18 April 2018

List of hospital committees and teams for NABH accreditation preparation

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.


      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
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


      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.