Excellent Care for All Act Updates

Quality Committees

Update - as of February 7, 2011

The Excellent Care for All Act (ECFAA) requires every health care organization to establish a quality committee responsible for monitoring and reporting on quality issues at the hospital. Regulations describing the composition of quality committees have been filed and came into effect January 1, 2011.

Quality Committee Composition

Each hospital's quality committee will be a sub-committee of the Board (see PHA Regulation 965 for updated information on board membership), with at least one third of the membership being voting members of the Board. In addition, the quality committee must include :

  1. One member of the hospital's medical advisory committee (MAC).
  2. The hospital's chief nursing executive.
  3. One person who works in the hospital and who is not a physician or a nurse. This individual can be either a manager or an individual who provides direct care. This promotes inter-professional practice and wider involvement with the committee.
  4. The hospital's administrator, as defined by the Public Hospitals Act.
  5. Such other persons as are appointed by the hospital's board. There is no limit to the number of individuals who sit on a hospital's quality committee, and hospitals can appoint additional members to the quality committee to meet the needs of the hospital and the community it serves.

The chair of the quality committee will be a voting member of the hospital's board, appointed by the hospital's board. Any member of the quality committee mentioned above may, with the approval of the hospital's board, appoint a delegate to sit as a member of the committee in his or her stead. It is expected that these delegates be temporary in nature and should not be permanent members of the quality committee. Additional individuals may attend quality committee meetings and provide advice to the committee (for example, Director of Quality and Patient Safety), but are not required to be voting members.

Other similar committees that might qualify

Your organization may have an existing Board sub-committee that could potentially qualify as a quality committee. For example, a Performance Monitoring Committee could qualify as a quality committee as long as it fulfills the composition requirements and meets the responsibilities described in the legislation and regulations.

It is not advisable to designate the Board Quality Committee as a hospital's Quality of Care Committee under the Quality of Care Information Protection Act, 2004 (QCIPA). Please see the Ontario Hospital Association's Frequently Asked Questions on Critical Incident Reporting for more information.

Responsibilities of the Quality Committee

The Quality Committee has the following responsibilities:

  1. Monitor and report to the Board on quality issues and on the overall quality of services provided in the health care organization (making use of appropriate data).
    • This includes the review of critical incident data. As of January 1, 2011, the PHA Regulation 965 will be amended to ensure that the administrator provides aggregated critical incident data to the quality committee at least two times per year. See the update on critical incidents for more information.
    • This includes considering the medical advisory committee's recommendations that relate to systemic or recurring quality of care issues at the hospital (see updated the PHA Regulation 965).
  2. Consider and make recommendations to the Board regarding quality improvement initiatives and policies
  3. Ensure that best practices information is shared with staff at the health care organization and monitor the use of these materials. A list of resources for best practices information has been provided.
  4. Oversee the preparation of annual quality improvement plans

Next steps

Regulation 445/10 came into force on January 1, 2011. It is expected that hospitals will begin to address the composition requirements of their quality committees as soon as the regulation has been filed, and that quality committees will be in the implementation phase well before April 1, 2011, at which date the annual Quality Improvement Plans must be posted.

For questions about Excellent Care for All, please email

Related Legislation

Section 3.
(1) Every health care organization shall establish and maintain a quality committee for the health care organization.

(2) The membership, composition and governance of quality committees shall be as provided for in the regulations.

(3) Every quality committee shall report to its responsible body.

Section 4.
Every quality committee has the following responsibilities :

1. To monitor and report to the responsible body on quality issues and on the overall quality of services provided in the health care organization, with reference to appropriate data.
2. To consider and make recommendations to the responsible body regarding quality improvement initiatives and policies.
3. To ensure that best practices information supported by available scientific evidence is translated into materials that are distributed to employees and per-sons providing services within the health care organization, and to subsequently monitor the use of these materials by these people.
4. To oversee the preparation of annual quality improvement plans.
5. To carry out any other responsibilities provided for in the regulations.

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