Hospital Committees

HOSPITAL COMMITTEES
The Hospital environment and facilities operate in harmonious mannerto ensure safety of the
patients, their families, staff and visitors through the continuous effort of 19 hospital
committees. The functions of these committees includes Case record maintenancein
confidential manner, Employee and Patient grievance redressal, assurance of Hospital
standards to NABH quality, organising quality improvement programmes for the health care
providers, management of emergency scenario, auditing, etc. The Hospital committees
includes
1. Quality Core Committee

2. Quality Assurance Committee
3. Safety Committee
4. Nursing Quality Improvement Committee
5. Sentinel Event Committee
6. Disaster Management Committee
7. CPR Committee
8. Death Review Committee
9. MRD Committee
10. Medical Audit Committee
11. Image Enhancement Committee
12. Infection Control Committee
13. Employee Grievance Redressal Committee
14. Patient Grievance Redressal Committee
15. Pharmaco therapeutic Committee
16. Anti Sexual Harassment Committee
17. Management Review Committee
18. Condemnation Committee
19. Capital Purchase Committee
1. QUALITY CORE COMMITTEE
Reporting to : Medical Superintendent

General Objective  Evaluate the quality improvement activities on an ongoing basis,
 Review policies & procedures relating to each function and make
necessary revisions to initiate quality improvement measurements
in priority areas.
 To take the accountability and responsibility of the task assigned
to them and ensure timely completion as per set target dates.
 Identify and evaluate general areas of potential risk in all aspects
of patient care and safety via active involvement and participation
in hospital rounds pertaining to facility/safety/quality etc.
 Coordinate Quality Initiatives of all the departments.
 Ensure monitoring and compliance of all the new processes
introduced routinely.
 To utilize a standard format for documenting and reporting all
quality measures hospital wide.
 To establish priorities for quality improvement activities.
 To take care of new processes and changes in the system required
for quality improvement
 Organize Quality Sensitization programs to train and educate the
staff about quality improvement activities and the transformation
associated with it.
 Review thequality of careprovided to patients through
the monitoringofindicators sentinel events and performance of
processes/system that are intradepartmental.
Members  CHAIRMAN
 MEDICAL SUPERINTENDENT
 QUALITY CO ORDINATOR
 HR MANAGER
 NURSING SUPERINTENDENT
 PATIENT LIAISON OFFICER
Credentials of the  They hold senior and responsible position influencing the
members decision-making and Implementation of Continuous Quality
Improvement program.
Meeting Scheduling The committee members will meet once in 6 months or as and
Minutes of the Meeting when required.
Minutes Of Minutes Prepared by- Quality coordinator

Meeting Proof read by – Medical superintendent
Authorized by : Medical superintendent
Archiving of MOM’s – All MOM are available with the Quality

department
2. ANTI SEXUAL HARASSMENT COMPLAINTS COMMITTEE

General Objective  Providing women protection against sexual harassment at the

workplace and for the prevention and redressal of complaints of
sexual harassment.
Specific Objectives The Responsibilities of the Anti Sexual Harassment Complaints

Committee shall be as follows.
 To create awareness about sexual harassment and its prevention in
organization
 Deal with cases of discrimination and sexual harassment against
women, in a time bound manner, aiming at ensuring support
services to the victimized and termination of the harassment;
 Recommend appropriate punitive action against the guilty party to

the
Medical Superintendent.
Head of Quality Department
HR manager- Chairperson
 LEGAL ADVISOR
 HR MANAGER
Meetings Scheduling The committee members will meet as and when Required Minutes
(written) by- Committee coordinator (once in 4 months)
Minutes of the Minutes Prepared by- HR Manager
meeting Proof read by – Medical superintendent

department
3. SAFETY COMMITTEE:
General Objective  Identify the potential safety and security risks to staff, patients, and
visitor in the hospital
 Give recommendation for patients, employees and visitors safety in
the hospital.
 Eliminate such risks by taking precautionary actions
 Coordinate, implement and monitor the Hospital-wide safety
program thatspecifically includes the Laboratory safety program
and the Radiation Safety Program Hazardous materials & waste,
Emergency management, Fire safety, Medical equipment, Utility
systems, Security and Management
 To design and implement safety management activities..
 Ensure safety manuals of respective Departments are updated and
the staff trained to adhere to the safety norms.
 Ensure Emergency Evacuation Drills are conducted twice a year in
the Hospital premises.
 Training of the hospital staff for the safety management plan
 Carrying out workplace inspections.
 Promoting the health and safety policy and program.
 The Responsibilities of the AntiSexual Harassment Complaints
Committee shall be as follows.
 To create awareness about sexual harassment and its prevention in
Organization
 Deal with cases of discrimination and sexual harassment against
women, in a time bound manner, aiming at ensuring support
services to the victimized and termination of the harassment;
 Recommend appropriate punitive action against the guilty party to
the Medical Superintendent.
Head of Quality Department – Chairperson
Safety Officer - Secretary
 SAFETY OFFICER
 BIO MEDICAL ENGINEER
 MAINTENANCE MANAGER
 HOUSE KEEPING INCHARGE
 PURCHASE MANAGER
 SECURITY SUPERVISOR
 INFECTION CONTROL NURSE
Credentials of the They hold senior and responsible position influencing the decision-
Members making and members
The committee members will meet once in every three months or as
Meetings Scheduling
and when required.
Minutes (written) by- Committee coordinator
Minutes of the
Minutes Prepared by- Safety officer
Meeting
Proof read by – Medical superintendent
department
4. DISASTER MANAGEMENT COMMITTEE

General Objective  To design and implement disaster management activities.
 Organizing training of the employees for Disaster preparedness
/ Emergency Evacuation..
 Ensure Emergency Evacuation Drills are conducted twice a year
in theHospital premises.
 To suggest & formulate policies pertaining to internal and
external disaster management of the Hospital.
 Training of the hospital staff for the disaster plans
 Testing and evaluation of Disaster management plan
 Planning for appropriate corrective and preventive action
 SAFETY OFFICER
 HR MANAGER
 CASUALTY MEDICAL OFFICER
 FINANCE MANAGER
 NURSING INCHARGE - I FLOOR
 NURSING INCHARGE - II FLOOR
 PHARMACY INCHARGE
Members making andimplementation and Manage in case of disaster.
The committee members will meet once in every four months or

Meetings Scheduling
as and when required.
Minutes of the
meeting Minutes Prepared by- Safety officer
Proof read by – Quality co-ordinator

department
5. INFECTION CONTROL COMMITTEE
General Objective  Preventing and reducing risk of healthcare associated infections.

Specific Objective  Develop policies and procedures and to guide the
implementation of infection control programme.
 Develop a system of identifying, reporting, investigating and
controlling the Hospital Acquired Infection.
 Develop and implement hospital antibiotic policy
 Provide adequate and appropriate resources for prevention and
control health care associated infection.
 Guide/take corrective and preventive action on the basis of
analysis of surveillance data.
 Development and formulation of preventive and corrective
programmes in view of infectious hazards.
 Periodically educate the healthcare workers of the institution on
infection control policies and protocol.
 Guidelines for Segregation of Disposal Hospital waste.
 INFECTION CONTROL OFFICER- Committee Co-ordinator
 QUALITY EXECUTIVE
 OPERATIONS MANAGER
 INFECTION CONTROL NURSE
Members making and implementation and Manage in case of infections.
Meetings Scheduling The committee members will meet on every month and when
required.
Written by - Committee Co-ordinator
Minutes of the
Minutes Prepared by- Infection Control officer
Meeting
Proof read by – Quality coordinator
Archiving of MOM’s – All MOM are available with the Infection

Control Officer (Microbiologist).
6. MANAGEMENT REVIEW COMMITTEE

General Objective To ensure that hospital governance in ethical and professional manner.
Complies with all applicable regulations. The responsibilities of the
leaders at all levels are defined.
Specific Objective  The Management Committee ensures that everything the
organization does supports its vision, purpose and aims.
 The organization complies with all applicable regulation
 They establish the fundamental values, the ethical principles and
strategic direction in which the organization operates.
 Management committee members have ultimate responsibility for
directing the activity of the organization, ensuring it is well run
and delivering the outcomes for which it has been set up.
 Ensuring the effective management of the organization and its
activities; and monitoring the activities of the organization to
ensure they are in keeping with the founding principles, objects
and values.
 The Management Committee evaluates all areas of the
organization’s performance
 LEGAL ADVISOR
 HR MANAGER
Members making and implementation and Manage in case of disaster.
Meetings The committee members will meet quarterly or as and when required.
Scheduling Minutes (written) by- Quality Department
Proof read by - Medical Superintendent
Minutes of the Minutes Prepared by- Quality co ordinator

Meeting Proof read by – Medical superintendent

department
7. MEDICAL AUDIT COMMITTEE
Reporting to : Medical Superintendent / Chairman

General Objective To improve patient care and outcomes through systematic review of
care against explicit criteria and the implementation of change.
Specific Objective  Define standards that are realistic and parallel to existing
standards
 Set the criteria to measure these standards
 The defined the parameters to be audited.
 Develop a sampling and data collection guidelines, preparation
of report and checklist where required.
 Take Remedial measures based on root cause analysis and
implemented.
 Evaluate change Review standard if required.
 LEGAL ADVISOR
 UNIT HEAD
 UNIT HEAD
 UNIT HEAD
Meetings Scheduling The committee members will meet once in two months.
Minutes Prepared by- Quality coordinator

Minutes of the
Meeting

department
8. EMPLOYEES GRIEVANCE REDRESSAL COMMITTEE
General Objective The Grievance Committee has accountability for reviewing and
resolving Objective Employee grievances. The committee assures
Employee complaints and grievances are handled according to
regulatory requirements
Specific Objective  Develop Redressal procedure addresses the employee grievance.
 The grievance committee shall hear all evidence relevant to the
grievance, make findings, and make recommendations to the
Medical Superintendent / Chairman based on its findings.
 Making written finding of fact and recommendation with regard
to the grievance
 HR MANAGER
Meetings Scheduling The committee members will meet half yearly or as and when
required.
Minutes of the
Minutes Prepared by- HR manager
Meeting
department
9. PATIENT GRIEVANCE REDRESSAL COMMITTEE
General Objective  Resolving grievances/complaints and concerns of patients or

their representatives.
Specific Objective  Develop and implement well-defined policies, procedures, and

processes for addressing and responding to patient grievances
and complaints.
 Responsible for reviewing and responding to all patient
grievances, and recommending action
 Grievance redressal mechanism must be accessible and
transparent.Displayed information must be clearly available on
how to voice a complaint.
 Educate all staff members, especially those with direct patient
contact, on grievance processes, and emphasize that staff should
communicate calmly with patients and show empathy for their
concerns.
 DIETICIAN
 LAB -INCHARGE
 RADIOLOGY INCHARGE
Meetings Scheduling The committee members will meet monthly or as and when
required.
Minutes of the
Meeting Minutes Prepared by- Operations manager

department
10. PHARMACOTHERAPEUTIC COMMITTEE

General Objective To guides the formulation and implementation of policy and
procedure for pharmacy services and medication usage
Specific Objective  To develop hospital formulary and updated at regular
interval
 To guide the safe and rational prescription of medication
 An Advisory role on the pharmaco-economic evaluations of

drugs.
 To co-ordinate the introduction of new drugs/extended use of
existing medicines
 To develop & maintain policies & procedures to support use
of medicines including:
i. Policy for the acquisition, storage , prescribing, dispensing,
administration and medication management
ii. Prepare list of high risk and narcotic medication
iii. Use and storage of Narcotic and chemotherapeutic drug
iv. Policies and procedures govern usage of radioactive drugs
Analyzed and monitor that all event like Near misses,
medication errors and adverse drug events are reported within
specified time and guide to take corrective and preventive action
on the basis of analysis report where appropriate.
Members  CHAIR MAN
 LEGAL ADVISOR
 PHARMACY HOD
 PHARMACY INCHARGE
Meetings Scheduling The committee members will meet once in every two months
Minutes of the
Minutes Prepared by- HOD of Pharmacy department
Meeting
department
11. CARDIO-PULMONARY RESUSCITATION COMMITTEE

General Objective To guide the care of patient requiring cardiopulmonary resuscitation.
Specific Objective  Develop policies and procedure that guides the uniform use of
cardiac resuscitation throughout the organization.
 Periodically update in Cardiac Pulmonary Resuscitation.
 Post event analysis of all Cardiac Pulmonary Resuscitation in the

hospital which include the cause, steps taken to resuscitation and
the outcome
 Guide to take corrective and preventive measures based on the post
event analysis.
 Training and Retraining of the staff providing direct patient care
 UNIT HEAD
 CONSULTANT
Meetings The committee members will meet as and when required. Minutes
Scheduling (written) by- Quality Department
Minutes of the
Meeting
department
12. CAPITAL PURCHASE COMMITTEE

General To guide for planning, selection and installation of new equipment in
Objective hospital
Specific  Responsible for value analysis. This is defined as the process by
Objective which all new technology, products and services current and
proposed, are reviewed to ensure that the Hospital is receiving the
optimum benefit and outcome from all moneys spent in hospital
operations.
 Approve or reject new technology, products, medical devices,
equipment, and services for use in the Hospital.
 Responsibility of reviewing and approving both product selection and
sources of purchased services to ensure the standards established by
the Hospital are met and does not compromise the quality of patient
care.
 This committee is accountable for reporting any savings or costs
related to the decisions made.
 STORE KEEPER
Credentials of They hold senior and responsible position influencing the decision-
the Members making and implementation and Manage in case of disaster.
Meetings The committee members will meet half yearly or as and when required.
Scheduling
Minutes of the
Meeting

department
13. CONDEMNATION COMMITTEE

General Objective To guide the condemnation and disposal of goods.
Specific Objective  Planning and defining protocols of condemnation and disposal of
goods
 Responsible for breakage and condemnation of goods
 All the goods are condemned on the decision of the committee
 Documents and Maintain records of all the goods disposed or
condemned by the organization.
 SAFETY OFFICER
Members making andimplementation and Manage in case of disaster.
Meetings The committee members will meet quarterly or as and when required.
Scheduling Minutes (written) by- Committee secretary
Minutes Prepared by- Purchase manager

Minutes of the
Meeting

department
14. NURSING QUALITY IMPROVEMENT COMMITTEE:

General Evaluate the quality improvement activities on an ongoing basis,
Objective
Specific  To utilize a standard format for documenting and reporting all quality
Objectives measures hospital wide.
 To take care of new processes and changes in the system required for
quality improvement
associated
with it.
 Review the quality of care provided to patients
through the monitoring of indicators sentinel events and
performance of processes/system that are intradepartmental as well as
interdepartmental.
Suggested  MEDICAL SUPERINTENDENT
members
Credentials of They hold senior and responsible position influencing the decision-making
the members and Implementation of Continuous Quality Improvement program.
Meetings The committee members will meet monthly or as and Minutes of the
Scheduling Meeting when required.
Minutes of the
Minutes Prepared by- Nursing Superintendent
Meeting

department
15. QUALITY ASSURANCE COMMITTEE
General Objective To Ensure that the hospital has a high quality facility
The Management Committee ensures that everything the
Specific Objectives  Management committee members have ultimate responsibility
of directing the activities of the organisation, As well as
ensuring it is well run and delivering the outcomes for which
it has been set up.
 Management committee evaluates all the areas of the hospital
for further improvisation.
Members  DEPUTY MEDICAL SUPERINTENDENT
 HR MANAGER
 FINANCE MANAGER
Meeting Scheduling The committee members will meet every month. (Written by
Quality Department)
Minutes Of Meeting
department
16. SENTINEL EVENT COMMITTEE
General Objective To Ensure the Reporting, Documentation, Responsibilities Of all

Committees In the management
 The Management Committee ensures that everything the
Specific Objectives
 The organization complies with all applicable regulation
 They establish the fundamental values, the ethical principles and
strategic direction in which the organization operates.
 UNIT HEAD
 UNIT HEAD
Meeting Scheduling The committee members will meet Once in Six Months, Or every
month whenever necessary. (Written by Quality Department)

Minutes of the
Meeting
department
17. MEDICAL RECORDS COMMITTEE
Reporting to : Medical Superintendent.

General Objective To improving the quality of data of the patient.
Easy reference of patient data in one place.
Specific Objective  Improve the quality of completing the Data of the patient
 Co-ordinate all the data of the patient in one report.
 To Standardized the case record.
 LEGAL ADVISOR
 MRD INCHARGE
Credentials of the They hold senior and responsible position influencing the
Members decision-making and implementation and Manage in case of
disaster.
Meetings Scheduling Committee Members Meet at every Once in a month.As and when
required (depend upon the proposals submitted)

Minutes of the
Meeting
department
18. IMAGE ENHANCEMENT COMMITTEE

General Objective Evaluate the quality improvement activities.
Specific Objectives  To take the accountability and responsibility of the task assigned
to them and ensure timely completion as per set target dates.
 Identify and evaluate general areas of potential risk in all aspects

of patient care and safety via active involvement and
participation in hospital rounds pertaining to
facility/safety/quality etc.
 Coordinate Quality Initiatives of all the departments.
 Ensure monitoring and compliance of all the new processes

introduced routinely.
 To utilize a standard format for documenting and reporting all

quality measures hospital wide.
 To establish priorities for quality improvement activities.

 To take care of new processes and changes in the system required
for quality improvement
associated with it.
 Review the quality of care provided to patients

through the monitoring of indicators sentinel events and
performance of processes/system that are intradepartmental.
Members  MEDICAL SUPERINTENDENT

Meeting Scheduling The committee members will meet once in 4 month. (Written by
Quality Department)
Minutes Of Meeting Minutes Prepared by- Quality coordinator


department
19. DEATH REVIEW COMMITTEE MEETING
Reporting to : Medical Superintendent.

General Objective To identify the case of predominant causes for death
 UNIT HEAD
 UNIT HEAD
making and
Members
implementation and Manage in case of disaster.
Committee Members Meet as and when required (depend upon the

Meetings
proposals submitted)
Scheduling
Minutes (written) by- Quality co-ordinator
Proof read by – Quality co-ordinator

Minutes of the
Meeting
department

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HOSPITAL COMMITTEES

1. Quality Core Committee

Reporting to : Medical Superintendent

Minutes Of Minutes Prepared by- Quality coordinator

Archiving of MOM’s – All MOM are available with the Quality

2. ANTI SEXUAL HARASSMENT COMPLAINTS COMMITTEE

General Objective  Providing women protection against sexual harassment at the

Specific Objectives The Responsibilities of the Anti Sexual Harassment Complaints

 Recommend appropriate punitive action against the guilty party to

Archiving of MOM’s – All MOM are available with the Quality

Reporting to : Medical Superintendent

Reporting to : Medical Superintendent

The committee members will meet once in every four months or

Archiving of MOM’s – All MOM are available with the Quality

5. INFECTION CONTROL COMMITTEE

Reporting to : Medical Superintendent

General Objective  Preventing and reducing risk of healthcare associated infections.

Archiving of MOM’s – All MOM are available with the Infection

6. MANAGEMENT REVIEW COMMITTEE

Reporting to : Medical Superintendent

Proof read by - Medical Superintendent

Minutes of the Minutes Prepared by- Quality co ordinator

Archiving of MOM’s – All MOM are available with the Quality

7. MEDICAL AUDIT COMMITTEE

Reporting to : Medical Superintendent / Chairman

Minutes Prepared by- Quality coordinator

Archiving of MOM’s – All MOM are available with the Quality

8. EMPLOYEES GRIEVANCE REDRESSAL COMMITTEE

Reporting to : Medical Superintendent

9. PATIENT GRIEVANCE REDRESSAL COMMITTEE

Reporting to : Medical Superintendent

General Objective  Resolving grievances/complaints and concerns of patients or

Specific Objective  Develop and implement well-defined policies, procedures, and

Archiving of MOM’s – All MOM are available with the Quality

10. PHARMACOTHERAPEUTIC COMMITTEE

Reporting to : Medical Superintendent

 An Advisory role on the pharmaco-economic evaluations of

11. CARDIO-PULMONARY RESUSCITATION COMMITTEE

Reporting to : Medical Superintendent

 Post event analysis of all Cardiac Pulmonary Resuscitation in the

12. CAPITAL PURCHASE COMMITTEE

Reporting to : Medical Superintendent

Archiving of MOM’s – All MOM are available with the Quality

13. CONDEMNATION COMMITTEE

Reporting to : Medical Superintendent

Minutes Prepared by- Purchase manager

Archiving of MOM’s – All MOM are available with the Quality

Reporting to : Medical Superintendent

Archiving of MOM’s – All MOM are available with the Quality

15. QUALITY ASSURANCE COMMITTEE

Reporting to : Medical Superintendent

Reporting to : Medical Superintendent

General Objective To Ensure the Reporting, Documentation, Responsibilities Of all

Minutes Prepared by- Quality coordinator

Reporting to : Medical Superintendent.

Minutes Prepared by- Quality coordinator

Reporting to : Medical Superintendent

 Identify and evaluate general areas of potential risk in all aspects

 Coordinate Quality Initiatives of all the departments.