Tool for evaluating committees

November 1, 2006

Credentialing Resource Center Digest - Volume 7 Issue 44

Understanding committees and their role

Committee and/or department meeting: _________________________________

Analysis prepared by: _________________________________

Time period covered by analysis: _________________________________

Date: _________________________________

Issue	Comments
Committee purpose What is the purpose of the committee? Is it clearly articulated? Where is the purpose of the committee described? Do the committee members know the purpose? How do we determine if the purpose is being fulfilled?
Committee members Who are members of the committee? In what document are the members specified (and their roles, if any). Which members are voting members vs. "ex officio?"
Committee support Does this committee have adequate support (clerical, administrative, etc.)? Are minutes (if required) completed and distributed well in advance of meetings? Are agendas provided to members at least five days in advance of the meeting? Is follow-up performed in a timely manner? What evidence does the committee have that follow-up is performed?
Frequency of meetings (Review attendance records) How often is the committee supposed to meet? How often did the committee meet during the past 12 months (go back two years, if possible). Was a meeting ever canceled because of lack of a quorum? Was a meeting ever held despite not having a quorum? Does anyone know what a quorum is? Do physicians regularly attend this meeting? What percentage of meetings are attended by each physician and other key individuals?
Committee relationships How does this committee relate to other medical staff organization (or non-medical staff organization) committees? Is this committee a sub-committee of another committee? To what group does this committee report? How does the committee report (send a copy of minutes somewhere, give a verbal report at another meeting, etc.)? How does the committee receive feedback? (When the committee reports something to another committee or group, how does the committee hear back what happened?)
Information reporting What information (reports) does the committee regularly receive? What does the committee do with the information? Analyze? Make Decisions? Refer Somewhere Else? Is the decision-making authority of the committee defined?
Regulatory requirements Who will be reading the minutes? What will "they" be looking for in the minutes? What are the external requirements of the committee? Are there specific regulations that pertain to the functioning of the committee? Do we have a copy of these regulations? When there are regulatory requirements which pertain to the workings of the committee, who is responsible to assure that requirements are being met? What are the possible consequences of not performing the functions in accordance with regulatory agency requirements?
Committee cost What is the cost of the committee? Figure: Number of physicians who attend meeting times an hourly rate for their time; number of administrative personnel who attend meetings times an hourly rate for their time; number of support personnel who support the meeting times an hourly rate for their time (the time that support personnel spend is higher than for the other people because they make arrangements, write minutes, prepare follow-up, etc.); food; copying costs; meeting room costs; etc.
Key accomplishments What are the committee's key accomplishments during the past 12 months?

Issue

Comments

Committee purpose

What is the purpose of the committee?
Is it clearly articulated?
Where is the purpose of the committee described?
Do the committee members know the purpose?
How do we determine if the purpose is being fulfilled?

Committee members

Who are members of the committee?
In what document are the members specified (and their roles, if any).
Which members are voting members vs. "ex officio?"

Committee support

Does this committee have adequate support (clerical, administrative, etc.)?
Are minutes (if required) completed and distributed well in advance of meetings?
Are agendas provided to members at least five days in advance of the meeting?
Is follow-up performed in a timely manner?
What evidence does the committee have that follow-up is performed?

Frequency of meetings

(Review attendance records)

How often is the committee supposed to meet?
How often did the committee meet during the past 12 months (go back two years, if possible).
Was a meeting ever canceled because of lack of a quorum?
Was a meeting ever held despite not having a quorum?
Does anyone know what a quorum is?
Do physicians regularly attend this meeting? What percentage of meetings are attended by each physician and other key individuals?

Committee relationships

How does this committee relate to other medical staff organization (or non-medical staff organization) committees?
Is this committee a sub-committee of another committee?
To what group does this committee report?
How does the committee report (send a copy of minutes somewhere, give a verbal report at another meeting, etc.)?
How does the committee receive feedback? (When the committee reports something to another committee or group, how does the committee hear back what happened?)

Information reporting

What information (reports) does the committee regularly receive?
What does the committee do with the information?
Analyze? Make Decisions? Refer Somewhere Else?
Is the decision-making authority of the committee defined?

Regulatory requirements

Who will be reading the minutes?

What will "they" be looking for in the minutes?

What are the external requirements of the committee? Are there specific regulations that pertain to the functioning of the committee?
Do we have a copy of these regulations?
When there are regulatory requirements which pertain to the workings of the committee, who is responsible to assure that requirements are being met?
What are the possible consequences of not performing the functions in accordance with regulatory agency requirements?

Committee cost

What is the cost of the committee?
Figure: Number of physicians who attend meeting times an hourly rate for their time; number of administrative personnel who attend meetings times an hourly rate for their time; number of support personnel who support the meeting times an hourly rate for their time (the time that support personnel spend is higher than for the other people because they make arrangements, write minutes, prepare follow-up, etc.); food; copying costs; meeting room costs; etc.

Key accomplishments

What are the committee's key accomplishments during the past 12 months?