LIST OF COMMITTEES WITH THEIR ROLES AND SAMPLE COMPOSITION

QUALITY ASSURANCE / IMPROVEMENT COMMITTEE

ž  Purpose

This is an apex committee and has been established for the purpose of planning, monitoring, providing resources, accountability and reviewing all activities related to the quality management system at the hospital. This includes the process of management review.

ž  Role and Responsibilities

1.       Planning of the manuals, policies and protocols that guide the specific areas and to develop quality improvement programme.

2.       Establish, monitor and review of quality objectives, quality indicator and to set benchmark for the same.

3.       Ensuring the availability of resources as required for the quality management programme.

4.       Conducting management reviews.

5.       Reviewing non-conformances related to services across the hospital..

6.       Reviewing internal audit reports and working of all other committee.

7.       Analysis of patient satisfaction data and complaints.

8.       Ensuring timely corrective and preventive actions.

9.       Ensuring continual improvement of the quality management system and accreditation.

ž  Frequency of meeting

The Committee shall meet once every month

ž  Sample composition

Quality improvement Committee
Composition	Designation
Director/CEO/Medical superintendent	Chairperson
NABH Coordinator/Quality Manager	Convenor
One representative each department
GM - Administration	Member
Medical specialty	Member
Pathology	Member
Imaging	Member
Nursing Head	Member
Infection Control officer	Member
Anesthesiologist	Member
Surgeon	Member
Intensivist	Member
Purchase & Stores	Member
HR department	Member
Blood bank	Member
Pharmacy	Member

INFECTION CONTROL COMMITTEE

ž  Purpose

To ensure that there is an active, effective, institution-wide infection control program that develops effective measures to prevent, identify, and control infections acquired in the hospital or brought into facilities from the community. It provides a multidisciplinary forum for laying down the infection control policies and procedures and ensures their implementation. The Infection Control Committee is generally comprised of members from a variety of disciplines within the healthcare facility. Representation may include: physicians, nursing staff, infection control practitioners, quality assurance personnel, risk management personnel as well as representatives from microbiology, surgery, central sterilization, environmental services, etc.

ž  Role and Responsibilities

1.       To oversee the infection control program of the HCO, so as to ensure that the best standards are in place and that risks of infection are minimized.

2.       To ensure that infection control policies and procedures are being consistently followed throughout the HCO. Establish standard precaution practices to be implemented across the hospital.

3.       To assess hospital-acquired infection rates through regular surveillance, and to ensure that interventions are prioritized in order to reduce these rates.

4.       To monitor surveillance data and identify opportunities for improvement.

5.       To advise on matters related to the proper use of antibiotics, to develop antibiotic policies, and to recommend remedial measures when antibiotic-resistant strains are detected.

6.       Provides input into the Hospital Employee Health Programme.

7.       Review HAI rates periodically and recommend actions accordingly.

8.       Report’s findings and recommendations to Management.

9.       The committee will report to the hospital QI Committee for necessary action.

10.   Follows-up to ensure compliance with recommendations made to eliminate hazardous situations.

11.   To ensure that training programs on infection control-related parameters (such as hand hygiene or biomedical waste segregation) are held for staff on a regular basis.

ž  Frequency of meeting

The Committee shall meet once every month

ž  Sample Composition

  

Hospital Infection control committee
Composition	Designation
Microbiologist/Anesthesiologist	Chairperson
Infection control nurse/Quality Manager	Convenor
One representative each department
Medical Administration	Member
GM - Administration	Member
3-4 HOD (clinical)	Member
Pathology	Member
staff representation from CSSD	Member
Nursing Head	Member
Head of support services	Member
Head of Engineering	Member
Purchase & Stores	Member
Head of Food and Beverages	Member
Head of Housekeeping	Member
Blood bank	Member
Operation theatre	Member

                                                                                                                         

Pharmaco-therapeutic committee/Team

ž  Purpose

          To ensure that the selection, compliance, distribution, storage, safe use, and administration of              drugs within the HCO are as per standards laid down.

ž  Role and Responsibilities

1.       To formulate and implement that policies and procedures related to medication management are consistently being followed throughout the HCO.

2.       To manage the drug formulary system by evaluating the usage of medications periodically and requesting additions or deletions. The Committee is responsible for updating hospital formulary every year.

3.       To move the HCO towards a generic drug regime and away from the branded drug system.

4.       To monitor Adverse drug reactions and adverse drug events and ensure that corrective and preventive actions are taken.

5.       The Pharmaco-Therapeutic Committee is responsible for all the drugs & pharmaceutical purchases.

6.       All purchases made by this committee will be based on the purchase policy of the hospital.

7.       To design and implement methods for ensuring the safe prescribing, distribution administration and monitoring of medication.

8.       The formulation of Antibiotic policy and implementation.

9.       Report to management and Quality improvement committee.

ž  Frequency of meeting

The Committee shall meet once every month

ž  Sample composition

Pharmaco- therapeutic committee
Composition	Designation
Clinical HOD	Chairperson
Pharmacy Head	Convenor
One representative each department
Medical Administration	Member
GM - Administration	Member
3-4 HOD (clinical)	Member
Quality Manager	Member
Nursing Head	Member
Pharmacy store incharge	Member
Representative from IPD	Member
Representative from OT	Member
Representative from Emergency department	Member

CPR Committee/CODE BLUE COMMITTEE

ž  Purpose

To ensure an effective hospital-wide Cardio Pulmonary Resuscitation (CPR) programme.

ž  Responsibilities

1.          To ensure that policies and procedures related to CPR are consistently followed throughout the organization.

2.          To ensure CPR training for all staff in CPR (Basic life support), training for selected staff for ACLS (advance life support), and to ensure that they understand their roles and responsibilities for code blue.

3.          To use simulation in the form of mock drills in order to assess the responsiveness and competence of the CPR Team. Shall be responsible to analyze the code blue events periodically.

4.          To advise on the design and implementation of the audit process that monitors the incidence and outcomes of cardiac arrest/medical emergency calls.

5.          To ensure the availability and maintenance of the equipment and drugs required.

6.          To advise on the appropriate choice of equipment and medicines for use in resuscitation procedures.

7.          To offer guidance on the minimum level of resuscitation training for individual staff groups based on their role and exposure to cardiac arrest/emergency situations.

8.          To review all cardiac arrest case files to assess the adequacy of response and to evaluate the scope of improvement for the same.

ž  Frequency of meeting

The Committee shall meet once every month

ž  Sample composition

                

CODE BLUE COMMITTEE
Composition	Designation
HOD Emergency/Intensivist	Chairperson
Medical Administration	Convenor
Emergency Doctor	Member
Anesthesia representative	Member
Quality Manager	Member
ICU representative	Member
HOD security	Member
Nursing Head	Member

Safety committee

ž  Purpose

To addresses all areas of hospital operations in an attempt to ensure and improve safety for all patients, staffs and visitors. To ensure a safe working environment by requiring supervisors to enforce training, documentation and safety practices set forth in various hospital safety programs.

ž  Responsibilities

1. All safety related reporting and data collections mechanisms shall be established and pursued like.
1. Incident Reporting
2. Medication Error Reporting
3. Adverse Drug Reactions
4. HAI Infection Reports
5. Facility Safety Surveillance
2. The hospital shall collect data and analyze it regarding the following aspects with a view to improve patient safety plan.
1. Staff perceptions and suggestions for improving patient safety
2. Staff willingness to report errors
3. Patient/family perceptions and suggestions for improving patient safety
3. The hospital may also focus on the improvement of the patient safety program through utilizing proactive risk reduction strategies like.
1. Identification, reporting, and management of sentinel events
2. Identification of high-risk processes
3. Failure mode, effects, and criticality analysis
4. Responsible for implementation of policies related to Radiation and Laser safety.
5. Undertake Facility & Loss Prevention Surveillance every quarter to identify and analyze potential patient safety issue and submit the report to the Quality Improvement Committee.
6. Prepare Fire Plan, Fire Drawings, fire training and conduct 2 fire drills/ year.
7. Prepare Disaster Plan, Internal & external disaster drill annually.

ž  Frequency of meeting

The Committee shall meet once at least every four month

    ž              Sample composition

SAFETY COMMITTEE
Composition	Designation
General Manager/Administrator	Chairperson
Safety officer	Convenor
One representative each department
Laboratory safety officer	Member
Radiation safety officer	Member
Maintenance HOD	Member
Fire safety officer	Member
OT incharge	Member
ICU incharge	Member
Infection Control Nurse	Member
HOD security	Member

GRIEVANCE REDRESSAL, INTERNAL COMPLAINT AND SEXUAL HARRASSMENT  (VISHAKHA) COMMITTEE  

žPurpose

The purpose of the Human Resources, Credentials & Privileges Committee is to assist the Board in fulfilling its obligations relating to human resources issues, including the evaluation and compensation of the employee, succession planning and significant human resources policies, handling of  Grievance redressal and recommend disciplinary action to be taken.

ž  Responsibilities

1.       To review and analyse employee grievance cases brought in committee.

2.       Investigate the facts and surrounding circumstances, and showing the employees that this been done thoroughly and sensitively.

3.       Actively look for a solution that will satisfy the employee and involved party.

4.       Provide feedback to the employee about what can, and cannot be done to resolve the grievance.

5.       Take necessary follow-up action.

6.       To issue the policy and guidelines to prevent discrimination and sexual harassment in institution.

7.       Deal with cases of discrimination and sexual harassment against women, in a time bound manner, aiming support services to the victimized and termination of the harassment.

8.       To ensure that rights of complainant and complainee are protected.

9.       Recommendation appropriate punitive action against the guilty party in accordance to the legal guidelines under the act- to the director.

ž  FREQUENCY

The Committee shall meet once at least every four month/or as and when required

    ž  Sample composition

GRIEVANCE REDRESSAL, INTERNAL COMPLAINT AND SEXUAL HARRASSMENT  (VISHAKHA) COMMITTEE
Composition	Designation
Director/CEO/Medical superintendent	Chairperson
HR Manager	Convenor
General Manager/Administrator	Member
Nursing Head	Member
3-4 HOD (clinical)	Member

PURCHASE & CONDEMNATION COMMITTEE

ž  Purpose

The purpose of this committee is to purchase the new material and equipment as per need of the hospital and also to evaluate the item and declaring the item competent or surplus or obsolete or unserviceable so as dispose the item.

ž  Responsibilities

1.       Managing and monitoring the material management system of the hospital.

2.       Responsible for the selection, monitoring and rating of suppliers.

3.       Annual purchase planning activity and preparing the materials management budget.

4.       Ensure planning and implementation of inventory management practices. Conduct random stock audits of the stores and the department stocks.

5.       Checking of all records including the moment registers & Gate Pass registers

6.       Condemnation of unusable items. Damaged linen shall be stored in an identified place at the laundry.

7.       The equipments / instrument / furniture for condemnation shall be certified by the Bio-medical engineer/ Housekeeping Supervisor that the item is beyond repair / un-usable with proper stickers for condemnation & stored at the concerned units.

8.       Notify all departments in advance and receive the list of items identified for condemnation.

9.       Prepare a consolidated list of condemned items, a copy of the same to CMD for information.

ž  Frequency

The Committee shall meet once at least every four month

     ž  Sample composition

Purchase and condemnation COMMITTEE
General Manager/Administrator	Chairperson
Store Incharge	Convenor
One representative each department
Medical administrator	Member
Nursing head	Member
Pharmacy Incharge	Member
Maintenance HOD	Member
Biomedical engineer	Member
Concern Department representative	Visitor
Concern Department representative	Visitor
Concern Department representative	Visitor

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