National Quality Council - Charter

Refer to: OQ

1. PURPOSE. The purpose of the Indian Health Service (IHS) National Quality Council (NQC) is to serve as a permanent advisory body established by the IHS Director to ensure that all IHS Health Care quality improvement programs are operated effectively.
   
   The efforts of the NQC will align with IHS Strategic Plan Goal 2: To promote excellence and quality through innovation of the IHS into an optimally performing organization.
2. AUTHORITY. The Snyder Act, codified at 25 U.S.C. § 13. The Indian Health Care Improvement Act, codified at 25 U.S.C. §1661(c) and 1675. The NQC functions under the guidance and authority of the IHS Deputy Director for Quality Health Care (DDQHC) and the Director, Office of Quality (DOQ).
3. MEMBERSHIP.  The NQC is a permanent member of the IHS National Combined Councils (NCC) consisting of Federal IHS employee representatives with knowledge and expertise of matters relating to quality within the Indian Health System and who work at IHS Headquarters, IHS Area Offices, or Federal Service Units. The NQC has two components as described below: an Executive Committee and a General Board. The NQC will determine the number of members needed to fulfill its responsibilities and review membership at least every two (2) years. The Executive Committee and the General Board members will make recommendations to determine the need for Ad Hoc subcommittees and the subcommittees’ memberships.
   1. NQC Executive Committee The NQC Executive Committee includes both elected and appointed representatives. The NQC Executive Committee includes the following positions with voting rights unless otherwise noted:
      1. Senior Sponsor (DDQHC or designee);
      2. DOQ or designee;
      3. Office of Quality (OQ) Staff Member;
      4. NQC Chairperson(s): may have one chair, or two co-chairs;
      5. NQC Vice Chairperson;
      6. NQC Secretary;
      7. Statistician: An expert in developing, analyzing, interpreting, and reporting quality measures as designated by the NQC Executive Committee or DOQ. The statistician will be a non-voting member.
      The Chairperson is selected by consensus of the NQC and approved by the DDQHC and the DOQ. The Vice Chairperson and Secretary will be selected by consensus of the NQC Executive Committee and General Board members. The Chairperson, Vice Chairperson, and Secretary serve 2-year terms, and may hold consecutive terms. The OQ Staff Member will be selected by the DOQ as a standing member for the duration of the assignment.
      
      The Executive Committee structure may be redesigned as needed to meet its intended purpose based on functional and outcome needs of the NQC.
   2. NQC General Board Members
      1. Area Quality Managers;
      2. Service Unit Representatives; and
      3. Office of Quality Subject Matter Experts.
      The NQC Executive Committee solicits NQC General Board Members from Quality Managers at both the IHS Area level and Federal Service Units. For each Area Office that contains at least one IHS Federal direct service facility, the Area Director will appoint one Area-level Quality Lead (up to 12 total), and up to two Service Unit level Quality Managers (up to 24 total).
4. ELECTIONS. Selection by consensus.
   1. Chairperson. The NQC Chairperson is selected by consensus of the NQC members, and approved by the DDQHC and the DOQ;
   2. Vice Chairperson. The NQC Vice Chairperson is selected by consensus of the NQC Executive Committee and General Board members;
   3. Secretary. The NQC Secretary is selected by consensus of the NQC Executive Committee and General Board members; and
   4. General Board Members. When a NQC General Board membership vacancy occurs, it will be up to the NQC Executive Committee to submit a request to the Area Director to appoint a General Board member to serve on the NQC.
5. ROLES AND RESPONSIBILITIES.
   1. The NQC. The primary roles and responsibilities of the NQC are to:
      1. Develop and recommend to the DDQHC, through the DOQ, solutions to quality and patient/clinical safety reporting, improvement, and management issues that affect the health care or safety of American Indian and Alaska Native patients served by the IHS;
      2. Develop and update, in conjunction with the OQ, IHS policies related to patient/clinical safety and facility quality assurance, monitoring, reporting, and improvement;
      3. Identify existing quality measures and metrics, and conduct analysis between current quality metrics and national standards;
      4. Identify a core set of quality measures that align across the Indian Health System;
      5. Make recommendations on policies that affect health care quality for American Indians and Alaska Natives;
      6. Recommend scientific quality improvement methods to maximize high quality, safe patient care, and operations;
      7. Provide quality improvement leadership to support health care quality improvement and quality of care measurement and reporting;
      8. Support change management in quality improvement activities by addressing IHS or accreditation requirements, and support change management processes for implementation;
      9. Support and participate in quality of care and patient/clinical safety webinars and training events for IHS staff;
      10. Provide advisory support to IHS Area Offices and Services Units to identify and implement new quality requirements; and
      11. Implement responsibilities as assigned by the DDQHC and IHS Director.
   2. Chairperson. The Chairperson of the NQC will:
      1. Act as liaison for the council in all communications with the IHS Director, through the DDQHC, and key management staff as appropriate;
      2. Coordinate the development (drafting, reviewing, clearance) of NQC specific reports, position statements, and recommendations;
      3. Report Headquarters-specific information and issues of Agency-wide significance to the NQC membership;
      4. Preside over NQC meetings held in person, by teleconference, or virtually through videoconference; and
      5. Represent the position(s) of the NQC at IHS leadership meetings, or other meetings as required.
      6. If appropriate, convene executive sessions of the NQC meeting to maintain confidentiality and comply with the requirements of federal law at 25 U.S.C. § 1675 in the performance, communication, and handling of IHS medical quality assurance activities and records.
   3. Vice Chairperson. The NQC Vice Chairperson presides in the absence of the NQC Chairperson and will:
      1. Assume the duties of the NQC Chairperson in the event of his or her absence; and
      2. Serve in any capacity as requested by the NQC Chairperson or the NQC Executive Committee.
   4. Secretary. The NQC Secretary will:
      1. Assume the duties of the NQC Chairperson in the event that both the NQC Chairperson and the NQC Vice Chairperson are unavailable;
      2. Coordinate the preparation of meeting agendas and communicate information to the NQC Executive Committee;
      3. Record, maintain, and distribute meeting minutes to the NQC Executive Committee and post meeting minutes to the IHS OQ SharePoint; and
      4. Serve in any capacity as requested by the NQC Chairperson, NQC Vice Chairperson, or the NQC Executive Committee.
   5. Senior Sponsor (DDQHC or designee). The Senior Sponsor will provide NQC quality improvement activity support and expertise to the NQC Executive Committee.
6. RECOMMENDATION MAKING.   Make recommendations on requests by stakeholders for quality improvement related health care activities. Assist in the development of improvement activities utilizing existing national quality measures to support the mission of the IHS.
7. SELF-ASSESSMENTS.   The NQC will conduct an annual performance evaluation to assess the outcomes and effectiveness of actions undertaken by the NQC. The evaluation will be formulated into an annual effectiveness report and submitted annually to the DDQHC, through the DOQ, for review at the annual IHS NCC meeting.
8. MEETINGS.  
   1. Scheduled Meetings. The NQC will meet at least quarterly via teleconference, but may have additional meetings as needed;
   2. Concurrent Meeting. The NQC will meet during IHS NCC meetings.
   3. Additional Meetings. Additional meetings will be scheduled if the need arises, or as requested by the NQC Executive Committee, the DDQHC, or the DOQ to achieve the goals of the NQC;
   4. Meeting Minutes. Meeting minutes will be developed by the NQC Secretary and distributed within 30 days following the meeting. These meeting minutes will be maintained in accordance with IHS records, management policies, and procedures, and available electronically for review and comment by any NQC member. Meeting minutes will be maintained on the IHS NQC File Repository.
      
      In the event that the NQC enters into discussions as described in Section 5, B.6., of this Charter, minutes associated with any of these executive sessions will be segregated and protected by 25 U.S.C. § 1675.
9. AD HOC SUBCOMMITTEES.   Ad Hoc subcommittees will be established through a collaborative effort between the NQC Executive Committee, General Board members, other federal staff on established IHS National Councils and subject matter experts. Ad Hoc subcommittees will be instituted to support quality and safety improvement initiatives. A NQC Executive Committee or NQC General Board member will lead Ad Hoc Subcommittees.
10. SUPERSEDURE.   None.
11. EFFECTIVE DATE.   This IHS Circular is effective upon date of signature.

Distribution IHS-wide
Date 7/13/2023