Committees

Composition
In every facility, the Board of Directors must institute a Governance and Ethics Committee. The Committee must be made up of at least five (5) members, with the majority being independent members. The Committee must be chaired by an independent member (art. 181, LSSSS). The President-General Director must be an ex-officio member of this Committee.

Responsibilities

Generally speaking, the Governance and Ethics Committee carries out the functions outlined by the LSSSS. Specifically, these functions include drawing up :

1. governance rules for the conduct of the institution’s affairs;
2. a code of ethics and professional conduct for administrators, in accordance with section 0.4 of the Act Respecting the Ministère du Conseil Exécutif (RLRQ, c. M-30);
3. criteria for evaluating the performance of the Board of Directors, which much be approved by the Board of Directors;
4. initiation and ongoing training programs for Board of Directors members.
5. This Committee shall also carry out the evaluation of the Board of Directors in accordance with the criteria approved by the Board (art. 181.0.0.1, LSSSS).
6. Operating RulesThe Committee’s operating rules, in addition to those outlined above, can be determined by a regulation adopted by the facility’s Board of Directors.
7. Appointment of a President
   Members of the Board of Directors will designate the president from among the independent members of the Governance and Ethics Committee.

Composition

The Board of Directors must establish an Audit Committee made up of at least five (5) members, with the majority being independent members. The Committee must be chaired by an independent member. At least one Committee member must have accounting or financial experience. Members of the Committee must not be employed or practice a profession in the institution.

Responsibilities

The Audit Committee must notably :

• ensure a plan for the optimal utilization of the institution’s resources is put in place and monitored;
• ensure that a risk-management process for the conduct of the institution’s affairs is put in place and followed;
• review any activity brought to their attention that is likely to be detrimental to the institution’s financial health;
• examine the financial statements with the auditor appointed by the Board of Directors;
• recommend the approval of financial statements by the Board of Directors;
• see that the internal control mechanisms are put in place and ensure they are appropriate and effective;
• formulate views to the Board of Directors regarding the internal control of the facility and, if needed, on the external and internal monitoring work;
• carry out any other mandates related to the facility’s financial affairs as entrusted to them by the Board of Directors (art. 181.0.0.3, LSSSS).

Appointment of a President

Members of the Board of Directors will designate the president from among the independent members of the Audit Committee.

Report

The Audit Committee gives account of their activities at a time determined by the Board of Directors, at least once per year.

Users’ Committee

The Users’ Committee (UC) implements mechanisms to better understand patient concerns and promote direct links with them. For example, the Committee reaches all patients via an Advisory Committee that brings together representatives from each care unit, except those for acute care due to their short stay at the Institut.Committee

Composition

Users’ Committee (for non-merged facilities only)

The Users’ Committee is composed of five (5) members elected by users of the institution and a representative designated by and from each UC, as established by the second paragraph of article 209 of the LSSSS.

Length of Mandate

The length of the mandate for CUCI, CUC, Users’ Committee, and CR members may not exceed three years.

Fonctions

The functions of the CUC and UC are to (art. 212, LSSSS) :

1. inform users of their rights and obligations;
2. foster the improvement of the quality of the living conditions of users and assess the degree of satisfaction of users with regard to the services obtained from the institution;
3. defend the common rights and interests of users or, at the request of a user, their rights and interests as a user before the institution or any competent authority;
4. accompany and assist a user, on request, in any action they undertake, including the filing of a complaint in accordance with Divisions I, II, and III of Chapter III of Title II of the LSSSS or the Act respecting the Health and Social Services Ombudsman (chapter P‐31.1);
5. ensure the proper operation of each of the in-patient committees, if applicable, and see that they have the resources necessary to exercise their functions;
6. assess the effectiveness of any measure implemented under section 209.0.1.

Operating Rules

All CUCI, CUC and UCs must establish their operating rules. These rules go into effect as soon as they are adopted by committee members. These rules and all updates must be shared with the Board of Directors for information purposes.

Annual Activity Report for Various User Committees

User Committees at non-merged facilities must submit to the Board of Directors, on an annual basis and based on terms outlined in the 2015-2019 circular, a report of activities, including a financial report and a report of UC activities under their responsibility, and submit a copy on request to the MSSS (art. 212, LSSSS).

The Board of Directors must ensure that the content of these annual activity reports, including the financial report, is integral to their respective mandate and does not diverge from applicable legislative provisions or the frame of reference for the exercise of functions to be taken on by user and patient committee members. If a divergence occurs, the Board of Directors must alert the MSSS.

Composition

The Board of Directors must establish a Risk Management Committee at every facility. The composition of that committee must ensure a balanced representation of employees of the facility, users, persons practicing in the centre operated by the institution and, if applicable, persons who under a service contract provide services to users on behalf of the institution. The President-Executive Director or person they designate shall be an ex-officio member of the committee (art. 183.1, LSSSS).

Functions

The functions of the Risk Management Committee include seeking, developing, and promoting ways to:

• identify and analyze the risk of incidents or accidents in order to ensure the safety of users and, in particular in the case of nosocomial infections, prevent such risks and reduce their recurrence;
• make sure that support is provided to the victim and their loved ones;
• establish a monitoring system including the creation of a local register of incidents and accidents for the purpose of analyzing the causes of incidents and accidents, and recommend to the Board of Directors of the institution measures to prevent such incidents and accidents from recurring and any appropriate control measures.

Operating Rules

The number of committee members and operating rules are determined by regulation of the facility’s Board of Directors.

Composition

The facility must include a Review Board, made up of three (3) members appointed by the facility’s Board of Directors.

The Review Board president is appointed from among the facility’s Board of Directors who must not be employed or practice a profession in the institution.

For a CISSS or CIUSSS, the other two (2) members are appointed from among the physicians, dentists, and pharmacists who practice in a centre operated by one of the institutions in the territory of a local health and social services network. For a non-merged facility, only physicians, dentists, and pharmacists who are employed or practice a profession in the institution can be named to the Review Board. These appointments are made by the Board of Directors on the recommendation of the facility’s physician, dentist, and pharmacist councils (art. 51, LSSSS).

Mandate

The length of a Review Board member’s mandate is 3 years. Even at the end of their mandate, Review Board members remain in their function until they are re-appointed or replaced (art. 51 al. 4, LSSSS).

Functions

Except where a complaint is referred for a disciplinary investigation, the function of the review committee is to review the handling of a user complaint by the medical examiner of an institution in the territory of the local health and social services network (art. 52, LSSSS).

Annual and Other Reports

The Review Board must transmit to the facility’s Board of Directors, with a copy sent to the facility’s physician, dentist, and pharmacist councils, and to each facility in the territory of the local health and social services network, no later than April 30th each year, and whenever it’s deemed necessary, a report outlining the motives for the complaints sent to the Review Board since the previous report, the Board’s conclusions, as well as the delay for processing each file. It can, among other things, provide recommendations with the specific aim of improving the quality of medical, dental, or pharmaceutical care provided at the centre operated by the facility in the territory of a local health and social services network.

A copy of these reports is also sent to the facility’s Complaint and Service Quality Commissioner, who will integrate the report’s content as per article 76.10 of the LSSSS, as well as to the Health and Social Services Ombudsman (art. 57, 76.10, 76.11, LSSSS).

The Watchdog Committee, reporting to the Board of Directors, primarily ensures the follow-up, with the board, of the recommendations made by the local service quality and complaints commissioner or the Health and Social Services Ombudsman regarding complaints or interventions made under the LSSSS or the Act respecting the Health and Social Services Ombudsman (RLRQ, c. P-31.1) (art. 181.0.1, LSSSS).

The Watchdog Committee shall ensure that the Board of Directors fulfils its service quality responsibilities effectively, especially when it comes to the pertinence, quality, safety, and efficiency of services provided and the respect of users’ rights and diligent treatment of their complaints.

To that end, the committee must, in particular:
receive and analyze the reports and recommendations sent to the board of directors on the accessibility of services, the pertinence, quality, safety or effectiveness of the services provided, the enforcement of user rights, or the handling of user complaints;

promote joint action and cooperation among facility stakeholders to carry out this responsibility and ensure recommendations are carried out;

establish systemic links between those reports and recommendations and draw from them the conclusions necessary to make recommendations to the Board of Directors;

make recommendations to the Board of Directors on the action to be taken following those reports or recommendations in order to improve access to services and the quality of user services;

ensure the follow-up, with the Board of Directors, of the board’s implementation of the recommendations made;

ensure that the local service quality and complaints commissioner has the necessary human, material, and financial resources required to carry out the responsibilities of the office effectively and efficiently;

exercise any other function that the Board of Directors considers useful in fulfilling the mandate entrusted to the committee under the first paragraph (art. 181.0.3, LSSSS).

List of Members

The ethical examination of a research project cannot be carried out before approval from a duly authorized scientific committee, without exception.

For a list of committee competences linked to requests governed by the ministerial circular, please see the Multicentric Projects

Requests not Governed by the Ministerial Circular

The Institut’s Research Ethics Committee has the competency to evaluate research activities involving humans that fall into one of the following categories:

• The project is carried out, in part or in full, at the facility, whether or not it falls under the responsibility of a stakeholder affiliated with the Institut; if this is a database, it is located in part or in full at the facility or under the responsibility of a stakeholder affiliated with the Institut;
• People solicited for the research activity are users at the facility or stakeholders affiliated with the Institut, including persons that are part of their entourage, whether their support is direct or indirect, meaning it is based on files or biological material that falls under the responsibility of the facility;
• The research activity necessitates human, material, or financial resources from the facility;
• The promoter or researcher states or implies to research participants that the Institut is part of the research project or that they are affiliated with the facility; if this is a database, participants are led to believe that the Institut has a stake in the database or that the stakeholders responsible are affiliated with the facility.

Notwithstanding the above, the researcher must not submit their research project to the Research Ethics Committee in the following situations:

• In the initial exploratory phase when they are meeting with people or communities to establish research partners, study the project feasibility, or collect information to set up their research project; note that these persons are not considered research participants, unless they themselves are the topic of study;
• If they can prevail themselves of the simplified procedure for ethical review.

Special Procedures

• • For projects that may be exempt from scientific review, even if they have never been approved by a peer-review committee (projects led by students).
  • For projects that have never been subject to a scientific basis review by a peer-review committee.

Note that the file will be sent first to the Director of the Research Centre for a summary review. If, on its face, the summary contains major scientific issues, the Director will communicate with the researchers to suggest improvements. Although the researcher is free to modify the summary based on comments received, the results of the Director’s summary examination will be available to the Research Ethics Committee, who can can then make the decision, as needed, to transfer the file to the scientific committee or wait for the committee’s decision before transferring the file for a project sustainability review.

The Institut’s Research Ethics Committee encourages all researchers to consult their secretariat for complementary information, as needed. As well, if you have any doubts about the obligation to present your request to the Research Ethics Committee, it’s best to err on the side of caution.

The Research Ethics Committee meets at fixed dates to examine all submitted research projects. Note that the committee will not examine requests with incomplete files. For a new research project to be reviewed, it must first have been approved by a duly qualified scientific committee.

Documents must first be sent by mail to the committee secretary no later than midnight on the day of the deadline.

Ethics Committee Meeting Calendar (French only)

List of Members

The key mandate of the Institut’s Scientific Committee is to evaluate, on a scientific basis, the acceptability of research projects using humans under the responsibility of the facility. However, the researcher must not submit their research project to the Scientific Committee in the following situations:

• The project is in the initial exploratory phase wherein the researcher is meeting with people or communities to establish research partners, studying the project feasibility, or collecting information to set up their research project;
• The project can use the simplified procedure for ethical review;
• The project can be delegated to the Institut’s Research Ethics Committee for review (limited REB), unless the committee expressly requests review by the Scientific Committee;
• The project has already been subject to a scientific basis review by a peer-review committee, unless the Institut’s REB specifically requests review by the Scientific Committee.

A peer-review committee is a Scientific Committee of:

• a facility where the Research Centre receives subsidies from a Québec or Canadian funding organization;
• a Québec or Canadian funding organization, or an organization recognized by either;
• a Canadian university (e.g. Program Committee, Thesis Committee);
• an organization recognized either by a member state of the Organization for Economic Co-operation and Development, or by one of their recognized organizations (e.g. an organization of the U.S. National Institutes of Health).

A review by the peer-review committee must be carried out on the totality of the project that you wish to lead at the Institut. For example, if funds earmarked for a research program support multiple projects that have not yet been defined at the time of the review by the Scientific Committee of the subsidizing organization, or if certain parts of the project were not yet stopped when funding was received, the project must be reviewed again by the facility’s Scientific Committee. As well, a review by the subsidizing organization’s Scientific Committee is considered valid if they deemed the project acceptable in the case where, due to lack of funding, it would not have been subsidized.

The Committee also has the jurisdiction to review any project or request affiliated with a project for which the Research Ethics Committee deemed it necessary to obtain their opinion before making a decision, notwithstanding any exemption a researcher could have availed themselves of.

Special Procedures

• • All projects led by students must be sent to the Scientific Committee.
  • For projects that have never been subject to a scientific basis review by a peer-review committee.

  Note that the file will be sent first to the Director of the Research Centre for a summary examination. If, on its face, the summary contains major scientific issues, the Director will communicate with the researchers to suggest improvements. Although the researcher is free to modify the summary based on comments received, the results of the Director’s summary examination will be available to the Research Ethics Committee, who can can then make the decision, as needed, to transfer the file to the scientific committee or wait for the committee’s decision before transferring the file for a project sustainability review.

List of Members