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1. Purpose

To ensure a multidisciplinary team approach to oversee and coordinate the accreditation process and implementation of standards

 Accreditation Steering committee will ensure development, review, approval and implementation of required policies, procedures and guidelines. Provide oversight to the implementation of the standards and progress toward achieving and maintaining accreditation. Provide guidance for preparing for accreditation surveys.


2. Organization and composition

The Accreditation Steering committee is a multidisciplinary committee composed of members from the hospital administration and clinical support service areas.

Committee members of Accreditation Steering committee are chair of committees:

  • Infection prevention and control: 1

  • Health and safety : 1

  • Ethics: 1

  • Quality Improvement: 1

  • Resuscitation: 1

  • Pharmacist: 1

  • Quality improvement focal person: 1

  • Hospital Director of Administration: 1

  • Human resource officer: 1

  • Planning, Monitoring and evaluation officer:1

  • Clinical Heads of departments:

    • Internal medicine : 1

    • Surgery: 1

    • Paediatrics: 1

    • Obstetrics and Gynaecology: 1

    • Laboratory:1

    • Radiology:1



3. Responsibilities


  • Standards Compliance

  • Ensure compliance of standard in all risk areas

  • Ensure coordination and monitoring of the accreditation work Plans

  • Policies and Procedures Develop an implementation framework of policies and procedures

  • Coordinate development, Testing, Customize and endorse all policies, procedures and guidelines.

  • Ensure that policies and procedures are validated

  • Ensure that all comments and feedback from the policies, procedures and guidelines testing from each service area is compiled and provided appropriately and on time

  • Coordinate the implementation and compliance to policies and procedures throughout the hospital

  • Ensure the circulation and recall of policies at the Hospital  level

  • Ensure that an updated list of current policies and procedures is available to all staff in all service areas of the hospital

  • Provides oversight to the implementation of the standards and progress toward achieving and maintaining accreditation. Provides guidance for preparing for accreditation surveys.



4. Meeting

The committee shall meet every quarter unless otherwise decided by the committee. Meetings shall be considered quorum if five members or more than 50% are present, otherwise the meeting shall continue as an ad hoc meeting. If two successive ad hoc meetings occur, binding decisions may be taken in the second meeting.

Minutes of the meetings and documentation of the recommendations made shall be submitted to the Hospital Health committee through the Director General of the Hospital and kept by the chairperson of accreditation steering committee.


5. Reporting


  • The committee must submit a report of its activities to the hospital management; such reports will include advice and recommendations.

  • The minutes of all meetings of the Committee will be safely kept by hospital  Management team and copy to Accreditation Steering committee chairperson

  • Minutes will only be circulated to members of the Committee.


NB: The Accreditation Steering committee chairperson shall be appointed in writing and provided with clear roles and responsibilities. The chairperson will have mandate of three years. Others like the Co-Chair, Secretary and the Timekeeper will be voted among committee members.



6. Linkages

  • Relevant committees are informed when there are new policies and procedures to be developed or existing ones require review, or revised policies and procedures are approved and their compliance monitored.

  • All clinical service policy, procedure and treatment guidelines developed must be reported to the Accreditation Steering committee to check if they comply with the set standards.