Quality Improvement and Patient Safety Committee - (DOM QUIPS-C)

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Name: Quality Improvement and Patient Safety Committee - (DOM QUIPS-C)
Function: Improve quality of healthcare within the Department of Medicine, assist coordination of quality improvement initiatives, and ensure that departmental quality improvement projects are in line with the department of Internal Medicine strategic plan and goals

Background and Purpose

This document describes the functions of the DOM QUIPS-C. It outlines the structure, membership, function, and responsibilities. The primary responsibilities of the QUIPS-C are to support initiatives to improve quality of health care within the Department of Medicine, assist coordination of quality improvement initiatives, and ensure that departmental quality improvement projects are in line with the Department of Internal Medicine strategic plan and goals. Secondary objectives include promotion and facilitation of development in QUIPS for DOM members, and furthering education in QUIPS for members. This committee seeks to promote care and support best practices based on the values of:

  1. Patient safety
  2. Excellence in health care delivery
  3. Patient centred care
  4. Efficient and effective utilization of resources
  5. Timely delivery of care
  6. Equitable health care

Reporting Structure

The committee will report to the Department Head of Internal Medicine.


The members of the committee shall include the following:

Section Members
Allergy and Clinical Immunology Dr. Lana Rosenfield
Biomedical Proteomics who
Cardiology who
Critical Care Dr. Allan Garland
Dermatology who
Endocrinology / Metabolism Dr. Elizabeth Salamon
Gastroenterology Dr. Harminder Singh
General Internal Medicine Dr. Sandip Bhangoo
Geriatric Medicine Dr. Dilpriya Mangat
Hematology and Oncology Dr. Benjamin Goldenberg
Hepatology who
Infectious Diseases Dr. Catherine Smith
Nephrology Dr. Jay Hingwala
Neurology Dr. Dan Roberts
Clinical Pharmacology who
Physical Medicine and Rehabilitation Dr. Alan Casey
Respiratory Medicine Dr. Justin Ling
Rheumatology Dr. Konstantin Jilkine
  • One to two (1-2) additional faculty members with interest/training in quality initiatives
  • Bio-Statistician/programmer-analyst, collating the departmental databases: Julie Mojica

Terms of Office

The term of the members will be two (2) years, with possible one renewal. Those consistently not participating for 6 months or longer in the committee work (for example 2 consecutive committee meetings) may be asked to retire from the committee. All physician members will be expected to attend at least 75% of the meetings.


The committee will serve to promote the delivery of high quality health care services across all sections in the Department of Internal Medicine.

The primary focus of this committee will be the identification of opportunities for the improved delivery of quality health services across all sections in the Department of Internal Medicine, and support DOM members to complete QI initiatives. The committee will especially promote reduction in variations in care, duplication of work, and waste of resources. Within this focus, committee emphasis may include, but not necessarily be limited to the following:

  • Objective and systematic assessment of individual, facility, system-wide challenges to quality health services delivery, the cause/source of those challenges/potential challenges, systems or processes
  • Development and implementation of quality improvement action plans and educational initiatives
  • Monitoring and evaluation of implemented initiatives, and reporting on delivery of quality indicators
  • Improvement in communication within the sections, across the sections and with other health care providers (such asfamily medicine)
  • Oversee collection of data for quality reporting and improvement
  • Capacity building with discussion and development of methodology for quality improvement initiatives and trainee programs
  • Discussion and feedback on quality initiatives in the different sections of Department of Internal Medicine, when requested by the section members
  • Provide recommendation to the DOM Department Head on funding for QI initiatives within the DOM.


A quorum shall consist of a majority of voting (>50%) committee members.

Number of Meetings

The committee will generally meet at 2-3-month intervals, 4-6 times a year. Meeting dates for the year will be set by December 31st the year prior. Generally, meetings will take place on the second Tuesday of a month at 5 p.m.


  • Minutes will be taken at all meetings by the designate administrative assistant.
  • Minutes will include attendance, regrets, absences, as well as all key discussion points, decisions, and actions.
  • Minutes will be approved at each meeting by vote.

Agenda Format

Agenda will be circulated one week prior to the meeting date by the co-lead(s).

  1. Call to Order
  2. Approval of Agenda
  3. Approval of Minutes
  4. Round Table review and feedback on Sections of DOM QI initiatives
  5. Items for Discussion
  6. Items for Approval
  7. Correspondence
  8. Other Business
  9. Adjournment

Terms of Reference

The committee shall review their terms of reference every two years. Recommendations for change will be forwarded to the Department Head for approval.

Conflict of Interests

Conflicts of interest must be declared and, if relevant, committee members may be asked to leave the room for the discussion and, in any case, are not allowed to vote on that particular agenda item.