LIST OF COMMITTEES WITH THEIR ROLES AND

COMPOSITION
      
      1.       Quality Improvement Committee:
This committee takes responsibility of developing and periodically reviewing the organization
wide quality improvement programme. The committee generally works as an apex committee
for a hospital preparing for accreditation
Roles and responsibilities
         Develop and approve organization wide quality improvement programme, policies, manual and
activities
         Identify quality indicators for monitoring quality
         Recommend suitable benchmarks for indicators
         Review quality indicators performance periodically and take appropriate decisions for further
improvement
         Recommend best practices for implementation in hospital
         Review and identify accreditation requirements and make plans to address them
         Guiding departments in matters related to quality and accreditation
         Develop and monitor quality improvement activities across the organization
 Suggested members
   Chairperson – Someone from top management such as CEO, Vice president or director.
         Convener/Coordinator – Accreditation coordinator / Quality Officer or similar
  Other members – One representative each from medical specialities, surgical specialities,
Gynaecology and Obstetrics, Paediatrics, Super-specialities, Laboratory services, Blood Bank,
Imaging Services, General Management, HR management, Pharmacy services and Support
services

      2.       Infection Control Committee:

This committee bears the responsibility of infection control measures with an objective of
reducing the risk of HAI in the hospital. The committee discuss and decides on each matter that
can have an effect on infection control.
Roles and responsibilities
   Develop and approve organization wide infection control programme, policies, activities and
manual
      Establish standard precaution practices to be followed across the hospital
     Establish definitions and criteria for identifying and reporting of all infections among patients
and personnel
         Guide departments on evidence based infection control practices
     Set benchmark HAI rates for monitoring the effectiveness of infection control measures
         Validate methods for calculating HAI rates
         Review HAI rates periodically and recommend actions accordingly
         Develop antibiotic policy in conjunction with pharmaco-therapeutics committee
         Develop protocol for handling of infection outbreak and manage such situations
         Other similar matters related to infection control
Suggested members
         Chairperson – Someone from top management such as CEO, Vice president or director
         Convenor/Co-ordinator  – Infection Control Officer / Medical Microbiologist / Infectious
diseases specialist
         Clinical members – One representative each from all clinical specialities and super-
specialities, including Anaesthesiology, Critical Care, Emergency Medicine, Laboratory services,
Blood Bank, Nursing Services and Allied health specialities
         Non-clinical members – Person in-charge for administration of Operation theatre, ICU, IPD,
OPD, Emergency department, CSSD, Laundry, Bio-medical waste, Maintenance, Medical
Equipment and General Management

      3.       Pharmaco-therapeutics committee (Drugs

committee):
This committee deals with all matters pertaining to pharmacy, medicines and medical
consumable used in the hospital for patient care. There are many issues related to safety,
quality and ethics under use of drugs and this committee resolve those issues
Roles and responsibilities
         Develop and approve policies related to medication management
         Establish safe medication practices in the organization
         Develop and approve hospital formulary
         Issue guidelines for rational prescription of medication
       Develop mechanism for reporting and tracking of medication errors and adverse events
related to medication
         Review indicators related to medication safety and take necessary decisions
         Monitor medication practices through audits such as prescription audit, pharmacy audit etc.
         Help Infection Control Committee in formulating antibiotic policy
         Other similar matters related to medication management
 Suggested members
         Chairperson – A senior member such as HOD of medicine or vice-president or general
manager
         Convenor/Co-ordinator  – Chief pharmacist
         Clinical members – One representative each from all clinical specialities and super-
specialities,  Representatives from nursing department, OPD, IPD, ICU, OT and Emergency
         Non-clinical members – Purchase Manager, Pharmacy store in-charge

      
      4.       Safety Committee:
Safety committee bears the responsibility of ensuring safety of all across the organization.
Scope of this committee is wide and in larger hospital it can be further segregated into radiation
safety committee, lab safety committee and hospital safety committee. If there are multiple
committees working on safety issue, the interaction between these committees are very
important to ensure uniform policy making and actions. This can be achieved by having few
members common between these committees
Roles and responsibilities
         Develop and issue policies related to safety based upon best national and international safety
practice
         Monitor implementation of safety practices through appropriate indicators, audits and
feedbacks
         Oversee the development and implementation of various emergency codes such as code
blue, code pink, code red, code yellow etc.
         Investigate sentinel events and other safety related adverse events
         Issue guidelines related to safety pertaining to clinical and non-clinical activities
        Develop mechanism for reporting and tracking of safety related adverse events
Suggested members
         Chairperson – A senior member such as general manager
         Convenor/Co-ordinator – Safety manager
     Clinical members – Representatives from clinicians (specially surgery, medicine),
representatives from laboratory and radiology, radiation safety officer, representative from
nursing department, ICU in-charge and OT in-charge,
         Non-clinical members – Maintenance in-charge, security in-charge, representative from
general management, fire safety officer and any other relevant

      5.       Disaster and emergency preparedness

committee: 
     This committee has a specific role to develop a working plan on handling disaster situation. In
smaller hospitals, this can be merged with safety committee, but in larger hospitals it is
preferable to have a separate committee.
                Roles and responsibilities
      Identifying relevant disaster and emergency situations that may occur within hospital’s range and
prioritize them as per risk
         Formulate a plan for each identified disaster and emergency situation to be followed in case it
occurs
         Assess the level of preparedness of the hospital from time to time to meet all such identified
disaster situations
         Identify and recommend resources required to meet disaster and emergency situations
         Recommend modifications required in facility to address disasters
         Recommend training and mock drills required to be conducted for staff preparedness
         Conduct analyses and make improvements post-event
Suggested members:
Similar to that of safety committee. An expert in disaster management either from organization
or from outside should be added in the committee to provide technical expertise

        6.      Ethics committee:

Ethics committee plays an advisory role in all matters related to ethical dilemma. While research
ethics committee can be constituted as per ICMR guidelines and which undertakes approval
and monitoring of clinical researches, hospital ethics committee deals with unusual, complicated
ethical problems involving issues that affect the care and treatment of patient.
Roles and responsibilities
         Identifying issues and events in patient care that has an ethical concern
         Discuss all such events from ethical and patient care perspective
         Ensure that legal guidelines are met in all such issues
         Take most appropriate decision in all ethical issue
         To develop and issue ethical guidelines to healthcare staff and provide clarifications as and
when required
Suggested Members:
Members should be a mix of clinical and non-clinical people. Senior and experienced people
from the organization should be taken as member in this committee. It is advisable if one or two
members from outside of hospital can also be taken on board. The committee should be chaired
 by some-one from the senior most designation. HCO should try to find and include members
who have experience of dealing with ethical issues in patient care

      7.      Grievance redressal and disciplinary action

committee:
This committee presides over cases related to employee grievance and recommends
appropriate disciplinary actions to be taken. The committee plays an important role from Human
Resources management point of view and ensures that rights of the employees are
protected.
Roles and responsibilities
         To analyse in-depth all cases of employee grievance brought in committee
         To preside over the cases in most unbiased manner
         To take decisions on the basis of evidences and after listening to all concerned parties
         Ensure that disciplinary policy of the organization is followed
(In case the grievance is of nature of sexual harassment, it must handed over to Vaisakha
Committee for further process)
Suggested members
         Chairperson – A top management person
         Convenor / Co-ordinater – Head/Manager HR
         Other members – 5-6 members from different departments

     8.       Internal Complaints Committee (Vishakha

Committee) For prevention of sexual harassment at
workplaces
This committee is a legal requirement under ‘prevention of sexual harassment’ law. The
purpose of this committee is to investigate and take action against any complaint received which
has a nature of sexual harassment
Roles and responsibilities
         To receive complaints related to sexual harassment at workplace
         To investigate each and every complaint in light of evidence and following the principles of
natural justice
         To decide appropriate actions in each case, in accordance to the legal guidelines under the act
         To ensure that rights of complainant and complainee are protected
         To issue guidelines from time to time regarding prevention of sexual harassment
Members requirements
         Presiding officer – This should be a female employee of the organization working at a senior
level.
         Not less than 2 members from amongst employees who have experience in social work or have
good legal knowledge
         One member from NGO or association working for the cause of woman or an independent
person familiar with issues related to sexual harassment
         Other members as appointed by the organization
         Minimum 50% of the members of this committee shall be females
       9.       Clinical committee
This is a multi-purpose committee to deal with various types of clinical issues that requires a
decision based upon inputs from different fields. More than one clinical committee can be
 formed if the scope and range of work is large. There are a large number of issues that are
clinical in nature and requires a depth clinical discussion. Range of issues that can be taken up
in clinical committee are
         Developing a policy for credentialing and privileging of clinicians and whetting of credentials of
doctors and assigning clinical privileges
         Conducting medical/clinical audits and recommend measure of improvement
         Conducting clinical analysis of exceptional cases such as death, major medical errors etc.
         Development of clinical protocols that requires multi-speciality inputs
         Deciding measures to improve clinical capabilities amongst clinicians
         Advising on policy matters that have clinical aspects, such as antibiotic policy, infection
control policies etc.
         Providing clinical opinion to managers on making patient care better
Members
Clinical committee is composed of clinical members from all specialities of the organization with
one or two nursing and non-clinical members to provide supportive assistance
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