Internal Complaints Committee (Vishakha Committee) 

The Internal Complaints Committee (ICC) plays a vital role in workplaces by addressing and preventing sexual harassment, thereby ensuring a safe and respectful environment for all employees. It was established under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act of 2013, which is based on the Vishakha Guidelines issued by the Supreme Court of India in 1997.

 Background: The Vishakha Guidelines

The Vishakha Guidelines were established following the tragic case of Bhanwari Devi, a social worker in Rajasthan who was assaulted for attempting to prevent child marriage. This incident highlighted the absence of legal protections against sexual harassment in the workplace. In response, the Supreme Court of India issued the Vishakha Guidelines in 1997, which later became the basis for the Prevention of Sexual Harassment (POSH) Act of 2013.

 Understanding Sexual Harassment in the Workplace

Sexual harassment in the workplace refers to any unwelcome behaviours of a sexual nature, including:

- Physical contact or advances

- Requests for sexual Favors

- Sexually coloured remarks

- Showing pornography

- Any other unwelcome physical, verbal, or non-verbal conduct of a sexual nature

 It also encompasses hostile work environments, where individuals may feel unsafe, intimidated, or discriminated against due to sexual harassment.

 

Objectives of the Internal Complaints Committee (ICC):

Prevent workplace sexual harassment through effective policies and awareness campaigns.

Protect employees' rights and ensure a safe working environment.

Address complaints of harassment fairly and confidentially.

Recommend corrective actions to the employer to ensure compliance with the law.

Composition of the ICC

Member Eligibility:

Presiding Officer: A senior female employee from the organization.

Employee Members (at least 2): Individuals knowledgeable about law, social work, or women’s rights.

External Member: A professional from an NGO, legal field, or social work, ensuring neutrality.

If an organization does not have a senior female employee, they may appoint an external expert to serve as the Presiding Officer.

 

Functions & Responsibilities of the ICC

The ICC is responsible for addressing complaints related to sexual harassment and ensuring a respectful work environment.

Key Responsibilities:

1. Receiving Complaints:

   Employees experiencing sexual harassment can file a written complaint within 3 months of the incident (extendable to 6 months in special cases).

    If the complainant is unable to file the complaint themselves, the ICC must provide assistance.

2. Conducting Inquiries:

   - Upon receiving a complaint, the ICC must initiate an inquiry within 7 days.

   - Both the complainant and the accused have equal opportunities to present their cases.

3. Mediation & Resolution:

   - The ICC may attempt mediation if requested by the complainant, but no monetary settlement is permissible.

4. Recommendation of Action:

   - If harassment is substantiated, the ICC can recommend penalties, such as:

     - Warning or written apology

     - Transfer or suspension of the accused

     - Deduction of salary as compensation to the complainant

     - Termination of employment for severe cases

5. Awareness & Training:

   - The ICC is responsible for conducting regular awareness programs to educate employees about sexual harassment, their rights, and the complaint process.

6. Confidentiality & Record Keeping:

   - The ICC must maintain strict confidentiality regarding complaints, inquiries, and actions taken. Any breach of confidentiality may result in penalties.

 

How to File a Complaint with the ICC

Employees who experience sexual harassment can follow these steps:

1. Submit a Written Complaint:

   - Complaints should be filed within 3 months of the incident (extendable to 6 months in special cases). If the complainant cannot write, the ICC must assist them.

2. Inquiry Process:

   - The ICC conducts an internal investigation and hears both parties involved. The inquiry must be completed within 90 days.

3. Submission of Report:

   - The ICC submits its findings and recommendations to the employer within 10 days of completing the inquiry.

4. Employer’s Action:

   - The employer must act on the ICC's recommendations within 60 days.

5. Appeal Process:

   - If either party is dissatisfied with the decision, they can appeal to a court or tribunal within 90 days.

 

Penalties for Non-Compliance

Organizations that fail to comply with the Prevention of Sexual Harassment (POSH) Act and ICC requirements may face serious legal consequences, including:

- A fine of ₹50,000 for non-compliance

- Cancellation of business licenses in cases of repeated violations

- Potential personal liability for employers due to negligence

 

Why is the ICC Important?

- Ensures a safe, respectful, and inclusive workplace.

- Encourages victims to report harassment without fear of repercussions.

- Helps organizations avoid legal consequences.

- Promotes a culture of gender equality.

 

 Key Takeaways

- Every workplace with 10 or more employees must have an ICC.

- Sexual harassment complaints must be addressed within a strict timeline.

- Confidentiality is critical to protect all parties involved.

- Employers are required to conduct awareness programs to prevent harassment.

- The Internal Complaints Committee is not just a legal obligation; it is a vital step toward establishing a safer and more respectful work culture for everyone.

Quality Improvement Committee

 

Quality Improvement Committee (QIC): Driving Excellence in Organizations

Introduction

In any organization—whether in healthcare, manufacturing, education, or business—establishing and maintaining high-quality standards is non-negotiable. Achieving and sustaining these standards demands a commitment to a culture of continuous improvement where enhancements are expected and prioritized. This is precisely where a Quality Improvement Committee (QIC) becomes essential.

A QIC is a dedicated team that focuses on actively monitoring, evaluating, and enhancing the quality of processes, products, and services, with the ultimate goal of not only meeting but consistently exceeding quality standards. This commitment leads to improved outcomes for customers, patients, employees, and stakeholders alike.

To grasp the critical role of a QIC, let’s explore its purpose, functions, and key responsibilities in a straightforward and impactful manner

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The Purpose of a Quality Improvement Committee

In any organization—whether in healthcare, manufacturing, education, or business—establishing and maintaining high-quality standards is non-negotiable. Achieving and sustaining these standards demands a commitment to a culture of continuous improvement where enhancements are expected and prioritized. This is precisely where a Quality Improvement Committee (QIC) becomes essential. A QIC is a dedicated team that focuses on actively monitoring, evaluating, and enhancing the quality of processes, products, and services, with the ultimate goal of not only meeting but consistently exceeding quality standards. This commitment leads to improved outcomes for customers, patients, employees, and stakeholders alike. To grasp the critical role of a QIC, let’s explore its purpose, functions, and key responsibilities in a straightforward and impactful manner

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Key Roles of a Quality Improvement Committee

A QIC typically has a broad set of roles that can be divided into five major areas:

1. Monitoring and Evaluating Performance

• Collect and analyze data related to key performance indicators (KPIs).
• Review trends, patterns, and outcomes to identify gaps in quality.
• Assess the effectiveness of current policies, procedures, and processes.

For example, in a hospital, a QIC might track infection rates, patient satisfaction scores, and medication errors to determine whether changes are needed.

2. Identifying Areas for Improvement

• Conduct audits and root cause analyses to uncover problems.
• Engage frontline employees to understand pain points in daily operations.
• Gather feedback from customers, employees, and stakeholders to identify issues that impact quality.

Example: A restaurant QIC might identify that customer wait times are too long and investigate potential causes, such as staffing levels or inefficient workflows.

3. Developing and Implementing Improvement Plans

• Brainstorm and propose solutions to quality issues.
• Create structured improvement initiatives, such as Lean or Six Sigma projects.
• Assign responsibilities and set realistic goals and timelines for implementation.

Example: A software company’s QIC might implement a bug-tracking system to reduce errors in product releases.

4. Ensuring Compliance with Regulations and Standards

• Stay updated on industry standards and regulatory requirements.
• Ensure the organization adheres to safety, legal, and ethical guidelines.
• Prepare for external inspections and certifications (e.g., ISO, Joint Commission).

Example: In aviation, a QIC ensures compliance with FAA safety regulations to maintain flight safety and reliability.

5. Promoting a Culture of Quality and Accountability

• Educate and train employees on best practices for quality improvement.
• Encourage staff involvement in identifying and solving quality problems.
• Foster a mindset where quality improvement is seen as everyone’s responsibility.

Example: A retail company’s QIC might launch a customer service excellence program to train employees on handling complaints effectively.

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Core Responsibilities of a Quality Improvement Committee

Now that we’ve covered the main roles, let’s break down the specific responsibilities a QIC typically handles:

1. Developing Quality Improvement Strategies

• Establish short-term and long-term quality improvement goals.
• Align quality initiatives with the organization's overall mission and vision.
• Create structured frameworks like Plan-Do-Study-Act (PDSA) cycles or DMAIC (Define, Measure, Analyze, Improve, Control).

2. Conducting Regular Quality Assessments

• Perform periodic quality audits to assess performance.
• Use surveys, interviews, and data analysis to evaluate effectiveness.
• Report findings to senior management and recommend action plans.

3. Analyzing Data and Measuring Outcomes

• Set up dashboards or tracking systems to monitor key metrics.
• Use statistical tools and quality methodologies (e.g., Six Sigma, Total Quality Management).
• Identify trends and patterns to inform decision-making.

4. Managing Risk and Ensuring Safety

• Identify potential risks and hazards that impact quality.
• Develop risk mitigation strategies and emergency response plans.
• Ensure compliance with safety and security protocols.

5. Leading Quality Improvement Projects

• Oversee pilot projects to test new quality improvement initiatives.
• Gather feedback from employees and customers during implementation.
• Adjust strategies based on real-world results.

6. Facilitating Training and Development

• Organize workshops, training sessions, and certification programs.
• Educate employees on quality improvement techniques and methodologies.
• Promote continuous learning to keep teams updated on best practices.

7. Ensuring Cross-Department Collaboration

• Work with different teams (HR, Operations, Customer Service, IT) to improve overall quality.
• Break down silos and ensure smooth communication between departments.
• Encourage team-based problem-solving and innovation.

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Who Should Be in a Quality Improvement Committee?

A well-rounded QIC should include members from diverse backgrounds to ensure different perspectives. Typical members include:

✅ Quality Assurance Officers – Experts in quality standards and compliance.
✅ Department Heads/Managers – Leaders responsible for implementing changes.
✅ Frontline Staff – Employees who directly engage in day-to-day operations.
✅ Data Analysts – Specialists in measuring and interpreting quality metrics.
✅ Customer Representatives – Advocates who ensure customer concerns are heard.
✅ Senior Leadership – Executives who provide strategic direction and support.

This mix ensures that quality improvement is practical, data-driven, and aligned with real-world needs.

hospital committees and teams for NABH accreditation

List of hospital committees and teams for NABH accreditation preparation

Hospital teams and committees are crucial to hospital management and decision-making. Although hospitals are divided into departments, many problems fall under the purview of multiple departments when it comes to something as complicated as healthcare. These problems need that individuals with various responsibilities and levels of knowledge work together to make the right choices and take the necessary actions. For this reason, committees and teams are established, with the formation of several committees and teams based on the nature of the issues to be addressed. This page outlines and describes the many committees and teams that a hospital should have in accordance with NABH guidelines.
To effectively distinguish between a committee and a team, we must recognize that a committee is a collection of individuals (often with different roles and areas of expertise) who collaborate to discuss and debate an agenda in order to reach a consensus on what should serve as the foundation for planning and decision-making. Teams, on the other hand, are groups of people that work together to accomplish choices and functions that span several departments and are frequently challenging to execute.

LIST OF COMMITTEES WITH THEIR ROLES AND COMPOSITION

 

      1.       Quality Improvement Committee:
This committee takes responsibility of developing and periodically reviewing the organization wide quality improvement programme. The committee generally works as an apex committee for a hospital preparing for accreditation
Roles and responsibilities
·         Develop and approve organization wide quality improvement programme, policies, manual and activities
·         Identify quality indicators for monitoring quality
·         Recommend suitable benchmarks for indicators
·         Review quality indicators performance periodically and take appropriate decisions for further improvement
·         Recommend best practices for implementation in hospital
·         Review and identify accreditation requirements and make plans to address them
·         Guiding departments in matters related to quality and accreditation
·         Develop and monitor quality improvement activities across the organization
 Suggested members
·   Chairperson – Someone from top management such as CEO, Vice president or director.
·         Convener/Coordinator – Accreditation coordinator / Quality Officer or similar
·  Other members – One representative each from medical specialities, surgical specialities, Gynaecology and Obstetrics, Paediatrics, Super-specialities, Laboratory services, Blood Bank, Imaging Services, General Management, HR management, Pharmacy services and Support services
 
      2.       Infection Control Committee:
This committee bears the responsibility of infection control measures with an objective of reducing the risk of HAI in the hospital. The committee discuss and decides on each matter that can have an effect on infection control.
Roles and responsibilities
·   Develop and approve organization wide infection control programme, policies, activities and manual
·      Establish standard precaution practices to be followed across the hospital
·     Establish definitions and criteria for identifying and reporting of all infections among patients and personnel
·         Guide departments on evidence based infection control practices
·     Set benchmark HAI rates for monitoring the effectiveness of infection control measures
·         Validate methods for calculating HAI rates
·         Review HAI rates periodically and recommend actions accordingly
·         Develop antibiotic policy in conjunction with pharmaco-therapeutics committee
·         Develop protocol for handling of infection outbreak and manage such situations
·         Other similar matters related to infection control
Suggested members
 
·         Chairperson – Someone from top management such as CEO, Vice president or director
·         Convenor/Co-ordinator  – Infection Control Officer / Medical Microbiologist / Infectious diseases specialist
·         Clinical members – One representative each from all clinical specialities and super-specialities, including Anaesthesiology, Critical Care, Emergency Medicine, Laboratory services, Blood Bank, Nursing Services and Allied health specialities
·         Non-clinical members – Person in-charge for administration of Operation theatre, ICU, IPD, OPD, Emergency department, CSSD, Laundry, Bio-medical waste, Maintenance, Medical Equipment and General Management
 
      3.       Pharmaco-therapeutics committee (Drugs committee):
This committee deals with all matters pertaining to pharmacy, medicines and medical consumable used in the hospital for patient care. There are many issues related to safety, quality and ethics under use of drugs and this committee resolve those issues
Roles and responsibilities
·         Develop and approve policies related to medication management
·         Establish safe medication practices in the organization
·         Develop and approve hospital formulary
·         Issue guidelines for rational prescription of medication
·       Develop mechanism for reporting and tracking of medication errors and adverse events related to medication
·         Review indicators related to medication safety and take necessary decisions
·         Monitor medication practices through audits such as prescription audit, pharmacy audit etc.
·         Help Infection Control Committee in formulating antibiotic policy
·         Other similar matters related to medication management
 Suggested members
      ·         Chairperson – A senior member such as HOD of medicine or vice-president or general manager
      ·         Convenor/Co-ordinator  – Chief pharmacist
      ·         Clinical members – One representative each from all clinical specialities and super-specialities,  Representatives from nursing department, OPD, IPD, ICU, OT and Emergency
      ·         Non-clinical members – Purchase Manager, Pharmacy store in-charge
 
      
      4.       Safety Committee:
Safety committee bears the responsibility of ensuring safety of all across the organization. Scope of this committee is wide and in larger hospital it can be further segregated into radiation safety committee, lab safety committee and hospital safety committee. If there are multiple committees working on safety issue, the interaction between these committees are very important to ensure uniform policy making and actions. This can be achieved by having few members common between these committees
Roles and responsibilities
·         Develop and issue policies related to safety based upon best national and international safety practice
·         Monitor implementation of safety practices through appropriate indicators, audits and feedbacks
·         Oversee the development and implementation of various emergency codes such as code blue, code pink, code red, code yellow etc.
·         Investigate sentinel events and other safety related adverse events
·         Issue guidelines related to safety pertaining to clinical and non-clinical activities
·        Develop mechanism for reporting and tracking of safety related adverse events
Suggested members
·         Chairperson – A senior member such as general manager
·         Convenor/Co-ordinator – Safety manager
·     Clinical members – Representatives from clinicians (specially surgery, medicine), representatives from laboratory and radiology, radiation safety officer, representative from nursing department, ICU in-charge and OT in-charge,
·         Non-clinical members – Maintenance in-charge, security in-charge, representative from general management, fire safety officer and any other relevant
 
      5.       Disaster and emergency preparedness committee: 
     This committee has a specific role to develop a working plan on handling disaster situation. In smaller hospitals, this can be merged with safety committee, but in larger hospitals it is preferable to have a separate committee.
                Roles and responsibilities
·      Identifying relevant disaster and emergency situations that may occur within hospital’s range and prioritize them as per risk
·         Formulate a plan for each identified disaster and emergency situation to be followed in case it occurs
·         Assess the level of preparedness of the hospital from time to time to meet all such identified disaster situations
·         Identify and recommend resources required to meet disaster and emergency situations
·         Recommend modifications required in facility to address disasters
·         Recommend training and mock drills required to be conducted for staff preparedness
·         Conduct analyses and make improvements post-event
Suggested members:
Similar to that of safety committee. An expert in disaster management either from organization or from outside should be added in the committee to provide technical expertise
 
        6.      Ethics committee:
Ethics committee plays an advisory role in all matters related to ethical dilemma. While research ethics committee can be constituted as per ICMR guidelines and which undertakes approval and monitoring of clinical researches, hospital ethics committee deals with unusual, complicated ethical problems involving issues that affect the care and treatment of patient.
Roles and responsibilities
·         Identifying issues and events in patient care that has an ethical concern
·         Discuss all such events from ethical and patient care perspective
·         Ensure that legal guidelines are met in all such issues
·         Take most appropriate decision in all ethical issue
·         To develop and issue ethical guidelines to healthcare staff and provide clarifications as and when required
Suggested Members:
Members should be a mix of clinical and non-clinical people. Senior and experienced people from the organization should be taken as member in this committee. It is advisable if one or two members from outside of hospital can also be taken on board. The committee should be chaired by some-one from the senior most designation. HCO should try to find and include members who have experience of dealing with ethical issues in patient care
 
      7.      Grievance redressal and disciplinary action committee:
This committee presides over cases related to employee grievance and recommends appropriate disciplinary actions to be taken. The committee plays an important role from Human Resources management point of view and ensures that rights of the employees are protected.
Roles and responsibilities
·         To analyse in-depth all cases of employee grievance brought in committee
·         To preside over the cases in most unbiased manner
·         To take decisions on the basis of evidences and after listening to all concerned parties
·         Ensure that disciplinary policy of the organization is followed
(In case the grievance is of nature of sexual harassment, it must handed over to Vaisakha Committee for further process)
Suggested members
·         Chairperson – A top management person
·         Convenor / Co-ordinater – Head/Manager HR
·         Other members – 5-6 members from different departments
 
      8.       Internal Complaints Committee (Vishakha Committee) For prevention of sexual harassment at workplaces
This committee is a legal requirement under ‘prevention of sexual harassment’ law. The purpose of this committee is to investigate and take action against any complaint received which has a nature of sexual harassment
Roles and responsibilities
·         To receive complaints related to sexual harassment at workplace
·         To investigate each and every complaint in light of evidence and following the principles of natural justice
·         To decide appropriate actions in each case, in accordance to the legal guidelines under the act
·         To ensure that rights of complainant and complainee are protected
·         To issue guidelines from time to time regarding prevention of sexual harassment
Members requirements
·         Presiding officer – This should be a female employee of the organization working at a senior level.
·         Not less than 2 members from amongst employees who have experience in social work or have good legal knowledge
·         One member from NGO or association working for the cause of woman or an independent person familiar with issues related to sexual harassment
·         Other members as appointed by the organization
·         Minimum 50% of the members of this committee shall be females
       9.       Clinical committee
This is a multi-purpose committee to deal with various types of clinical issues that requires a decision based upon inputs from different fields. More than one clinical committee can be formed if the scope and range of work is large. There are a large number of issues that are clinical in nature and requires a depth clinical discussion. Range of issues that can be taken up in clinical committee are
·         Developing a policy for credentialing and privileging of clinicians and whetting of credentials of doctors and assigning clinical privileges
·         Conducting medical/clinical audits and recommend measure of improvement
·         Conducting clinical analysis of exceptional cases such as death, major medical errors etc.
·         Development of clinical protocols that requires multi-speciality inputs
·         Deciding measures to improve clinical capabilities amongst clinicians
·         Advising on policy matters that have clinical aspects, such as antibiotic policy, infection control policies etc.
·         Providing clinical opinion to managers on making patient care better
Members
Clinical committee is composed of clinical members from all specialities of the organization with one or two nursing and non-clinical members to provide supportive assistance
 
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.