HOSPITAL COMMITTEES

Hospital committees and teams plays an important role in management and decision
making in hospital. While, hospitals are organized into departments with each
department, for something as complex as healthcare, there are many issues which cut
across the responsibilities of more than one department. These issues require people in
different roles and with different expertise, to collectively take appropriate decisions and
actions. Committees and teams are formed for this purpose and depending upon the
type of issues to be dealt with different committees and teams are formed. NABH
standards indicates several types of committees and teams to be functioning in a
hospital and this post lists and explains the same.
To functionally differentiate between a committee and a team, we must understand that
a committee is a group of people (often with varied expertise and roles), who together
discuss and debate on an agenda to arrive at a consensus opinion regarding which
forms the basis for planning and decision making. Teams on the other hand is a group
of people who plays a role in implementing those functions and decisions, that cut
across multiple departments and are often difficult to implement.
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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
 5
6

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
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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 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

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 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)

MEMBERS:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
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 complainer are protected
 To issue guidelines from time to time regarding prevention of sexual harassment

MEMBERS:

SL. MEMBERS DESIGNATION

NO
.
1 Dr. Hemlata Bharti Director cum Committee Head
2 Mr. Sanjay Tiwary CAO
3 Mr. Vishal Dinkar GM
4 Ms. Tanisha K Singh HR cumm QAM
5 Ms. Sweta Kumari Lawyer (Jharkhand High Court)
6 Ms. Mercy Smita Lugun Nursing Superintendent
 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:

SL. MEMBERS DESIGNATION

NO.
1
2
3
4
5
6
 LIST OF TEAMS
1. Quality Improvement team – This team is formed of accreditation /
quality manager (as team leader) and 2-4 executives from quality and
operations department. The role of this team is to implement quality related
policies and practices across the organization. Specific work under this team
includes.

 Communicate policies and procedures related to quality with departments

 Monitor the compliance with quality plans

 Collect and analyse data for calculating quality indicators

 Conduct on the job training of staff related to quality improvement

initiatives

 Conduct or help in inter-departmental quality audits

2. Infection Control team – Infection control team work under the

leadership of infection control officer with infection control nurses being the
part of it. The team works to implement infection control practices across the
hospital and improve the compliance level. Specific tasks performed by the
team includes

 Implement Standard Precaution and other infection control policies and

practices
 Infection control surveillance

 Monitoring of infection control practices compliance

 Training and orientation on infection control practices

 Review the implementation of various infection control policies such

as antibiotic policy, sterilization policies etc.

 Acquire data and calculate various HAI rates

 3. Safety Team – This team consist of safety manager (team leader)
along with 2-3 executives from operations or quality. The team is responsible
for implementing patient safety and other safety practices across the hospital.
Specific tasks include

 Conducting facility safety inspection round

 Monitoring compliance to safety practices

 Conducting mock drills for safety

 On the job training and orientation on safety matters

 Liaisoning with management to provide necessary safety resources

4. Firefighting team – This team consist of 4-8 people from security and
maintenance. One of the supervisors can be the team leader. Every member
of the team is trained in firefighting. The team takes control of any fire
situation in the hospital, till the time fire is under control or external help is
arrived

5. Code blue team – This team handles any medical emergency

situation arising anywhere in the hospital. For details of members and roles
please read this post on code blue system in hospital

6. Hazardous materials team (HazMat team) – This a is a team made of

3-4 housekeeping staff who are trained in handling large spills of hazardous
materials such as blood, mercury etc. If any large spills happens any-where in
the hospital, this team must be called for the safety of others.