and approve the clinic audit submitted by the auditor
• To scrutinize and approve the audit proforma submitted by the auditor
• To scrutinize and approve the audit methodology
• To review and approve the audit report
• To take action as required based on the audit findings

Role of Chairperson

• Acts as a liaison between the clinical audit committee members and the apex committee chairman
• Receives all the clinical audit reports and information pertaining to clinical audit hospital, initiate necessary action based on the reports
• Initiate clinical audit programmes in the hospital
• Keep oneself abreast with the recent developments in the field.

Role of secretary (Member secretary)

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of meeting shall be prepared by the secretary
• Get the approval of minutes by the chairperson
• Circulate the agenda approved by the chair person to the members and the concerned persons
• To maintain all records ( as per list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting signature from all the concerned members

Agenda

Agendas for the meeting shall be prepared by the secretary in consultation with the chair person and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.

A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.

Minutes

• Shall be prepared by secretary
• MoM is send to the chairperson for the approval within three days of the meeting.
• After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation.
• A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary

Decision making

• A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.
• The decision of the committee will be finally taken by a majority vote and that shall be implemented.

Records to be maintained

1. List and details of all members
2. The TOR of the committee
3. Copy of all agendas, minutes of all meeting
4. Attendance sheet
5. Copy of any other correspondence to the committee members or non-members
6. Copy of any study conducted for the sake of the committee