Committees


Committees

AN OVER VIEW

Lisie Hospital consists of 14 committees which meet on scheduled intervals. The committees are as follows:

  • Clinical Audit Committee
  • Code Blue Committee
  • Infection Control Committee
  • Pharmacy and Therapeutic Committee
  • Patient Safety Committee
  • Quality Improvement Committee
  • Purchase Committee
  • Ethics Committee
  • Facility Safety Committee
  • Management Review Committee
  • Medical Informatics/ Medical Audit Committee
  • Internal Compliance Committee
  • Employee Grievance hearing & disciplinary Committee
  • Grievance Hearing & Complaint Redressal Committee

CLINICAL AUDIT COMMITTEE

Purpose: The purpose of the clinical audit committee is to conduct clinical audits and to review Clinical indicators and take necessary actions.

MEMBERS
Dr. Babu Francis- Medical Superintendent Chairman
Dr. Sreevalsan T – HOD, Critical Care Medicine Convener
Fr. Paul Karedan- Director Member
Fr. Jery Njaliath- Asst. Director Member
Dr. Augustine- Deputy Medical Superintendent Member
Dr. T. K Joseph- HOD, General Medicine Member
Dr. Rajaram- HOD, Orthopeadics Member
Dr. Koshy George- HOD, Neuro Surgery Member
Dr. Dhanika Suresh- HOD, Emergency Medicine Member
Dr. Paramez- HOD, Pulmonology Member
Dr. Rony Mathew- HOD, Cardiology Member
Dr. Rohitha S Chandra- Clinical Microbiologist Member
Sr. Anslem- Nurse Administrator Member
Quality Assurance Team Member
Special invitees

CODE BLUE COMMITTEE

RESPONSIBILITIES
  • To organize and make better response to Code Blue calls
  • To study each Code Blue case on the following:
    • How to act
    • How to regulate the response and assign responsibilities to nurses & doctors
    • How to monitor & critique the response
    • Post Event analysis
  • The committee should keep a Survival statistics
  • Analyze risk issues and prevention of cardiac arrests in non-critical areas
  • Conduct Mock Drills for Code Blue
  • Organize ACLS & BLS training for staff.
  • Review necessary policies and protocols, algorithms etc related to Code Blue as per American Heart Association recommendation on Resuscitation Procedures.
MEMBERS
Dr. Dhanika Suresh- HOD, Emergency Medicine Convener
Fr. Paul Karedan- Director Member
Dr. Babu Francis- Medical Superintendent Member
Dr. Sreevalsan- HOD Critical Care Medicine Member
Dr. Augustine- Deputy Medical Superintendent Member
Dr. Rajeev K- HOD, Anesthesiology Member
Dr. Rony Mathew- HOD Cardiology Member
Dr. Paramez- HOD Pulmonary Medicine Member
Sr. Anslem- Nurse Administrator Member
Sr. Julia- Nursing Manager ICU complex Member
Representatives from code blue team Member
Quality team Member
Special invitees

EMPLOYEE GRIEVANCE HEARING AND DISCIPLINARY COMMITTEE

RESPONSIBILITIES
  • Analyzing and scrutinizing any complaints that are received from staff.
  • Maintain the confidentiality of the complaints.
  • Conduct enquiry based on the complaint obtained.
  • Discuss the issue with the concerned staff.
  • Recommend remedial measures to resolve the issue.
MEMBERS
Asst. Director- Concerned Department Chairman
Mr. Jose Cherian- Administrator, Operation and Control Convener
Respective Department HODs Member
Respective Department In charges Member
Special invitees

CREDENTIALING AND PRIVILEGING COMMITTEE

RESPONSIBILITIES
  • Develops a general outline regarding credentialing and privileging to be contained in the bylaws and presents it to the committee for approval.
  • Establish criteria for those privileges that are within the scope of the department.
  • Determine whether each applicant for privileges meets the established criteria.
  • Ensures that the credentials of applicants for Medical staff membership meet requirements.
  • Monitor the performance of department members with clinical privileges.
  • Reviews clinical privileges of the Medical staff members every year.
  • Delineates the specific privileges of Medical staff members.
  • Reviews and approves the qualifications and status of specified professional personnel, such as nurses and others, at least every year
  • Reviews the credential and consider clinical staff for higher positions and promotion.
DOCTORS PRIVELAGING COMMITTEE
Fr. Paul Karedan- Director Chairman
Dr. Babu Francis- Medical Superintendent Member
Dr. Augustine- Deputy Medical Superintendent Member
Respective Department HODs Member
NURSE’S PRIVILEGING COMMITTEE
Fr. Paul Karedan- Director Chairman
Sr. Anslem- Nurse Administrator Member
Nurse Manager- Concerned Department Member
Special Invitees

INFECTION CONTROL COMMITTEE

RESPONSIBILITIES
  • Monitors functional compliance with infection control policies and procedures.
  • Reviews the types of surveillance and reporting programs.
  • Develop standard criteria for reporting all types of infections.
  • Provides input into the Hospital Employee Health Programme.
  • Reviews department and Hospital – wide infection control policies and procedures every year and recommends revisions.
  • Evaluates and approves the applicability and appropriateness of all action(s) taken to prevent and control infections based on records and reports of infections and infection potential among patients and hospital personnel.
  • Report’s findings and recommendations to Management.
  • Follows-up to ensure compliance with recommendations made to eliminate hazardous situations.
  • Consults with other hospital staff as needed to implement an effective infection control program
MEMBERS
Dr. Rajaram- HOD, Orthopeadics Chairman
Dr. Rohitha S Chandra- Infection Control Officer Vice chair person
Fr. Paul Karedan-Director Member
Fr. Jery Njaliath- Asst. Director Member
Fr. Shanu Moonjely- Asst. Director Member
Dr. Babu Francis- Medical Superintendent Member
Dr. Augustine- Deputy Medical Superintendent Member
Dr. Amy D’Souza- HOD, OBG Member
Dr. Sreevalsan T V- HOD, Critical Care Medicine Member
Dr. Rajeev K- HOD, Anesthesiology Member
Sr. Anslem- Nurse Administrator Member
QSr. Julia- Nurse Manager Member
Sr. Tessy Ponnezath- Nurse Manager Member
Sr. Remya- Nurse Manager Member
MS. Priya Unnikrishnan- Quality Manager Member
Sr. Mini- CSSD Incharge Member
Sr. Mercy Puthenpurackal- Facility Manager Member
Ms. Tinty Baby- ICN Member
Ms. Greeshma Antony- ICN Member
Ms. Bindhu Paul- ICN Member
Ms. Manju Varghese- ICN Member
Special invitees

MEDICAL INFORMATICS COMMITTEE/ MEDICAL AUDIT COMMITTEE

RESPONSIBILITIES
  • Identifying and correcting the deficiencies in medical records.
  • Presenting the deficiency statistics and action taken.
  • Develop policies for Medical records & IT based on statutory requirements and National standards.
  • Develop a training program for personnel responsible for Hospital Information System, Electronic Medical Records, Intranet usage, record storage and maintenance.
  • Publish retention and disposal schedule that is in compliance with local laws and annually review the compliance and monitor laws affecting record retention.
  • Annually review the record retention and disposal schedules.
  • Develop protocols and policies governing electronic records including establishing requirements when specified paper records should be digitized.
  • Give due consideration to preservation of records of historic value.
  • Develop guidelines on destruction of records.
  • Implement all measures to maintain confidentiality in Lisie Hospital.
  • Develop new formats for patient care areas
MEMBERS
Fr. Jery Njaliath- Assistant Director Chairman
Ms. Joby V Joseph- Medical Records Officer Convener
Dr. Babu Francis- Medical Superintendent Member
Dr. Augustine Athapalli- Deputy Medical Superintendent Member
Dr. T K Joseph- HOD, General medicine Member
Dr. Rony Mathew Kadavil- HOD, Cardiology Member
Sr. Anslem- Nurse Administrator Member
Sr. Manju- In charge, Emergency Medicine Member
Mr. Jijo- IT Department Member
Mr. Eldho Kuriakose- PRO Member
Quality Assurance team Member
Special invitees

PHARMACY AND THERAPEUTIC COMMITTEE

RESPONSIBILITIES
  • The P & T committee is responsible for formulation of hospital policies pertaining to purchase of drugs & pharmaceuticals, pharmacy system and medication management.
  • All purchases made by this committee will be based on the purchase policy of the hospital.
  • Selection of approved manufacturers and suppliers.
  • Shall be responsible for the development of a hospital formulary of accepted drugs for use in the hospital.
  • Providing advice on matters pertaining to the choice of drugs to be stocked, or to be added or deleted from list of drugs accepted for use in the hospital.
  • Shall be responsible for all Clinical pharmacological practices.
  • Monitoring of drug related incidents like Adverse Drug Reactions, Antibiotic Sensitivity and Quality of Drugs etc.
  • Development of an effective drugs information system within the hospital; providing timely warnings / information to the users on news drugs, information on adverse reactions, drug warnings and details of banned drugs.
  • The committee is responsible for investigating any drug reactions and deciding on its final course of action.

Monitor overall functioning of the hospital pharmacy service

MEMBERS
Dr. T. K Joseph- HOD, General Medicine Chairman
Sr. Snehaja SD- Pharmacy Incharge Convener
Fr. Paul Karedan- Director Member
Fr. Jery Paul Njaliath- Asst. Director Member
Fr. Shanu Moonjely- Asst. Director Member
Dr. Rony Mathew- HOD,Cardiology Member
Dr. Jose Chacko Periyapuram- HOD,Cardio Thoracic Surgery Member
Dr. Augustine Athappilly – Dyp. Medical Supt Member
Dr. Jaisankar P- HOD, Oncology Member
Dr. Joy Mamippli- HOD, General Surgery Member
Dr. Babu Francis- Medical Supt, HOD-Nephrology Chairman
Dr. Damodaran Nambiar- HOD,Urology Convener
Dr. Suresh Paul- HOD, Orthopedics Member
Dr. Amy D’Souza- HOD, Gynecology Member
Dr. Soman Peter- HOD, Dermatology Member
Dr. Ajith Kumar K R- Consultant,Cardiology Member
Dr. Arun Kumar M L- HOD,Neurology Member
Dr. Tony Paul Mampilly- HOD, Pediatrics Member
Dr. Mathew Philip- HOD,Gastro Entrology Member
Dr. Parameez A R- HOD, Pulmonology Member
Dr. Sreevalsan T V- HOD, Critical Care Medicine Member
Dr. Rajeev K- HOD, Anesthesiology Member
Dr. Koshy George- HOD, Neuro Surgery Member
Dr. Rohitha S Chandra- Clinical Microbiologist Member
Dr. Dhanika Suresh- HOD,Emergency Medicine Member
Dr. Reena Varghese- HOD, ENT Member
Mr. Sabu George- DGM, Procurement & Logistics Member
Ms. Priya Unnikrishnan- Quality Manager Member
Ms. Anju Paul- Clinical Pharmacology Member

PURCHASE COMMITTEE

RESPONSIBILITIES
  • Managing and monitoring the purchase of the hospital.
  • Responsible for the selection, monitoring and rating of suppliers.
  • Annual purchase planning activity and preparing the purchase budget.
  • Ensure planning and implementation of inventory management practices. Conduct random stock audits of the stores and the department stocks.
  • Condemnation of unusable items.
  • The equipments / instrument / furniture for condemnation shall be certified by the Bio-medical engineer/Department Heads that the item is beyond repair / un-usable with proper stickers for condemnation & stored at the concerned units.
  • Notify all departments in advance and receive the list of items identified for condemnation.
  • Prepare a consolidated list of condemned items, a copy of the same to Purchase Committee for information.
  • The Purchase Committee shall sell the condemned items after approval from Purchase Committee Vice Chairman based on quotations. Items not suitable for scrap sales shall be suitably destroyed through incineration
MEMBERS
Fr. Paul Karedan- Director Chairman
Mr. Sabu George- Deputy General Manager , Procurement Convener
Fr Jery Njaliath- Assistant Director Member
Fr. Shanu Moonjely, Assistant Director Member
Fr. Joseph Makothakattu- Assistant Director Member
Mr. Paul Antony- Purchase Department Member
Mr. Venugopal- Administrator Member
Mr. Joji- Biomedical Engineer Member
Sr. Kochuthresia - Central Store Member
Sr. Anslem- Nurse Administrator Member
Quality Assurance team Member

QUALITY IMPROVEMENT COMMITTEE

RESPONSIBILITIES
  • Planning of the policies and protocols that guide the specific areas
  • Establish, monitor and review of quality objectives
  • Ensuring the availability of resources as required for the quality management systems
  • Conducting management reviews
  • Reviewing non-conformances related to services
  • Reviewing internal audit reports
  • Analysis of patient satisfaction data and complaints
  • Ensuring timely corrective and preventive actions
  • Ensuring continual improvement of the quality management system
MEMBERS
Fr. Jery Njaliath- Asst. Director Chairman
Ms. Priya Unnikrishnan – Manager Quality Assurance Convener
Fr. Paul Karedan- Director Member
Fr. Shanu Moonjely- Assistant Director Member
Dr. Babu Francis- Medical Supt, HOD- Nephrology Member
Dr. Dhanika Suresh- HOD, Emergency Medicine Member
Dr. Rajaram- HOD, Orthopedics Member
Dr. T K Joseph- HOD General Medicine Member
Mr Jose Sebastian- CFO Member
Dr. Rohitha.S. Chandra- Infection Control officer Member
Sr. Anslem- Nurse Administrator Member
Sr. Snehaja -Pharmacy In charge Chairman
Sr. Mercitta- Laboratory In Charge Convener
Ms. Prajothy- OT Coordinator Member
Mr. Sabu George- DGM, Purchase Member
Mr. Venugopal- Administrator Member
Mr. Jose Cherian- Administrator, Operations and Control Member
Mr. A R Lopez- Manager, Facility and Safety Member
Mr. Jose Jacob- Manager Security Member
Mr. Joji- Biomedical Engineer Member
Mr. Jijo- IT Manager Member
Ms. Joby V Joseph- MRO Member
Mr. Rajesh- Cardiology PRO Member
Quality Assurance Team Member
Special invitees

PATIENT SAFETY COMMITTEE

RESPONSIBILITIES
  • To implement the patient safety initiatives
  • To monitor and develop the patient safety initiatives
  • Discussion and action taken for patient safety events
  • Audit on patient safety
  • Risk assessment
MEMBERS
Fr. Paul Karedan- Director Chairman
Sr. Anslem- Nurse Administrator, Patient safety officer Convener
Fr. Joseph Makkothakat- Asst. Director Member
Fr. Jery Njaliath- Asst. Director Member
Fr. Shanu Moonjely- Asst. Director Member
Dr. Babu Francis- Medical Superintendent Member
Dr. Sreevalsan T V- HOD, Critical Care Medicine Member
Mr. Sabu George- DGM, Purchase Member
Sr. Remya MSJ- Nursing Manager Member
Sr. Julia- Nursing Manager Member
Sr. Tessy- Nursing Manager Member
Mr. A R Lopez- Facility and Safety Manager Member
MS. Priya Unnikrishnan- Quality Manager Member
Ms. Tinty Baby- Infection Control Supervisor Member
Sr. Mercitta – In-charge Laboratory Member
Clinical Pharmacology team Member

RESEARCH ETHICS COMMITTEE

RESPONSIBILITIES
  • To sort and screen all thesis protocols, thesis and scientific papers.
  • To identify the best papers that should be published or presented by any candidate.
  • Screening of all research activities.
  • Analyze all protocol violations/deviations reported.
MEMBERS
Dr. Paul Puthooran Chairperson
Dr. Amel Antony, Member - Clinician
Justice John K Mathew Member – Legal Person
Mr. Suresh Antony Member- Lay person
Dr. Sissy Thankachan Member- Basic Member Scientist
Rev Fr. Dr. Joseph Kaniyamparambil Member – Theologian
Dr. Jabir Abdulakutty Member - Clinician
Dr. P P Mohanan Member - Clinician
Dr. T. K Joseph Member - Clinician
Dr. USha Marath Member - Clinician
Dr. Babu Joseph Member
Dr. Laliamma Jose Member

SAFETY COMMITTEE

  • 1) All safety related reporting and data collections mechanisms shall be established and pursued like.
    • Incident Reporting
    • Facility Safety Surveillance
  • The hospital shall collect data and analyze it regarding the following aspects with a view to improve patient safety plan.
    • Staff perceptions and suggestions for improving patient safety
    • Staff willingness to report errors
    • Patient/family perceptions and suggestions for improving patient safety
  • The hospital may also focus on the improvement of the patient safety program through utilizing proactive risk reduction strategies like.
    • Identification, reporting, and management of sentinel events
    • Identification of high-risk processes
    • Failure mode, effects, and criticality analysis
  • Responsible for implementation of policies related to safety.
  • Undertake Facility rounds every month to identify and analyze potential patient safety issue & take necessary actions and submit the report to the Quality Improvement Committee.
  • Prepare Fire Plan, Fire Drawings, fire training and conduct 2 fire drills/ year.
  • 7Prepare Disaster Plan, Internal & external disaster drill annually.
MEMBERS
Fr. Shanu Moonjely- Asst. Director Chairman
Mr. Jose Jacob- Manager, Security Convener
Fr. Jery Njaliath- Asst. Director Member
Mr. Venugopal-Administrator Member
Sr. Anslem- Nursing Administrator Member
Sr. Mercy- Manager House keeping Member
Ms. Priya Unnikrishnan -Mgr. Quality. Assurance Member
Mr. MP Joseph-,Electrical In charge Member
Mr.AR Lopez- Manager Facility, Safety Member
Mr. Joji,- HOD Bio medical Eng. Member
Mr. KC Peter- Supervisor. H&H Member
Mr. Joseph- HVAC Dept Member
Mrs. Moly Wilson- HK Supervisor
Mr. Prince- In charge, Plumbing Dept Member
Mr. Sabu George- DGM, Purchase Member

PATIENT COMPLAINT REDRESSAL COMMITTEE

RESPONSIBILITIES
  • Review the patient complaints and feedback.
  • MSW department will submit a monthly report on patient complaints
  • Based on the nature of Grievances received appropriate steps will take with a view to minimize Grievances. evision of feedback form.
MEMBERS
Fr. Shanu Moonjely -Asst Director Chairman
Sr. Alphonsa-HOD, MSW Convener
Fr. Paul Karedan-Director Member
Fr. Jery Njaliath-Asst Director Member
Mr. Jose Sebastian -CFO Member
Mr. Anti Jose-H R Manager Member
Sr. AnslemMSJ-Nursing Administrator Member
Sr. Tessy Ponnezath -Nursing Manager Member
Sr. Remya MSJ-Nursing Manager Member
Sr. Julia-Nursing Manager Member
Sr. Tessy-OPD In charge Member
Mr. Lopez-Facility Manager Member
Sr. Mercy-Facility Manager Chairman
Mrs. Priya-Manager, Quality Assurance Convener
Mr. Peter-Health & Hygiene Supervisor Member
Sr. Mercitta -Lab Incharge Member
Mr. Sajeev-Public Relation Manager Member
Mr. Eldho Kuriakose-Public Relation Manager Member
Mr. Rajesh-Public Relation Manager Member
Mr. Joseph-Public Relation Manager Member
Mrs. Anitha-HOD, Dietetics Member
Mr. Joshy- -HOD, Billing Member
Mr. Jose Jacob--Security manager Member
Mr. Jijo-IT Manager Member
Mrs. Joby Joseph-Medical Record Officer Member
Dr. Anju -Clinical Pharmacist Member
Special invitees

INTERNAL COMPLIANCE COMMITTEE

RESPONSIBILITIES
  • To ensure gender equality in the organization.
  • To safe guard women employees at work place.
  • To investigate charges of sexual harassment at work place.
  • To take necessary measures, if any action relating to sexual harassment is noticed / reported
  • To ensure a safe working environment for all women employees.
MEMBERS
Sr. Anslem- Nurse Administrator Chairman
Sr. Remya- Nurse Manager Convener
Mrs. Usha Marath- Principal College of Nursing Member
Mr. Jose Cherian- Administrator, Operations and control Member
Adv. Xavier- Legal Representative Member

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