Have an idea? Don’t know whom to tell? Or, do you have an issue that you cannot figure out who to bring it to for solving? The Children’s Hospital has a representative on nearly every major Medical Center committee. In addition, the Children’s Hospital also has its own committees to bring issues to light. Finally, every unit and clinic has their own bodies that develop unit/clinic-specific guidelines and policies.
Please view the CSEC Organization Chart for more information.
Medical Center Committees:
Clinical Staff Executive Committee (CSEC)
CH Reps: Jim Nataro, MD, PhD, MBA; Paul Matherne MD, MBA
Purpose: Monitor, oversee and manage the quality of clinical care delivered within the Medical Center. Establishes and enforces policies applicable to the Clinical Staff.
Nominating Committee
CH Rep: Nancy McDaniel, MD
Purpose: Nominates members to serve as Officers of the Clinical Staff and members for the Clinical Staff Representatives
Bylaws Committee
CH Rep: Nancy McDaniel, MD
Purpose: Ensures that the Bylaws of the Clinical Staff are consistent with the Medical Center’s operational needs, current Joint Commission Standards, applicable CMS Conditions of Participation and other CMS requirements and the policies, procedures, rules and regulations of the Medical Center.
Credentials Committee
CH Rep: Gene McGahren, MD
CH Rep (Professional Practice Evaluation Subcommittee): Diane Pappas, MD, JD
Purpose: Reviews and evaluates the qualifications of each applicant prior to initial appointment, reappointment or modification of appointment. Reviews and makes recommendations for revisions to the Credentials Manual. Oversees the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes for members of the Clinical Staff.
Graduate Medical Education Committee
CH Reps: Linda Waggoner-Fountain, MD; Tracey Hoke, MD, MSc
Purpose: Oversees the quality of GME trainees’ training and working environment within the institution and the participating sites as regulated by the accreditation agencies, such as ACGME, AMA, AMC, NRMP.
Ethics Committee
CH Reps: Robert Boyle, MD; Lisa Letzkus, PNP
Purpose: Interdisciplinary committee charged with assisting leadership in ensuring consistency between mission and values, organizational behaviors and clinical practice. It has three primary functions, which include conducting education on ethical issues, recommending policies that are ethically important, and conducting case reviews with respect to ethical issues.
Surgical and Invasive Procedure Committee
CH Reps: Gene McGahren, MD; Tracey Hoke, MD, MSc
Purpose: Deals with issues of new technology, new procedures and environment of care, specifically in the operating room, at the bedside, and in other out-of-OR locations.
Patient Safety Committee
CH Rep: Tracey Hoke, MD, MSc
CH Reps (Patient Safety Advocacy Committee): Tracey Hoke, MD, MSc; Tausha Grim RN
Purpose: Interdisciplinary committee charged with the coordination and implementation of programs for ensuring patient safety within the Medical Center, including directing and overseeing proactive risk reduction and patient safety.
Quality Committee
CH Reps: Tracey Hoke, MD, MSc; Jonathan Swanson MD, MSc; Lynn McDaniel, MD; Steve Borowitz, MD; Karin League RN; Mark Romness, MD
CH Reps (Infection Control & Prevention Subcommittee): Laura Lee MD; David Kaufman MD
CH Reps (Medication Usage Safety & Informatics Subcommittee): Nancy Addison, RN
Purpose: Responsible for defining, prioritizing, overseeing and monitoring the performance improvement activities, including patient and environmental safety. The primary duties of the include analyzing and aggregating institutional performance data, monitoring performance improvement efforts for effectiveness, and making recommendations to the Patient Care Council and the Clinical Staff Executive Committee for changes in clinical practice and to the Medical Center Executive Committee for changes in operations.
Clinical Information Technology Oversight Committee
CH Rep: Michael Williams MD; Paul Matherne MD, MBA; Tracey Hoke MD, MSc
CH Rep (Clinical Informatics Subcommittee): Lynn McDaniel MD
CH Rep (Clinical Reporting and Analysis Subcommittee): Jonathan Swanson, MD, MSc
CH Rep (Health Information Management Subcommittee): Nancy McDaniel MD
CH Rep (Clinical Research Subcommittee): Steve Borowitz, MD
Purpose: Provide coherent and consistent clinician oversight and direction to the continuous revision, improvement and evaluation of Epic and the other clinical information systems.
Patient Grievance Committee
CH Rep: Jan Allaire
Purpose: Provides oversight to the processes set forth in Medical Center Policy 0070 – Patient Concerns and Grievances, and assures compliance with all other applicable laws and regulations.
Operating Room Committee
CH Rep: Gene McGahren, MD
CH Rep (Children’s Surgery Subcommittee): Tony Herndon, MD
Purpose: Coordinates and standardizes the care of patients undergoing surgical or other invasive procedures. Oversees clinical practice related to Pre, Peri and Post procedure care. Establishes clinical procedure and policy within the Medical Center Operating Rooms and recommends policy related to those procedures outside of the Operating Room.
Clinical Practice Committee
CH Reps: Paul Matherne MD, MBA; Jan Allaire
CH Reps (Critical Care Subcommittee): Jeannean Carver MD; Rob Sinkin MD, MPH
CH Rep (Ambulatory Care Subcommittee): George McDaniel MD
CH Rep (Pharmacy & Therapeutics Subcommittee): John Barcia MD
CH Reps (Patient & Family Educaiton Subcommittee): Desiree Yeago RN; Gilda Abaya RN
CH Reps (Medical Emergency Response Subcommitte): Laura Lee MD; Alix Paget-Brown MD
CH Reps (Resuscitation Subcommittee): Santina Zanelli MD; Alix Paget-Brown MD
Purpose: Coordinates and implements the Plan for Provision of Care for both the inpatient and outpatient setting.
Children’s Hospital Committees:
Children’s Hospital Outcomes and Operations Team (CHOOT)
Chair – Jonathan Swanson MD, MSc
Purpose: Charged to promote and ensure excellent and efficient care in a welcoming, comforting and culturally appropriate environment. Reviews CH quality and operational outcomes and makes recommendations for the development of policies and guidelines.
Meets: Monthly, 1st Tuesday at Noon, Medical Center Board Room
Children’s Hospital Clinical Practice Committee
Chairs – Jan Allaire, Paul Matherne MD, MBA
Purpose: Interdisciplinary committee charged with coordination and implementation of the Plan for Provision of Care for children in both the inpatient and outpatient setting. This Committee addresses clinical practice issues that extend beyond the scope of practice for a single professional discipline (e.g., pediatric medicine and surgery, nutrition, nursing, pharmacy, therapies, social work, etc.) in all settings across the continuum of care. The Committee is responsible for review, coordination, and submission of policies and practices that directly impact all aspects of the clinical and family-centered care of children. The Committee provides organizational guidance regarding faculty, staff, resident, nursing, and other clinician training and competency for the clinical care of children.
Meets: Monthly, 2nd Wednesday at 12:30, Medical Center Board Room
Children’s Hospital Patient & Family Centered Care Committee
Chair: Norma Dobbins
Purpose: Develop specific recommendations for involving families and children in decision-making, program development, and practices throughout the Children’s Hospital.
Central Line Associated Blood Stream Infection Team
Chair: Laura Lee, MD
Purpose: Review and implement best practices for central line care across the Children’s Hospital.
Meets: Monthly, Tuesday at 4:00 pm, 7 Central Day Room
Children’s Hospital Antibiotic Stewardship Team
Chairs: Marcia Buck PharmD; Leigh Grossman MD
Purpose: Review and establish best practices for antibiotic stewardship across the Children’s Hospital.
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