MUHC Committees

Governance and Ethics Committee (Established by art. 181 HSSA)

Terms of Reference

Statement of Purpose

The Governance and Ethics Committee shall ensure the effective , efficient and ethical governance of the Organization

Responsibilities:

  1. Develop the governance rules for the conduct of the institution’s affairs;
  2. Develop a code of ethics and professional conduct, in accordance with section 3.0.4 of the Act respecting the Ministère du Conseil exécutif (chapter M-30), applicable to members of the Board of Directors;
  3. Monitor the ongoing development of the institution’s Code of Ethics;
  4. Develop expertise and experience profiles to be used in appointing or co-opting independent Board members, making sure to identify the diverse expertise required and the desired representation of the milieu based on its characteristics;
  5. Develop criteria for evaluating the performance of the Board; and carry out the evaluation in accordance with the criteria approved by the Board;
  6. Develop initiation and ongoing training programs for Board members;
  7. Report its activities at the time chosen by the Board of Directors but at least once per year;
  8. Implementation and oversight of the code of ethics and professional conduct applicable to members of the Board of Directors;
  9. Provide oversight for a program dealing with organizational ethics issues of the institution;
  10. Recommend naming recognition agreements for approval by the Board;
  11. Recommend to the Board of Directors nominations of individuals to various committees, advisory groups, councils and/or Board as deemed appropiate by the Board; and
  12. Any other responsibilities, as requested by the Board of Directors, from time to time.

Membership

  • To be composed of a majority of independent directors (art. 181)
  • To be chaired by an Independent director (art. 181)   

Members

  • Dale MacCandlish-Weil, Chair
  • Kevin O'Farrell
  • Peter Kruyt
  • Pierre Gfeller
  • Clemens Mayr

Terms of Office

At the pleasure of the nominating committee in consultation with the Chair.

Frequency of Meetings

Minimum of four (4) per annum 

Board Reporting

Four (4) times per annum including an annual report.

Reports

Annual Report of the REB of the MUHC

Annual Report of the REB of the Neuro

Vigilance Committee  (Established by art. 181.0.1 HSSA)

Terms of Reference 

Mandate

Section 181.0.3 of the Act outlines the general functions of the Committee thus:

The watchdog committee shall ensure that the Board of Directors fulfils its service quality responsibilities effectively especially those set out in paragraphs 3 and 4 of section 172.

Responsibilities

To that end, the committee must, in particular,

  1. receive and analyze the reports and recommendations sent to the Board of Directors on the pertinence, quality, safety or effectiveness of the services provided, the enforcement of user rights or the handling of user complaints;
  2. establish systemic links between those reports and recommendations and draw from them the conclusions necessary to make recommendations under subparagraph 3;
  3. make recommendations to the Board of Directors on the action to be taken following those reports or recommendations in order to improve the quality of user services;
  4. ensure the follow-up, with the Board of Directors, of the board's implementation of the recommendations made under subparagraph 3;
  5. promote joint action and cooperation among the stakeholders concerned by subparagraph 1;
  6. ensure that the local service quality and complaints commissioner has the necessary human, material and financial resources required to carry out the responsibilities of office effectively and efficiently; and
  7. exercise any other function that the Board of Directors considers useful in fulfilling the mandate entrusted to the committee under the first paragraph.

Membership

The Committee is composed of five members, including: 

  • the Executive Director;
  • the Local Service Quality and Complaints Commissioner-Ombudsman; 
  • three other members chosen by the Board from among board members who do not work for the institution or do not practice their profession in any of the centres operated by the institution and include one of the persons designated by the Users’ Committee.

Members

  • Deep Khosla, Chair
  • Dr. Sarah Prichard
  • Martine Alfonso
  • Seeta Ramdass
  • Lynne Casgrain

Term of Office

At the pleasure of the nominating committee in consultation with the Chair. 

Frequency of Meetings

Minimum four (4) times per annum. 

Board Reporting

Four (4) times per annum including an annual report.

Audit Committee (Established by art. 181 HSSA)

Terms of Reference

Mandate

To provide financial oversight on behalf of the MUHC Board in areas related to financial reporting and financial controls. 

Responsibilities

 The responsibilities of the Committee are:

  1. To review and approve the scope of the work of the external auditor;
  2. To review the results of the external audit and ensure that any recommendations regarding internal controls are considered by management and implemented as appropriate;
  3. To recommend to the MUHC Board approval of the annual financial statements and the auditor’s report thereon;
  4. To advise the MUHC Board regarding the appointment of the external auditor;
  5. To review the budget of the MUHC and, if appropriate, recommend approval thereof by the MUHC Board.
  6. To periodically review with management adherence to the approved operating budget and any significant variances;
  7. To receive and review periodic (at least annual) reports from MUHC management concerning information security and any actual or potential breaches thereof; and,
  8. To review at least annually the risk management processes and any issues related thereto.

Membership

A majority of independent directors of the MUHC Board presided by an independent director, at least one member of the Committee shall possess financial or accounting expertise.

Members

  • Samira Sakhia, Chair
  • James Cherry
  • Michal Piotr Kuzmicki
  • Peter Kruyt
  • Dale MacCandlish-Weil
  • Martine Alfonso

Term of Office

At the pleasure of the nominating committee in consultation with the Chair.

Frequency of Meetings

Minimum four (4) times per annum. 

Board Reporting

Four (4) times per annum including an annual report

Quality and Risk Management (COQAR) (Established by art. 183.1 HSSA)

Terms of Reference

The Board of Directors oversees and assumes overall accountability of the quality of care, service delivery, and safety of its patients.  To fulfil this mandate, the Board delegates the following roles and functions to the Committee on Quality and Risk (COQAR).  Two committees - Patient Safety Committee and Safety and Environment Committee - provide regular reports to COQAR.

Mandate

COQAR contributes to and nurtures the development of the quality and safety culture, supports capacity building, contributes to priority setting for organization-wide quality and safety improvement activities, oversees action plan and ensures compliance with the legal requirements pertaining to quality and patient safety throughout the MUHC.

Responsibilities:

  1. Reviews and adopts a vision pertaining to quality and patient safety for the MUHC;
  2. Fosters a culture of quality and safety improvement and capacity building throughout the organization, by ensuring that resources and support (human, material, financial and informational) are provided;
  3. Reviews and approves the integrated quality plan (which also includes integrated risk management and patient safety strategies) and ensures it is aligned with the overall organization’s strategic plan;
  4. Ensures mechanisms are in place to enable leaders at all levels of the organization to fulfil their responsibilities relative to management of quality and safety;
  5. Makes recommendations to the Board on priorities related to quality and patient safety;
  6. Ensures the setting of priorities for organization-wide quality and safety improvement activities and the communication of the outcomes of these activities; 
  7. Monitors overall system performance relative to quality and safety. Ensures that quality-performance measures are reported, acted upon and integrated in the reporting structure;
  8. Reviews and approves policies related to quality and safety and ensures that it reinforces the culture of quality improvement;
  9. Ensures that there is a structure and process in place to improve patient involvement, measure patient experience/satisfaction and develop improvement plans;
  10. Ensures that there is a structure and process in place to develop and promote ways to identify patient safety events,  implement improvements and disseminate lessons learned, when appropriate;
  11. Ensures that there is a process  in place to develop a curriculum and deliver training programs in improvement methods and patient safety;
  12. Reviews the Patient Safety Committee (PSC) reports on frequency and severity of incidents and accidents and addresses recommendations;
  13. Reviews reports, recommendations and follow-up action plans from external visits, assessments or requests for information by members of inspection bodies, audit bodies or other external agencies;
  14. Ensures that the MUHC complies with statutory requirements pertaining to quality and patient safety and Accreditation Canada standards;
  15. Contributes to the skills development and knowledge of the Board Members as it relates to quality and safety.

Frequency of Meetings

Monthly.

Board Reporting

Monthly, including an annual report.

Users’ Committee  (Established by art. 209 HSSA)

Terms of Reference

Mandate

The Users' Committee must promote the continuous improvement of services to users of the McGill University Health Centre and defend the rights and interests of users, both collective and individual. 

The Users' Committee must accomplish this task with all clients and stakeholders of the institution, without any discrimination, in a spirit of collaboration and partnership, while preserving its autonomy as bestowed by the Act.

The Users’ Committee must ensure that the interest of the user be central to the actions and decisions of the Committee, respecting the confidentiality of the information provided by the user or his representative. 

Responsibilities: 

  1. inform users of their rights and responsibilities;
  2. foster the improvement of the quality of living conditions of users and assess the degree of satisfaction of users with regard to the services obtained from the institution;
  3. defend the common rights and interests of users or, at the request of a user, his rights and interests as a user before the institution or any competent authority;
  4. accompany and assist a user, on request, in any action he undertakes, including the filing of a complaint in accordance with the Act;
  5. ensure the proper operation of each of the in-patients’ committees, if applicable, and see that they have the resources necessary to exercise their functions;
  6. designate, by resolution, two (2) voting members to represent it on the board of directors;
  7. appoint users representatives on various committees of the institution;
  8. animate, organize and promote events or projects designed to inform, assist or support users on any subject that is likely to interest them;
  9. submit each year, no later than September 30th, a report of its activities to the Board of Directors, including a financial report;
  10. adopt its operating rules within sixty (60) days of its creation, and amend them if necessary, with the approval of the General Meeting.

Members

  • Seeta Ramdass, Co-chair
  • Lisa Rosati, Co-chair
  • Elizabeth Markakis
  • Hafeez Subhan
  • Pierre Hurteau
  • Amy Ma
  • Evelyn Seligman
  • Tom McCutcheon
  • Mari Jo Pires
  • Nicole Savoie
  • Deborah Radcliffe-Branch
  • Tristan Williams
  • Pierrette Leroux

Terms of Office

Voting members shall serve for a term of three (3) years and shall remain in office until they resign, are dismissed, re-appointed, re-elected or replaced. 

Frequency of Meetings

Ten (10) times a year or more, if necessary

Board Reporting

Quarterly activity report including an annual report.

Lachine Hospital Committee (Non - Legislated)

Attributions

Conformément aux termes de l’accord portant sur l’intégration de l’Hôpital de Lachine et du Centre Camille Lefebvre au Centre Universitaire de Santé McGill (CUSM), ce dernier s’était engagé à créer un comité de liaison au sein duquel siégeraient des membres de la communauté ainsi que des représentants de plusieurs groupes ou organismes jouant un rôle de premier plan dans la vie du Campus Lachine. 

Par conséquent, le CUSM a approuvé le mandat, tel que décrit ci-après, ainsi que sa composition. Le comité sera présidé par un membre du Conseil d’Administration.

Mandat

Le Comité aura pour mandat de veiller au bon déroulement du processus d’intégration de l’Hôpital de Lachine au sein du CUSM afin de garantir, d’une part, que les citoyens de Lachine aient accès aux meilleurs services et aux meilleurs soins et d’autre part, que les engagements du gouvernement, de l’Agence régionale et du CUSM soient respectés, et en particulier celui qui a trait au respect du caractère francophone des services de soins pour la population de Lachine et Dorval. 

Le Comité sera habilité à conseiller le CUSM sur les moyens à mettre en œuvre pour atteindre ces objectifs et pourra, si nécessaire, faire des recommandations au Conseil d’Administration du CUSM.

Au terme d’un délai de trois ans après la date de prise en charge de l’Hôpital de Lachine par le CUSM, le Comité devra présenter un rapport au Conseil d’Administration du CUSM et à l’Agence de la Santé et des services sociaux de Montréal sur le respect du caractère francophone des Services et Installations CHL et émettre les recommandations nécessaires, le cas échéant.

Membres

  • Kevin O'Farrell, Chair
  • Bernard Blanchet
  • Bruno Poudrier
  • Cassandra Massé
  • Chantal Souligny
  • Chantale Bourdeau
  • Dr. Paul Saba
  • Geneviève Dumont-Frenette
  • Karine Arpin
  • Margo Heron
  • Micheline Rouleau
  • Raymonde Deslauriers
  • Robert Leduc
  • Samuel Benaroya
  • Susan Guerra
  • Suzanne Leduc>

Durée du mandat

Non indiqué dans les attributions. À la discrétion du conseil d'administration.

Fréquence des réunions

Le Comité devrait se réunir au minimum quatre (4) fois par an.

Rapport au Conseil d’administration

Quatre (4) fois par an.

Intra-Hospital Dicipline Committee (Non - Legislated)

Statement of Purpose

The Board of Directors plays an active role in disciplinary matters pertaining to members of the Counsel of Physicians, Dentists and Pharmacists (“CPDP”), including with respect to the emergency suspension of physicians’ or dentists’ privileges, the emergency suspension of the status of pharmacists and the determination of disciplinary sanctions (collectively referred to herein as “Intra-Hospital Discipline”).

The purpose of the Intra-Hospital Discipline Committee (“IHDC”) is to exercise the functions and responsibilities of the Board of Directors pursuant to those sections of the Act respecting Health Services and Social Services, and all applicable regulations, (collectively “Health Act”) which pertain to matters of Intra-Hospital Discipline. The IHDC may also make recommendations to the Board of Directors regarding such matters.

Responsibilties

  • The IHDC shall exercise the functions and responsibilities of the Board of Directors pursuant to those sections of the Health Act, which pertain to matters of Intra-Hospital Discipline, including:
    • Reviewing the file, hearing representations and taking decisions regarding the emergency suspension of physicians’ or dentists’ privileges;
    • Reviewing the file, hearing representations and taking decisions regarding the emergency suspension of the status of pharmacists;
    • Reviewing the file, hearing representations, taking disciplinary sanctions against physicians, dentists and pharmacists in the context of disciplinary processes pursuant to the Health Act and giving reasons therefore;
    • Notify the relevant parties, including, as required, the President and Executive Director, the Medical Examiner, the Director of Professional Services and the  physician, dentist or pharmacist concerned;
  • Make recommendations to the Board of Directors regarding issues, comments, concerns and recommendations  that arise in the context of the Intra-Hospital Discipline process;
  • The committee reports its activities at the time chosen by the Board of Directors but at least once per year;

Any other responsibilities, as requested by the Board of Directors, from time to time.

Membership

  • Number: 5 members of the Board of Directors
  • Requirements for representation from Board of Directors: President and Executive Director (ex officio) and four (4) independant members of the Board of Directors, one whom must have legal expertise.

Members

  • James Cherry, Chair
  • Kevin O'Farrell
  • Deep Khosa
  • Dale MacCandish Weil
  • Martine Alfonso

Terms of Office

With the exception of ex-officio members, the term of office of a member is of two (2) years from the date of appointment. It is renewable. Committee members remain in office, after expiry of their term, until reappointed or replaced by the board.