NAHM Terms of Reference

nahmThe NAHM Governance Committee provides governance to this audit process which has been developed to analyse and display mortality patterns in Irish hospitals.   Relevant specialties and groups will be represented within the committee membership to ensure audit aims and objectives are achieved.


Responsibilities of the NAHM Governance Committee

The NAHM Governance Committee should provide governance to the audit.    It will provide both clinical and professional expertise when required, and work closely with the NOCA Executive Team and the NOCA Governance Board.

  • Adheres to the highest standards of corporate and social responsibility.
  • NAHM Governance Committee responsibilities are

    • Oversee deployment and improvement of the audit – this includes approval of updates to the NQAIS NAHM tool.
    • Shape the strategic direction of NAHM –  direct future evaluation of the audit structure and process.
    • Oversees  NOCA’s engagement with Hospital and Hospital Group Executives, Clinical Directors and governance structures  to interpret NAHM data to improve quality outcomes for patients.
    • Review and agree content of national reports / publications before forwarding reports for sign off by the NOCA Governance Board,
    • Ensure that NAHM complies with legal and statutory requirements e.g  all data protection legislation as advised by the NOCA Executive.


    Duty of Care

    The NAHM Governance Committee will, in the first instance, meet quarterly to review the output of NAHM.  This information will be provided by the NOCA Executive.    Should individual hospitals display  results that highlight ‘statistically unusual patterns’  the NOCA Executive acting on behalf of the NAHM Governance Committee will  notify individual Hospital / Group Management and Clinical Directors to draw such issues to their attention and request local review as per NOCA Monitoring and  Escalation Policy (NOCA, 2014).  The NAHM Governance Committee will be informed by the NOCA Executive of progress and close out of these reviews.



    The Clinical Indemnity Scheme (CIS) has been engaged by the Health Services Executive Quality Improvement Division (HSE QID)  to provide indemnity cover to the NOCA Team, its officers and the convened members of the NOCA Governance Board and its respective Audit Governance  Committees (including NAHM Governance Committee), in respect of all clinical audit conducted by NOCA.


    Management of Conflicts of Interest

    In order to ensure the NAHM Governance Committee operates in a transparent and unbiased way, all members will be requested to complete a written declaration of conflict of interest to the Chair. In line with the policy of the National Office of Clinical Audit on the Management of Conflicts of Interest, all NAHM Governance Committee members will be required to declare any conflicts of interest and this will be a standing agenda item for all meetings. All interests will be recorded and maintained by the National Audit Coordinator.


    Membership of NAHM Governance Committee

  • Public Representative
  • Members will be selected to reflect the interest of the healthcare community as a whole and to achieve an appropriate mix of relevant skills to support NAHM.   Relevant specialties and groups as identified by the NOCA Governance Board, shall be invited to become members of the NAHM Governance Committee as follows;

    • Health Service Executive Health and Wellbeing, Health Intelligence  Unit
    • International Academic Expert
    • Health Service Executive Quality Improvement Division
    • Health Service Executive Office of Nursing and Midwifery
    • Health Service Executive Clinical Strategy & Programmes
    • Health Service Executive Clinical Directors Programme
    • Health Service Executive Acute Hospital Services
    • Healthcare Pricing Office
    • Royal College of Surgeons in Ireland
    • Royal College of Physicians of Ireland
    • College of Anesthetists of Ireland
    • Joint Faculty of Intensive Care Medicine in Ireland
    • Hospital Group CEO Forum



    It is intended the NAHM Governance Committee will meet quarterly. Prior notice will be issued by email. In the event a member is not in a position to attend, apologies should be sent to the National Audit Coordinator. Inability to attend and contribute to 3 consecutive meetings per year will require review of your membership and possible re-nomination from individual stakeholder groups to ensure adequate contribution and national consensus is upheld at all NAHM Meetings.



    In line with the guidelines for the NOCA Governance Board, membership of Audit Governance Committees, are for a staggered period of three years. In certain circumstances where members are agreeable they may be asked to stay on for a second term. Agreement should be achieved on this point at the first governance committee meeting.


    Resignation of NAHM Governance Committee Members

    Membership of the NAHM Governance Committee will be for a staggered period of three years   to ensure continuity of committee memory and intellectual property.  Resignation before completion of tenure should be tendered and accepted only in writing to the Chair and will allow for no less than a two month notice period.  In the case of resignation of an individual, who may have been involved, or offering specific advice or guidance in respect of the completion on any particular audit, the Member     will first ensure all obligations are fully discharged before tendering resignation. The Chair shall invite additional members to fill casual vacancies from relevant cohort or as the need arises in order to ensure adequate specialist expertise is represented.



    The NAHM Governance Committee is a voluntary board and as such no member will be paid for their time.  Limited funding will be retained for external / public representatives to allow for vouched travel.


    Accountability and Reporting Relationships

    The NAHM Governance Committee is accountable to the NOCA Governance Board who in turn are accountable to the HSE Quality Improvement Division.  The NOCA executive team will furnish regular reports to the NOCA Governance Board.



    The NAHM Governance Committee requires the presence of six of its members in attendance in person or by telephone to establish a quorum for any meeting convened.   The quorum excludes NOCA executive team.   The NAHM Clinical Lead and/or NOCA Coordinator will report to and attend all Governance Committee meetings.


    Performance / Monitoring of the NAHM Governance Committee

  • Annual review the processes of the committee.
  • Performance outcomes will be measured to ensure that the committee is performing:

    • Percentage of attendance at meetings by members
    • Criteria against each of the Responsibilities of the NAHM Governance Committee
    • Minutes, reports and other outputs from the committee should be of a suitable standard



    A NOCA appointed audit coordinator/manager will be responsible for the administration of the NAHM Governance Committee and the day to day interactions with Hospital Executive Managers & /or Clinical Directors.


    Approval and Review Date

    The terms of reference are agreed and approved by the NAHM Governance Committee.   The terms of reference are  reviewed by the NAHM Governance Committee annually.