Medical Staff Governance

Medical Staff Governance

//////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////
Medical Advisory Committee (MAC)

The Medical Advisory Committee (MAC) is the senior administrative body for medical staff that is accountable to, and advises the Board of Directors and CEO on all aspects of medical care provide in PHC facilities, to inform administrative and Board decision-making. 

Responsibilities 

  • Advising on medical care quality and safety evaluation and improvements
  • Recommending practitioners for appointment to the Medical Staff
  • Ensuring the quality and safety of medical care is evaluated
  • Advising on steps to improve medical practice

The MAC meets 10 times a year and functions in the following ways:

  • Provides advice on all aspects of medical care to inform administrative and Board decision-making.
  • Provides advice to the Board of Directors and the CEO on the quality of medical care provided within all facilities operated by PHC.
  • Assures the Board of Directors and the CEO that the safety and quality of medical care in PHC facilities is continually being evaluated, and advises regularly of steps being taken to improve medical practice in PHC. This work will be conducted under the protection of Section 51 of the Evidence Act.

Medical Advisory Committee Meetings

Medical Advisory Committee meetings are normally held the first Tuesday of each month (no meetings in July & August).

COMMITTEES OF THE MAC

There are four sub-committees of the MAC. These committees report monthly to the Medical Advisory Committee.

Council for Excellence / CFE

The Council for Excellence is a sub-committee of the Medical Advisory Committee. Its purpose is to report on physician quality and performance enhancement, and each month a Department presents on their quality initiatives.  support the quality improvement of medical care and medical organization at Providence Health Care.  Click here for Terms of Reference

The Council for Excellence meetings are held the third Wednesday of each month except July and August. Articles and information coming from the meetings as well as articles that are for general interest will be available in this section.

Infection Prevention & Control
The Vision of the Infection Prevention and Control Team is to create and sustain a culture in which infection prevention and control is integrated into all aspects of care.

The Mission of the Infection Prevention and Control Team is to be dedicated to the prevention and control of health care acquired infections in a supportive working environment. The practices of the Infection Prevention and Control Team will be based on sound scientific principles. Infection control services will be provided to PHC with structure and authority in collaboration with local, regional and provincial partners.

Definition of Infection Prevention and Control (IPAC)

  • Interventions practiced in healthcare facilities to prevent and control the transmission and acquisition of infectious agents by patients and healthcare workers [e.g., proper hand hygiene, safe work practices, and the use of personal protective equipment (PPE)].
  • Control measures are based on how an infectious agent is transmitted, and include education and implementation of standard, contact, droplet, and airborne precautions.
  • Infections acquired in the hospital are referred to as “nosocomial infections,” with onset of symptoms >72 hours from admission. Community-acquired infections are those diagnosed on admission or within the first 72 hours following admission. These infections may have been acquired in the community, or potentially in other settings such as residential care facilities.
  • The Infection Prevention and Control service is an integral part of any healthcare facility’s internal quality improvement process. At PHC specifically, IPAC is committed to improving overall safety for our patients, residents, physicians, staff and visitors.
  • Surveillance of nosocomial infections is critical to the prevention and control of hospital-based transmission of infectious agents. Surveillance data are used to:
    • Determine the burden of specific infectious diseases in the institution.
    • Monitor trends in nosocomial transmission, and provide a means of determining when intervention is required.
    • Detect and manage infectious diseases outbreaks.

Infection Prevention and Control Team

  • The Infection Prevention and Control Team is multidisciplinary in nature, consisting of Infection Control Practitioners, a Medical Director, Infection Control Physicians and Medical Microbiologists, and a Healthcare Epidemiologist.
  • The Infection Prevention and Control Team has close links with the microbiology and virology laboratories at PHC.
  • The program works closely with local, regional, provincial and federal counterpart agencies and implements evidence-based practices in accordance with accepted standards and guidelines.
  • Specifically, PHC IPAC has a close relationship with Vancouver Coastal Health Public Health, with whom we collaborate for the management of outbreaks, reportable communicable diseases, and emerging infectious diseases.
Pharmacy & Therapeutics Committee
The Pharmacy and Therapeutics Committee recommends policies and procedures regarding the evaluation, selection, and therapeutic use of drugs within PHC for MAC approval. Pharmacy and Therapeutics Committee. See Terms of Reference.
Transfusion Committee
The Transfusion Committee is a standing committee of the MAC and reports on a monthly basis.