Lisie Hospital consists of 16 committees that meet at scheduled intervals. The committees are as follows:
| Sl. No | Members | Designation | Role Responsibilities |
| 1 | Managing Director | Chairman | Reviews the function of QIC, provides funding to QIC and also actively participates in discussion and raise the pros and cons of each decisions. |
| 2 | Executive Director - LMC | Member | Participates in the discussion and gives the managerial view points on discussed matter. Ensure that the actions are implemented in their respective departments. |
| 3 | Executive Director - LCC | Convenor | Chairs the QIC meeting, Acts as a liaison between QIC members and the hospital administration. |
| 4 | Joint Director | Member | Participates in the discussion and gives the managerial view points on discussed matter. Ensure that the actions are implemented in their respective departments. |
| 5 | Medical Supt, HOD- Nephrology | Member | Participates in the discussion and gives the managerial view points on discussed matter. Ensure that the actions are implemented in their respective departments. |
| 6 | HOD, Emergency Medicine | Member | Schedule the QIC, Finalizes the agenda and the presentation and conveys the meeting. Finalizes the minutes. Ensure the proposed actions are implemented. |
| 7 | HOD, Anesthesia | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Propose the quality improvement activities in clinical care. Ensure proper CAPA taken on clinical care related issues discussed. |
| 8 | HOD, Critical Care Medicine | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for surgical care and operation theatre. |
| 9 | HOD - Radiology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for ICUs and critical care is implemented. Suggest and implemented quality improvement activities for the department. |
| 10 | Operations Head - LCC | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Emergency Medicine, CPR and mass casualty is implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 11 | Infection Control Officer | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant to infection control activities are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 12 | Chief Administrative Analyst | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for imaging protocols are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 13 | CFO | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure management support for all the quality improvement activities. Implement CAPA on the discussed points in departments which are under administration analysis. |
| 14 | Administrator | Member | Ensure proper funding for Quality Improvement Initiatives. |
| 15 | CNO & COO | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure management support for all the quality improvement activities. Implement CAPA on the discussed points in departments which are under administrator. |
| 16 | PR Manager - Cardiology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Nursing care and patient safety are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 17 | Manager Security | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Nursing care and patient safety are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 18 | Manager Biomedical Engineer | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for IT services are implemented. Suggest and implemented quality improvement activities for the department. |
| 19 | Manager, HR | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Security services are implemented. Suggest and implemented quality improvement activities for the department. |
| 20 | Chief Procurement Officer | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for IT services are implemented. Suggest and implemented quality improvement activities for the department. |
| 21 | Senior Manager IT | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Medical equipment services are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 22 | Medical Record Officer | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant to patient complaint handling, patient satisfaction, patient rights, communication etc are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 23 | Laboratory In Charge | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Human Resource department (HRM) are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 24 | OT Coordinator | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Medical record department (IMS) are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 25 | Pharmacy In-charge | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Procurement and logistics services are implemented. Suggest and implemented quality improvement activities for the department. |
| 26 | Facility, Fire and Safety | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Facility safety, Emergency codes & fire safety services are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 27 | IP Manager | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Pharmacy services are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 28 | RSO | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Laboratory services are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 29 | Quality Manager | Secretary | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for Operation theatre are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 30 | Senior Quality Officers & Assistant Quality Controllers | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards are implemented. Present QI of their department and ensure CAPA on NCs raised. Suggest and implemented quality improvement activities for the department. |
| 31 | Special invitees |
| Sl. No | Members | Designation | Role Responsibilities |
| 1 | Executive Director – Quality | Chairman | Chairs the Code Blue meeting, Acts as a liaison between Code Blue members and the hospital administration. |
| 2 | HOD, Emergency Medicine | Convener | Schedule the Code Blue committee, Finalizes the agenda and the presentation and conveys the meeting. Finalizes the minutes. Ensure the proposed actions are implemented and ensure documentation. |
| 3 | Managing Director | Member | Reviews the function of Code Blue Committee, provides funding to CBC and also actively participates in discussion and raise the pros and cons of each decision. |
| 4 | Executive Director | Member | Participates in the discussion and gives the managerial view points on discussed matter. Ensure that the actions are implemented in their respective departments. |
| 5 | Medical Superintendent, HOD- Nephrology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Propose the quality improvement activities in CPR. Ensure proper CAPA taken on CPR related issues discussed. |
| 6 | Deputy Medical Superintendent | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Propose the quality improvement activities in CPR. Ensure proper CAPA taken on CPR related issues discussed. |
| 7 | HOD Cardiology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 8 | Anesthesiology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 9 | HOD, Critical Care Medicine | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 10 | Consultant- Anesthesiology, LCC | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 11 | HOD- Pulmonary Medicine | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 12 | CNO & COO | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 13 | Nursing Managers | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 14 | Code Blue representatives Emergency Medicine & ICU Complex | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Ensure NABH standards relevant for the department is implemented. |
| 15 | Quality Assurance Team | Member | Helps the convener in scheduling committee. Conducts mock drills and collects report. Preparing minutes. Act as a liaison between the team members and employees to improve the effectiveness of CPR. |
| 16 | Special Invitees | To raise suggestions and concerns. |
| Sl. No | Members | Designation | Role Responsibilities |
| 1 | Managing Director | Member | Reviews the function of HICC, provides funding to HICC and also actively participates in discussion and raise the pros and cons of each decisions. |
| 2 | Executive Director – LMC | Member | Participates in the discussion and gives the managerial view points on discussed matter. Heading the implementation of purchase related decisions of HICC. |
| 3 | Executive Director – LCC | Member | Participates in the discussion and gives the managerial view points on discussed matter. Guiding the implementation of all the HICC decisions and also gives insights for the agendas. |
| 4 | Joint Director | Member | Participates in the discussion and gives the managerial view points on discussed matter. Heading all the IT related works of HICC. |
| 5 | Medical Superintendent & HOD (Nephrology) | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 6 | HOD, Anaesthesia | HICC Chairman | Chairs the HICC meeting, Acts as a liaison between HICC members and the hospital administration. Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 7 | Infection Control Officer | Convener, HICC | Schedule the HICC, Finalizes the agenda and the presentation and conveys the meeting. Finalizes the minutes. |
| 8 | Senior Consultant: Neurosurgery | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 9 | Consultant, Critical Care Medicine | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 10 | Senior Consultant Pulmonology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 11 | Consultant: Emergency Medicine | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 12 | Surgical Oncologist | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 13 | Consultant - Urology | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 14 | Consultant - Anesthesiology (LCC) | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. |
| 15 | CNO/COO | Member | Proposes agenda, participates actively in discussion and raise their view points on discussed matter. Raise the nursing implications on the discussed matter and also actively participates in the discussion. Aids in the implementation of nursing and the daily operations related decisions. |
| 16 | Nursing Managers | Member | Raise the nursing implications on the discussed matter and also actively participates in the discussion. |
| 17 | CSSD Incharge | Member | Address the CSSD related concerns of the other HICC members and also speaks on any new changes in CSSD. |
| 18 | Facility Manager | Member | Address the facility and housekeeping related concerns of the other HICC members and aids the HICC team in conducting trial of new housekeeping products. |
| 19 | Quality Assurance Manager | Member | Speaks on NABH standards on HICC, actively participate in discussion and raise her view points on discussed matter. |
| 20 | IPCN Supervisor | Secretary | Prepares the PPT, Organizes the meeting, Gives the clarification to the members on the data presented whenever it is requested, Prepares the minutes and distribute the minutes among the members. |
| 21 | IPCNs | Member | Suggests the agenda, Aids in organizing the meeting and also opine on various matters discussed. |
| 22 | Special Invitees |
| Sl.No. | Designation | Role in the committee | Responsibilities |
| 1 | Managing Director | Member | * Actively participate in the discussion regarding pharmacy-related activities. * Provide proper advice on updating Hospital formulary. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 2 | Executive Director- LMC | Member | * Actively participate in the discussions. * Get to know the drug-related incidents. |
| 3 | Executive Director- LCC | Member | * Actively participate in the discussions. * Get to know the drug-related incidents. |
| 4 | HOD Cardiology | Chairman | * Involve in the overall functioning of the committee. * Actively participate in the discussions. * Brief the agenda to the committee. * Decide the agenda of the next meeting. |
| 5 | HOD (General Medicine & Diabetology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 6 | HOD (Cardio-thoracic) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 7 | HOD (Sr. Consultant, GM) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 8 | HOD (Oncology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 9 | HOD (General Surgery) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 10 | HOD (Nephrology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 11 | HOD (Urology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 12 | HOD (Orthopedic) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 13 | HOD (Gynaecology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 14 | HOD (Dermatology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 15 | Cardiology | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 16 | HOD (Neurology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 17 | HOD (ENT) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 18 | HOD (Paediatrics) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 19 | HOD (Gastro-enterology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 20 | HOD (Gastro Endoscopy) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 21 | Senior Consultant Pulmonology | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 22 | HOD-CCM | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 23 | HOD (Anaesthesiology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 24 | HOD (Neuro surgeon) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 25 | HOD (Infection Control Officer, Microbiologist) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 26 | HOD (Cardiac Anaesthesiology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 27 | HOD (Dentistry) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 28 | Senior Consultant- Neurosurgery- LMC | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 29 | HOD (Pain & Palliative) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 30 | HOD (Interventional Radiology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 31 | HOD (Surgical Gastroenterology) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 32 | HOD (Emergency Medicine) | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 33 | Chief Procurement Officer(Procurement & Logistics) | Member | * Provide details of all matters related to procurement of drugs and surgicals. |
| 34 | COO, CNO | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 35 | Quality Manager | Member | * Participate in the discussion regarding quality-related matters. * Get to know the drug incidents like ADR, quality of drugs, etc. |
| 36 | Clinical Pharmacist | Member | * Present drug incidents like ADR, antibiotic sensitivity, etc. * Actively participate in the discussion regarding drug incidents. |
| 37 | Pharmacy Incharge | Secretary | * Responsible for conducting PTC. * Preparation of documents and slide shares related to new drug indent, EMR issues, etc. * Actively participate in the discussions related to pharmacy services, drugs and surgicals, etc. * Preparation and circulation of minutes. |
| 38 | Consultant – Endocrinology | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 39 | Consultant – Psychiatry | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 40 | Consultant – Clinical Pharmacologist, Medication Safety Officer | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 41 | Consultant – Emergency Medicine – LMC | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 42 | Consultant – Geriatric Medicine | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 43 | Consultant – Plastic Surgery | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 44 | Consultant – Rheumatology | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 45 | HOD- Physical Medicine & Rehabilitation | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| 46 | HOD- Ophthalmology | Member | * Participate in the discussion regarding new drug indents. * Get to know the drug-related incidents like ADR, quality of drugs, etc. |
| Sl. No | Designation | Role in the committee | Responsibilities |
| 1 | Managing Director | Member | Reviews the function of patient safety committee. Actively participates in discussion and raises the pros and cons of each decision. |
| 2 | Executive Director – LMC | Member | Participates in the discussion and gives the managerial viewpoints on discussed matter. |
| 3 | Executive Director – LCC | Member | Participates in the discussions and provides suggestions in quality improvement in patient safety matters. |
| 4 | CNO & COO Patient Safety Officer |
Chairperson | Chairs the patient safety meeting, proposes the meeting agenda, and acts as a liaison between the committee members and the hospital administration. |
| 5 | Joint Director | Member | Participates in the discussions and provides suggestions in quality improvement in patient safety matters. |
| 6 | Medical Superintendent | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. |
| 7 | HOD- Critical Care Medicine | Member | Actively participates in the discussion and raises his viewpoint on matters discussed. Formulates suggestions for patient safety improvement. |
| 8 | Manager Quality Assurance | Member | Speaks on NABH standards on patient safety practices and actively participates in discussion and raises her viewpoints on discussed matter. |
| 9 | Administrator | Member | Addresses the facility-related safety concerns of the other committee members and helps the patient safety team in conducting patient safety rounds. |
| 12 | Head of Operations – LCC & Consultant Clinical Pharmacologist | Member | Raises the concerns regarding patient safety aspects of Lisie Cancer Centre & medication safety. |
| 13 | Nurse Managers | Member | Raises the nursing implications on the discussed matter and also actively participates in the discussion. |
| 14 | Incharge – Laboratory | Member | Raises the concerns regarding patient safety in sample collection and reporting results and actively participates in the discussion. |
| 15 | Incharge- Pharmacy | Member | Raises the concerns regarding patient safety in medication intending and dispensing and actively participates in the discussion. |
| 16 | Infection Control Supervisor | Member | Raises concerns regarding infection control aspects of patient safety and actively participates in the matters discussed. |
| 17 | LIRRIS Incharge | Member | Raises concerns regarding radiology aspects of patient safety and actively participates in the matters discussed. |
| 18 | Clinical Pharmacist | Member | Prepares and presents medication safety-related issues and puts forward suggestions on matters regarding medication safety. Actively participates in medication safety-related endeavors. |
| 19 | Senior Quality Officers & Assistant Quality Controllers | Members | Initiates, coordinates & actively participates in discussions, raises suggestions & follows up on recommendations taken. |
| 20 | Special invitees |
| Sl.No. | Designation | Role in the committee | Responsibilities |
| 1 | Managing Director | Chairman | * Actively participate in the discussion regarding purchase-related activities. * Ensures the committee adheres to its objectives and timelines. * To approve the final purchase request and issue necessary amendments. |
| 2 | Executive Director- LMC | Convenor | * Participate in the discussion regarding new requests raised from concerned departments. * Briefing the agenda to the committee. * Handles the procurement process, ensures compliance with procurement policies and regulations, and manages vendor relations. * Deciding the agenda of the next meeting. |
| 3 | Executive Director- LCC | Member | * Participate in the discussion regarding new requests raised from concerned departments. * Briefing the agenda to the committee. * Handles the procurement process, ensures compliance with procurement policies and regulations, and manages vendor relations. |
| 4 | Chief Financial Officer | Member | * Involve in the overall functioning of the committee. * Provides financial oversight, ensures budget compliance, and evaluates financial implications of purchases. |
| 5 | Chief procurement officer | Secretary | * Record the meeting records. * Documenting minutes of meeting, recording discussions, decisions, action items and responsibilities assigned to members. * Communicates decisions and action points to relevant stakeholders within the organization. * Ensures that action items agreed upon in meetings are followed through and completed within specified timelines. |
| 6 | Manager Biomedical Engineering | Member | * Participate in the discussion regarding new biomedical equipment. * Provides technical input, evaluates technical specifications and ensures compatibility with existing system or infrastructure. |
| 7 | Senior IT Manager | Member | * Participate in the discussion regarding new IT requirements to be purchased in the hospital. * Provides technical input, evaluates technical specifications and ensures compatibility with existing system or infrastructure. |
| 8 | Electrical Incharge | Member | * Participate in the discussion regarding new electrical requirements to be purchased in the hospital. * Provides technical input, evaluates technical specifications and ensures compatibility with existing system or infrastructure. |
| SL. NO. | MEMBER | ROLE |
| 1. | Dr. P Mohanan | Chairperson |
| 2. | Dr. Amel Antony | Member Secretary |
| 3. | Adv. Mohammed Sadique T. A. | Legal Person |
| 4. | Dr. Sissy Thankachan | Basic Medical Scientist |
| 5. | Dr. Susan Mani | Basic Medical Scientist |
| 6. | Rev. Fr. Dr. Joseph Kaniamparambil | Theologian |
| 7. | Dr. Jabir Abdullakutty | Clinician |
| 8. | Dr. Manu Raj | Clinician |
| 9. | Dr. Prakash Zacharias | Clinician |
| 10. | Dr. Babu Joseph | Member |
| 11. | Prof. (Dr.) Vani Kesari | Member |
| 12. | Mrs. Limi Rose Tom | Lay Person |
| Sl. No | Designation | Role | Responsibility |
| 1 | Asst. Director, Chairman of the Committee | Chairman | Chair the safety committee meeting. Acts as liaison between Facility Safety members and the Hospital administration. |
| 2 | Fire Safety Officer, Secretary of the Committee | Secretary | Note down the procedures and minutes in the meeting, finalize minutes and make report of the meeting. Ensure decisions are implemented. |
| 3 | Administrator, Convener of the Committee | Convener | Convener of the meeting. Schedule the safety committee meetings, finalize the agenda and presentation and convey the meeting to the members. Participate in the meeting and give the managerial viewpoints on the discussed matter. Ensure the actions are implemented in their respective departments. |
| 4 | Joint Director, Member | Member | Participate in the meeting and give the managerial viewpoints on the discussed matter. Ensure the actions are implemented in their respective departments. |
| 5 | Asst. Director, Construction Co-ordinator | Member | Participate in the discussions and give the managerial viewpoints, especially issues connected with buildings and main structure. |
| 6 | COO & Chief Nursing Officer | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 7 | Manager Facility, House Keeping | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 8 | Lab In Charge | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 9 | Manager Security | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 10 | Manager, Purchase & Logistics | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 11 | HOD Biomedical Engineer | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 12 | Manager IT (HW) | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 13 | Manager IT (SW) | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 14 | Manager Quality Assurance | Member | Helps the Convener in scheduling committee meetings, mock drills, and collection of reports. Liaison between the team members and their respective section and monitor for adherence to laid down NABH standards. |
| 15 | Supervisor General Maintenance | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 16 | Electrical In Charge | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 17 | HOD Plumbing | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 18 | Infection Control Supervisor | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 19 | Engineer Maintenance | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| 20 | Site Engineer (Civil) | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. Ensure NABH standards relevant for the department are implemented. |
| Sl.No | Designation | Roles | Responsibilities |
| 1 | Managing Director | Chairman | Chairs the Management Review Meetings. Approves the day-to-day functioning activities of the hospital, assigns roles for carrying forward activities, approves minutes of the committee and presents plans before the board. |
| 2 | Executive Director – LMC | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Presents purchase-related details before the committee and performance-related activities. |
| 3 | Executive Director – LCC | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Presents purchase-related details before the committee and performance-related activities. |
| 4 | Joint Director | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Organizes the committee and prepares minutes and gets approval from chairman. |
| 5 | Medical Superintendent | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Ensures quality health care services. Suggests good clinical practices. |
| 6 | Administrator- Operations & Control | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. |
| 7 | Administrator | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Ensures construction-related activities are. |
| 8 | CFO | Member | Ensures proper funding for hospital functioning. |
| 9 | CNO & COO | Member | Proposes agenda, participates actively in discussion and gives their viewpoints on discussed matter. Ensures quality nursing services. |
| Sl.No | Designation | Role in the committee | Responsibilities |
| 1 | Managing Director | Member | *Reviews the function of MRC, and also actively participates in discussion and raises the pros and cons of each decision. |
| 2 | Executive Director- LCC | Chairman | *Chairs the medical record committee meeting, acts as a liaison between MRC members and the hospital administration. |
| 3 | Joint Director | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation. |
| 4 | Medical Records Officer | Convener | Schedule the MRC, finalizes the agenda and the presentation and conveys the meeting. Finalizes the minutes. Ensures the proposed actions are implemented. Evaluate and monitor Medical Record Documentation. |
| 5 | Deputy Medical Superintendent | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation. |
| 6 | HOD - Cardiology | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 7 | HOD- General Medicine | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 8 | HOD - General Surgery | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 9 | HOD - Anaesthesiology | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 10 | HOD - Emergency Medicine | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 11 | HOD - Critical Care Medicine | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 12 | HOD - Pulmonary Medicine | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 13 | HOD - Orthopaedics | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 14 | HOD- Gastroenterology | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 15 | HOD - Urology Department | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 16 | COO, CNO | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 17 | Senior IT Manager | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 18 | Quality Manager | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 19 | HOD - Clinical Pharmacologist | Member | Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 20 | OP Manager | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 21 | IP Manager | Member | *Proposes agenda, participates actively in discussion and raises their viewpoints on discussed matter. To oversee, evaluate and monitor Medical Record Documentation in their respective department. |
| 22 | Special invitee |
| Sl. No | Name | Designation | Responsibility |
| 1 | Ms. Usha Marath, Chairman | Principal, Lisie College of Nursing, Chairman | Chairs the meeting, acts as a liaison between members & the hospital administration. |
| 2 | Ms. Icy Joseph, Member | COO/CNO, Member | Convening of meeting of committee as per Chairman’s direction. |
| 3 | Ms. Josephina P X, Member | Secretary to Director, Member | Brief the Committee about the details of complaints received from various departments/employees. |
| 4 | Adv. A.V Xavier, Member | Advocate, Member | Explaining the legal implications and procedure to be followed as per the Supreme Court decision in Vishaka Vs. State of Rajasthan. |
| 5 | Mr. Jose Cherian, Administrator (Operations & Control), Member | Administrator, Member | Preparation of minutes and initiating CAPA. |
| Sl No | Member | Role | Responsibility |
| 1 | Concern Director | Chairman | Chairs the meeting, acts as a liaison between member, concerned department In Charge and hospital administration. |
| 2 | Administrator (Operations & Control) | Member | Convening of meeting of committee as per Chairman’s direction. Preparation of minutes and initiating CAPA. |
| 3 | Manager HR | Member | Brief the Committee about the details of grievances received from various departments/employees. |
The committee will be conducted as and when required. The minimum quorum will be all the role specified committee members.
| Sl No | Name | Designation | Role |
| 1 | Concern Executive / Joint Director, Chairman | Chairman | Chairs the meeting, acts as a liaison between member, concerned department Incharge and hospital administration. |
| 2 | Administrator-(Operations & Control) | Member | Convening of meeting of committee as per Chairman’s direction. Preparation of minutes and initiating CAPA. |
| 3 | HOD/Incharge (of Concerned Dept.) | Member | Brief the Committee about the details of incident, complainant, delinquent etc. |
| Sl.No | Member | Role | Responsibility |
| 1 | Managing Director | Chairman | Get to know the current functioning of various departments, their issues, patient satisfaction level and find suitable solutions for the current issues. |
| 2 | Executive Director – LMC | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 3 | Executive Director – LCC | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 4 | Joint Director | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 5 | Chief Administrative Analyst | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 6 | Administrator | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 7 | Operations Officer – LCC | Member | Get to know the current functioning of various departments, their issues and patient satisfaction level. |
| 8 | CNO & COO | Member | To understand issues in nursing service and operations and to find suitable solutions for the current issues. |
| 9 | CFO | Member | To understand overall functioning of the various finance departments and provide suggestions to solve any sort of issues. |
| 10 | HR Manager | Member | To know the overall function of the human resources department in the hospital and their management, etc. |
| 11 | Quality Assurance Manager | Member | Overall analysis and performance level of various departments in accordance with NABH standards. |
| 12 | Nursing Managers | Member | To know the functioning of various departments and issues in wards. |
| 15 | IP Manager | Member | To know the functioning of IP department. |
| 16 | OP Manager | Member | To know the functioning of OP department. |
| 17 | OP Incharge | Member | To know the functioning of OP department. |
| 18 | Security Manager | Member | To understand security-related issues, performance and ward boys service. |
| 19 | Facility Incharge | Member | To know the basic facility-related issues and cleaning service. |
| 20 | Insurance Manager | Member | To understand issues in insurance services. |
| 21 | HOD Radiology | Member | To understand issues in radiology services. |
| 22 | HOD Physiotherapy | Member | To understand issues in physiotherapy services. |
| 23 | Incharge – Dietetics | Member | To understand canteen-related issues. |
| 24 | Manager - Billing | Member | To understand bill-related issues. |
| 25 | Senior Manager - IT Department | Member | To understand issues in hospital software and hardware management. |
| 26 | Laboratory Incharge | Member | To understand issues in laboratory-related services. |
| 27 | Incharge Admission Desk | Member | To understand issues in admission-related services. |
| 28 | Incharge – Registration Counter | Member | To understand issues related to registration. |
| 29 | Incharge – Pharmacy | Member | To understand issues in pharmacy service. |
| 30 | Incharge- Cardiology OPD | Member | To understand issues in cardiology OPD. |
| 32 | Medical Records Officer | Member | To understand issues in patient record and information management. |
| 33 | Incharge, Registration Counter | Member | To know the issues related to registration department. |
| 34 | Facility Manager | Member | To know about issues related to facility. |
| 35 | Maintenance Incharge | Member | To know about the issues related to maintenance department. |
| 36 | Incharge, IT Hardware | Member | To know about the issues related to IT hardware department. |
| 37 | HVAC Incharge | Member | To understand issues in HVAC services. |
| 38 | Incharge, Electrical Department | Member | To understand issues in electrical department. |
| 39 | Incharge Canteen | Member | To understand issues in OPD management. |
| 40 | Marketing Manager | Member | To understand issues in IP addressal. |
| DOCTORS PRIVELAGING COMMITTEE | |||
| Sl. No | Member | Role | Responsibilities |
| 1 | Managing Director | Chairman | Reviews the function of credentialing and privileging committee and chairs the committee meeting. Actively participates in discussion and raise the pros and cons of each decisions. |
| 2 | Medical Superintendent | Convener | Coordinates the credential and privileging committee meeting, Proposes the meeting Agenda, and finalises the minutes Acts as a liaison between the committee members and the hospital administration. |
| 3 | Respective Department HODs | Member | Proposes the agenda, participate actively in discussion and raise their view points on discussed matter |
| 4 | Director's Secretary/ HR | Member | Prepares the agenda, Prepare the meeting circular and distribute among the members, prepares the minutes and distributes among the members. Prepares and update the privileging tool and competency mapping tool as per the committee decision |
| NURSES PRIVELAGING COMMITTEE | |||
| Sl. No | Member | Role in the committee | Responsibilities |
| 1 | Director | Chairman | Reviews the function of credentialing and privileging committee and chairs the committee meeting. Actively participates in discussion and raise the pros and cons of each decisions |
| 2 | CNO, COO | Secretary | Coordinates the credential and privileging committee meeting, Proposes the meeting Agenda, and finalises the minutes Acts as a liaison between the committee members and the hospital administration |
| 3 | Assistant Quality Controller (N) | Member | Prepares the agenda, Prepare the meeting circular and distribute among the members, prepares the minutes and distributes among the members. Prepares and update the privileging tool and competency mapping tool |
| 4 | Nurse Managers | Member | Proposes the agenda, participate actively in discussion and raise their view points on discussed matter |
| PARAMEDICAL PRIVILEGING COMMITTEE | |||
| Sl. No | Member | Role in the committee | Responsibilities |
| 1 | Concern Director | Chairman |
|
| 2 | Respective Department HOD's | Member | Proposes the agenda, participate actively in discussion and raise their view points on discussed matter |
| 3 | HR Team Member | Member | Prepares the agenda, Prepare the meeting circular and distribute among the members, prepares the minutes and distributes among the members. Prepares and update the privileging tool and competency mapping tool as per the committee decision |
| Sl.No. | Member | Role in the committee | Responsibilities |
| 1 | Managing Director | Member |
|
| 2 | Executive Director - LCC | Member |
|
| 3 | Consultant - Nephrology | Chairman |
|
| 4 | HOD - Anaesthesia | Member |
|
| 5 | HOD - Gastroenterology | Member |
|
| 6 | Senior Consultant - Medical Gastroenterology | Member |
|
| 7 | Infection Control Officer | Convener |
|
| 8 | Clinical Pharmacist - AMS | Secretary |
|
| 9 | Clinical Pharmacist | Member |
|
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