Role of NABH Committee:

01. The NABH (National Accreditation Board for Hospitals and Healthcare Providers) Committee plays a critical role in setting standards for healthcare organizations in Hospital. It evaluates hospitals and healthcare providers for quality, safety, and patient care through accreditation. The committee works to ensure that healthcare facilities meet national and international standards. It also continuously reviews and updates these standards to improve healthcare quality.
02. It conducts Management Review Meetings related to Responsibilities of Management issues.
03. The core committee also Monitor and measure the performance of the health care services based on Internal Audits and feedbacks received from the Quality Assurance and other NABH committees.
04. Approve policy actions including preventive and corrective action recommended by the committees and submitted during Management Review Meetings.

Role of Safety Committee:

01. Review of Security of staff, patients and material.
02. Incident Reporting.
03. Plan for fire and non-fire emergencies within the facility.
04. Review of Safety program.
05. Accident reporting for Biomedical waste.
06. Risk Management issues and corrective action.
07. Training on safety aspects (First Aid/Firefighting).
08. Inspection rounds for patient safety devices Hazard Identification and analysis.
09. Prevention and Breakdown maintenance of infrastructure and equipment’s.
10. Review of Radiation safety program.
11. Review of Laboratory safety program.
12. Review of Sentinel event (Sentinel event is an unexpected incident related to system process deficiencies which may lead to death or Loss of function for recipient of health care service).

Role of Blood Transfusion Committee:

01. The Blood Transfusion Committee (BTC) is responsible for ensuring the safe, appropriate, and effective use of blood and blood products in healthcare settings.
02. It develops policies and guidelines, monitors blood usage, and promotes awareness and education about blood safety.
03. The BTC also ensures compliance with regulatory standards and works to maintain a sufficient and safe blood supply.
04. It collaborates with clinical staff to optimize patient care and minimize risks related to blood transfusions.

Role of Employee grievance committee:

01. All grievances of employees will be registered with HR Department who will ensure that prompt action is taken to settle the matter.
02. By Grievance not resolved by HOD Dept / HR Department related with employees and delays in decision making by concerned authority will be presented to the Grievance committee for redressal.
03. Recommendation of the Grievance committee will be submitted to the Core Committee for Approval.

Role of Cardio Pulmonary Resuscitation committee:

01. To study quality of CPR in patients who suffered cardiac arrest in hospital or emergency.
02. To give feedback on queries raised.
03. Analysis about quality of CPR events.
04. Prevent sudden cardiac death by early access action by Code Blue team, early CPR, restoring circulation.
05. To conduct training on CPR.

Role of Infection Control Committee:

01. To review the Infection Control activities and evaluate points submitted by Infection Control Team.
02. Review of Sterilization and Disinfection.
03. Organizing of Training Programs on Infection Control Procedures.
04. Disposal of BMW.
05. To submit minutes of meetings with recommendations on control of HAI.

Role of Quality Improvement Committee:

01. The Hospital has a multidisciplinary Quality Improvement Committee who is responsible to develop implement and maintain the Quality Improvement Program focused on Quality Improvement which is to provide confidence that quality requirements will be fulfilled the various hospital services are represented by clinician representatives who will present their quality improvement program.
02. Assuring that the review functions outlined in the QI program are completed.
03. Prioritizing issues referred to the QI Committee for review.
04. Assuring that the data obtained through QI activities are analyzed, recommendations made, with appropriate follow up and problem resolution.
05. Reporting on Quality Key Indicator findings, studies and submitting recommendations and trends to the core committee quarterly.
06. Identifying educational needs and assuring that staff education for quality improvement takes place.
07. Review of Clinical Audit reports submitted by the clinical audit subcommittees, assuring that the necessary resources are available for clinical Audits and QI Programs.
08. The committee meets every month, date and time to be decided by chairperson. Minutes of meeting are forwarded to the core committee and top management for information and circulated to all concerned for corrective action.

Role of the Pharmaco Vigilance Committee:

01. To guide the formulation and implementation of policies and procedures for Pharmacy services and medication usage
02. To guide and implement Policies and procedures related to Management of Medication and Pharmacy services.
03. To guide developing and updating the Hospital Formulary.
04. Audit of medication orders and prescriptions.
05. Monitoring and analysing Prescription writing and Medication Errors. 06. Monitoring and analysing adverse drug reactions.
07. Monitoring of medication charts with error prone abbreviations, illegible handwriting, look alike sound alike drugs.
08. Monitoring High risk medications and adverse outcomes thereof.
09. Monitoring quality key indicators for Pharmacy / Central Stores.
10. The Committee will meet once in three months, and submit minutes of meeting and recommendations for corrective and preventive action to the Core Committee.

Role of Medical Record Committee:

01. To conduct Medical Audit of patient care. Audit will cover administrative and technical aspects of OPD/IPD services.
02. Administrative aspects to include delays in initiating treatment, length of hospitalization, cost of treatment and administrative lapses in support services.
03. The technical aspects to include time for initial assessments, time for initiating treatment, quality of treatment, quality of nursing care, post-operative infection, progress report documentation, discharge/ death summary, quality of documentation.
04. Review of records, medical documentation, missing records etc.
05. Data will be provided by Record section and computer cell. 06. Root Cause analysis and remedial measures will be presented to core committee and discussed during quality committee meeting with the end to effect change for the better.
07. The Medical Audit committee will meet a month and submit report and recommendation for corrective action to Core Committee.

Role of Internal Complaint committee:

01. All grievances of employees will be registered with HR Dept who will ensure that prompt action is taken to settle the matter.
02. Grievance not resolved by HOD Dept / HR Department concerning majority of employees and delays in decision making by concerned authority will be presented to the Grievance committee for redressal.
03. Recommendation of the Grievance committee will be submitted to the Core Committee for Approval.

Role of Disaster Management Committee:

01. The team will assist the Command Nucleus in case of Disaster with mass casualties and is responsible for information, communication and action plan.
02. The committee will oversee the Disaster Management plan with essential elements of Alert code, Information and communication. Action cards for staff, availability and earmarking of resources, Training of hospital staff and conduct of mock drills.
03. The plan will be reviewed and recommendation for continuous improvement and communicated to core committee and all concerned.

Role of O.T. Management committee:

01. Policy Oversight: Develops and updates OT service policies and procedures.
02. Resource Management: Allocates budget, equipment, and staffing for OT services.
03. Quality Assurance: Monitors service quality and patient outcomes.
04. Staff Support: Oversees professional development and training for OT staff.

Role of Credentialing and Privileging Committee:

01. Ensures healthcare professionals meet required qualifications and standards.
02. It reviews qualifications, certifications, and work history to verify competence.
03. The committee grants or denies clinical privileges based on expertise and scope of practice.
04. It also monitors ongoing professional performance and compliance with standards..

Role of Clinical Audit Committee:

01. To conduct Medical Audit of patient care. Audit will cover administrative and technical aspects of OPD/IPD services.
02. Administrative aspects to include delays in initiating treatment, length of hospitalization, cost of treatment and administrative lapses in support services.
03. The technical aspects to include time for initial assessments, time for initiating treatment, quality of treatment, quality of nursing care, post-operative infection, progress report documentation, discharge/ death summary, quality of documentation.
04. Review of records, medical documentation, missing records etc.
05. Data will be provided by Record section and Computer cell.
06. Root Cause analysis and remedial measures will be presented to core committee and discussed during quality committee meeting with the end to effect change for the better.
07. The Medical Audit committee will meet once a month and submit report and recommendation for corrective action to Core Committee.

Role of Condemnation Committee for Biomedical Equipment :

01. The Condemnation Committee for Biomedical Equipment is responsible for evaluating and determining the condition of biomedical equipment that is outdated, damaged, or beyond repair.
02. It ensures proper disposal or decommissioning of such equipment in accordance with safety, regulatory, and environmental standards.
03. The committee also ensures that replacements are recommended when necessary to maintain healthcare facility operations.
04. Its goal is to safeguard patient safety and ensure the availability of functional medical devices.

Role of Radiation Safety Committee:

01. The Radiation Safety Committee is responsible for overseeing the safe use of radiation in medical and research settings.
02. It ensures compliance with safety regulations, monitors radiation exposure levels, and implements protocols to protect staff, patients, and the environment.
03. The committee also reviews and approves radiation-related procedures and equipment.
04. Its primary goal is to minimize risks associated with radiation and ensure safe practices across the organization.

Role of Institutional Ethical Committee:

01. As per the guidelines of medical council of India, Ethics Committee is constituted at this institution to ensure the protection of the right, safety and well-being of human subjects involved in research projects and to provide public assurance of that protection.
02. The Committee consists of above office bearers.
03. All research activities and thesis projects will be presented for approval and review follow up by the Ethics Committee including monitoring of quality key indicators for research activities conducted.

Role of Bio Medical Waste Management Committee:

01. A Biomedical Waste Management committee organizes training for staff on Biomedical Waste practices including how to segregate waste and its pre-treatment, wear a face mask and use 3 bucket trolly system.
02. The committee continuously monitors Biomedical waste practices.
03. The committee ensures safety of healthcare workers who handle Biomedical waste.

Role of Billing Tariff Committee:

01. Billing tariff committee role is to maintain transparency in billing.
02. To make the tariff list available.