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:
Roles and responsibilities
· Develop and approve organization wide quality improvement programme, policies, manual and activities
· Chairperson – Someone from top management such as CEO, Vice president or director.
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.
· Develop and approve organization wide infection control programme, policies, activities and manual
· Establish definitions and criteria for identifying and reporting of all infections among patients and personnel
· Chairperson – Someone from top management such as CEO, Vice president or director
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
· Develop and approve policies related to medication management
· Other similar matters related to medication management
· Chairperson – A senior member such as HOD of medicine or vice-president or general manager
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
· Oversee the development and implementation of various emergency codes such as code blue, code pink, code red, code yellow etc.
· Chairperson – A senior member such as general manager
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.
· Identifying relevant disaster and emergency situations that may occur within hospital’s range and prioritize them as per risk
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
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.
· To analyse in-depth all cases of employee grievance brought in committee
Suggested members
· Chairperson – A top management person
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
· Presiding officer – This should be a female employee of the organization working at a senior level.
· Developing a policy for credentialing and privileging of clinicians and whetting of credentials of doctors and assigning clinical privileges
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.
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
· Infection control surveillance
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
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.
Roles and responsibilities
· Develop and approve organization wide quality improvement programme, policies, manual and activities
· Chairperson – Someone from top management such as CEO, Vice president or director.
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.
· Develop and approve organization wide infection control programme, policies, activities and manual
· Establish definitions and criteria for identifying and reporting of all infections among patients and personnel
· Chairperson – Someone from top management such as CEO, Vice president or director
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
· Develop and approve policies related to medication management
· Other similar matters related to medication management
· Chairperson – A senior member such as HOD of medicine or vice-president or general manager
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
· Oversee the development and implementation of various emergency codes such as code blue, code pink, code red, code yellow etc.
· Chairperson – A senior member such as general manager
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.
· Identifying relevant disaster and emergency situations that may occur within hospital’s range and prioritize them as per risk
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
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.
· To analyse in-depth all cases of employee grievance brought in committee
Suggested members
· Chairperson – A top management person
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
· Presiding officer – This should be a female employee of the organization working at a senior level.
· Developing a policy for credentialing and privileging of clinicians and whetting of credentials of doctors and assigning clinical privileges
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.
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
· Infection control surveillance
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
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.
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