AN OVERVIEW

Lisie Hospital consists of 14 committees that meet at scheduled intervals. The committees are as follows:

• Clinical Audit Committee
• Code Blue Committee
• Infection Control Committee
• Pharmacy and Therapeutics 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.

CODE BLUE COMMITTEE

RESPONSIBILITIES

• To organize and make a 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.

EMPLOYEE GRIEVANCE HEARING AND DISCIPLINARY COMMITTEE

RESPONSIBILITIES

• Analyzing and scrutinizing any complaints that are received from the staff.
• Maintain the confidentiality of the complaints.
• Conduct inquiry based on the complaint obtained.
• Discuss the issue with the concerned staff.
• Recommend remedial measures to resolve the issue.

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/nursing/paramedical staff membership meet requirements.
• Monitor the performance of department members with clinical privileges.
• Reviews clinical privileges of the medical/nursing/paramedical staff members every year.
• Delineates the specific privileges of medical/nursing/paramedical 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 considers clinical staff for higher positions and promotion.

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 program.
• 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

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 systems, 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 the requirements when specified paper records should be digitized.
• Give due consideration to the preservation of records of historic value.
• Develop guidelines on the destruction of records.
• Implement all measures to maintain confidentiality in Lisie Hospital.
• Develop new formats for patient care areas

PHARMACY AND THERAPEUTICS COMMITTEE

RESPONSIBILITIES

• The P & T committee is responsible for the formulation of hospital policies pertaining to the purchase of drugs & pharmaceuticals, pharmacy systems, 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 the 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

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 equipment/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 the 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

QUALITY IMPROVEMENT COMMITTEE

RESPONSIBILITIES

• Planning of the policies and protocols that guide the specific areas
• Establish, monitor, and review 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

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

INSTITUTIONAL 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.

SAFETY COMMITTEE

• 1) All safety-related reporting and data collection mechanisms shall be established and pursued.
  • Incident Reporting
  • Facility Safety Surveillance
• The hospital shall collect data and analyze it regarding the following aspects with a view to improve the 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.
  • 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 issues & 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.

INTERNAL COMPLIANCE COMMITTEE

PATIENT COMPLAINT REDRESSAL COMMITTEE

RESPONSIBILITIES

• Patients’ complaints are accepted through a 24 hours active phone number held by a member of the top executive team. Other points of collecting patient, bystanders, and visitors feedback are offices of PROs, Complaint boxes placed in all the strategic locations, Complaint book held at ED PROs' office, and the patient feedback done by the hospital team.
• Before the committee meeting, a pre-committed meeting of the Chairman with PROs, MSW Head shall be held to consolidate recorded and tacit complaint data available that month. This consolidated data will be presented in the committee meeting.
• Based on the nature of grievances received appropriate steps will take with a view to minimizing grievances.

INTERNAL COMPLIANCE COMMITTEE

RESPONSIBILITIES

• To ensure gender equality in the organization.
• To safeguard women employees at the workplace.
• To investigate charges of sexual harassment at the workplace.
• To take necessary measures, if any action relating to sexual harassment is noticed/reported
• To ensure a safe working environment for all women employees.