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1. Purpose


Quality Health committee shall advise and coordinate all Quality Improvement activities at the Hospital.


2. Organization and composition


The quality Health committee will elaborate the hospital’s quality management activities in conformity with the national quality policy, National quality strategy and Rwanda Hospital accreditation process.

Gisenyi Hospital is to be represented by a quality management focal person with responsibilities in quality management and quality Improvement activities at the Health facility. Gisenyi hospital’s department (Internal medicine, surgery, Paediatrics, Neonatology, Gynaecology and obstetrics, Emergency, Allied services ) shall have a quality management and improvement person who should be the Clinical/Nurses heads of department to oversee implementation of departmental service quality improvement operational plans.


Quality Health committee members:

  • Hospital Director General: Chair person

  • Quality improvement focal person: Secretary

  • Director of nursing:1

  • Director of Administration and Finance:1

  • Customer care:1

  • P,M&E:1

  • Chairs committees;

    • Infection prevention and control:1

    • Health and safety:1

  • QI  Chair departments


    NB: The Hospital Director General shall be the Chairman of the committee; the Quality improvement focal point is the Secretary. ACo- Chair and the Timekeeper will be voted among committee members.


3. Responsibilities


  • Develop a Hospital action plan for quality improvement

  • Ensure coordination and monitoring of the Quality Improvement Plans, QI trainings and the effective implementation 

  • Develop the capacity on quality improvement of health services to hospital staff 

  • Develop and Assist departments to develop their individual service operational quality improvement plans

  • Ensure Departments apply Quality improvement in departments

  • Assure that objectives and indicators for quality improvement are included in the strategic and operational plans of the hospital

  • Review and analyze monthly reports from the service on quality improvement, identify problems, elaborate strategies to resolve problems, and provide feedback and advice to services.

  • Coaching of the Quality Management representatives and focal person in the different service areas

  • Arrange for periodic trainings in quality improvement for all health care workers in the hospital

  • Organize an annual conference/open day to present quality objectives achieved, during the year, gaps that remain, and gather input for planning in the following year.

  • Collaborate with hospital leadership to set QI priorities.


4. Meeting


  • The quality managements committee shall meet quarterly  to review quality management activities at the hospital.

  • Include Quality Improvement, Patient safety  and Risk management and infection control  reports as standing items on the committee agendas

  • The Meetings shall be conducted when 2/3 of members are present.

  • Document committee meeting notes


 5. Reporting

  • The quality management focal person reports to the Hospital accreditation steering committee.