100-03 Management and Program Committees

Category: 
Organization
Subject: 
Management and Program Committees
Policy Number: 
100-03
Effective Date: 
February, 2015
Next Review Date: 
February, 2016
Responsible Manager(s): 
Program Director
Purpose: 

To establish advisory committees for monitoring critical program activities functionally confined to unique service components of Student Health and Counseling Services (SHCS) program.

Policy: 

The Executive Committee establishes management and program committees with appropriate representation to monitor selected service areas and functions of the SHCS program. These Committees serve in an advisory capacity and operate as formal committees, following the procedures set forth in this document.

Procedure: 
  1. Committees
    1. The Executive Committee establishes the following management and program committees (Reference Attachment 1 – SHCS Committee Structure and Reporting Process):
      1. Governance Quality Management Committee
        1. Clinical Quality Committee
      2. Information Management Steering Committee
        1. Clinical Systems Sub-Committee
      3. Governance Risk Management Committee
        1. Infection Control/Safety Committee
        2. Counseling Services Quality Assurance Committee
        3. Medical Staff Peer Review Committee
        4. Credentials Committee
      4. Marketing Committee
      5. Department Heads
    2. Sub-Committees may be constituted to assist standing SHCS Management and Program Committees monitor SHCS programming and service delivery.
  2. Committee Membership
    1. The SHCS Executive Director in consultation with the Executive Committee appoints the chair of each committee.  The chair is a member of the staff with ongoing responsibilities in the clinical/functional service represented.
    2. Each committee includes in its membership a member of the SHCS Executive Committee who may appropriately provide administrative guidance to the committee.  The SHCS Executive Director appoints the Executive Committee representative.
      1. Executive Committee representation to the Medical Staff Peer Review committee and Counseling Services Quality Assurance Committee is ex-officio.
    3. Each committee includes in its membership SHCS staff appointed by the Executive Committee, in consultation with managers and department supervisors, who best represent the inter-disciplinary elements of the clinical/functional service or SHCS program represented.
      1. Committee medical staff membership is appointed by the Medical Director.
      2. Committee psychology staff membership is appointed by the Counseling Services Director.
  3. Responsibility/Authority
    1. Each committee monitors ongoing program activities, solves problems as they are identified and strives to improve the clinical care or service they provide.
    2. Each committee participates, when appropriate, in the Quality Management program by developing activities whose purpose is to evaluate and improve clinical care, service or operations pertinent to that area. When appropriate, two or more committees may work together on a quality improvement activity that involves more than one clinical or functional area.
    3. Each committee communicates its findings, activities and recommendations to affected departments through their staff membership at departmental meetings.  Each committee communicates its findings, activities and recommendations to the Executive Committee through their Executive Committee representative.
    4. SHCS department supervisors and managers have the authority to approve any committee-proposed policy or procedure changes affecting their unique department.  Supervisors may refer proposals back to committees for additional discussion with alternate recommendations as appropriate.  Supervisors and managers implement any departmental policy/procedure changes and communicate these to all affected SHCS personnel.
    5. The Executive Committee approves any committee-proposed interdepartmental policy or procedure changes and communicates these to all affected SHCS department supervisors and managers.  The Executive Committee may refer proposals back to committees for additional discussion with alternate recommendations as appropriate.  The Executive Committee may choose to appoint a workgroup of supervisors and managers to develop interdepartmental policy/procedure changes necessary to resolve problems or improve service as identified by committee where alternative representation is needed.
    6. The Executive Committee communicates interdepartmental policy/procedure changes to all affected SHCS department supervisors and managers.  Supervisors and managers implement such policies/procedures as appropriate within their departments.  The Executive Committee and the SHCS supervisors and managers of affected departments communicate these changes to all affected SHCS personnel.
  4. Meeting Schedules
    1. The Executive Committee determines a meeting schedule for all management and program committees.  The Assistant to the Executive Director communicates that schedule to all committee members and department supervisors to facilitate the coordination of staff schedules to assure meeting attendance.
    2. Committees meet at least quarterly.  Routinely, during academic quarters, management and program committees meet monthly or as necessary to complete agenda items.
  5. Chair Responsibilities
    1. Begins and ends the meeting on time.
    2. Structures/guides the discussions so that members stay focused.
    3. Calls for a vote when he/she feels there has been sufficient discussion.
    4. Prepares for each meeting by providing the agenda and reviewing meeting materials before the meeting.
    5. Ensures that items requiring follow-up of agenda items to assure project continuity and completion.
    6. If a task is assigned to a member by the committee, assures that the task is completed when due.  If a task is not completed when due, may extend the due date and/or provide assistance if needed.
    7. Assures communication of committee activities with other committees or departments and with supervisors/managers.
    8. Submits ongoing committee reports of identified quality improvement activities to the Executive Quality Management Committee.
    9. Reviews and gives initial approval to committee minutes in a timely manner.
  6. Member Responsibilities
    1. Maintain confidentiality.
    2. Actively participate in discussions.
    3. Complete assigned tasks in a timely manner. Ask the chair for assistance or an extension of the due date if needed.
    4. Review committee materials before each meeting if available.
    5. Request/suggest agenda items.
  7. Committee Secretary Responsibilities
    1. Transcribes accurate and complete minutes and obtains the chair’s signature.
    2. Maintains an action table of tasks assigned by the committee and other agenda items to track completion.
    3. Maintains a secured binder that contains, for each meeting, the agenda, signed minutes and any materials reviewed at the meeting.
    4. Provides for each member at each meeting (or prior to the meeting) a packet of information including the agenda, a copy of the minutes from the previous meeting and any documents pertinent to the agenda items.
    5. Reserves a room.
  8. Agenda
    1. The agenda is a list of issues/items the chair wants the members to address.
    2. The agenda is based on the previous meeting’s minutes, items, routine items/reports and new issues.
    3. Each agenda item has a person designated to present the issue/item.
  9. Minutes
    1. A standardized format is used for each meeting.
    2. Minutes are taken simultaneously during the meeting and reflect all decisions and actions of the committee.
    3. To ensure follow-up on all agenda items, an action table is maintained and items are carried until resolution.
    4. All agendas, minutes, reports and documents presented to the committee are maintained in a secure and confidential manner.
Originated: 
September, 1998
Supersedes: 
July, 2013
References
Attachments: 
PDF icon SHCS Committee Chart 2015