Purpose

To review the adherence of the organization to Quality Standards

Scope

Applicable for the entire Hospital

Constitution of the committee

• Centre Manager (Chairman)
• In-charge – Medical Service & Operation. (Secretary)
• Manager – Quality & Operations
• Nursing Superindentendent
• Dietician in-charge
• Lab HOD
• Lab in-charge
• Radiology Department HOD
• Nuclear Medicine HOD
• PET-CT Technician
• Radiation safety officer
• Pharamcy in-charge
• MRD HOD
• Anaesthesia Department HOD
• Surgical Oncologist
• Infection control nurse
• ICU – incharge
• Purchase and stores department HOD
• Safety officer
• HR Manager
• OT in-charge
• Bio medical engineer
• OPD and customer care HOD
• Maintenance Department HOD
• House Keeping Department HOD
• Radiotherapy Department HOD

The chairman shall have the authority to invite any non member to attend the meeting, if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.

Quorum

The minimum quorum for passing any resolution in the committee is more than 50%.

Following members to be mandatorily present in the committee to pass a resolution

• Chairman (Quality Manager)

Frequency of meeting

Members of the committee meet once in three months.

Selection of members

1. Chairperson – Selected by the chairman of Apex Committee
2. Secretary – Selected by the chair person, he or she is also a member of the committee
3. Members – Selected by the chair person

Responsibilities

• To review the adherence of the organization to Quality Standards,
• Performance against benchmark
• To plan new initiatives with respect to Quality and to discuss the resources required for the same.
• To discusses the progress towards Accreditation (when scheduled)
• Analyze quality Indicators and do Root Cause Analysis as required
• Strategy for continuous improvement is discussed and planned by the committee
• To update the developments made in the organization by the quality team/department

Quality Improvement Team

• This team consists of Quality Manager, and Quality Executives. On a need basis additional staff is included in the team.
• This team is responsible for guiding the organization towards quality improvement initiatives and accreditation in particular.
• Conducting training on NABH standards, Staff Safety, Hospital wide policies & procedures, Internal Quality Audits, Quality Indicators, and other Quality related issues.
• Coordinating with committee secretaries for conducting the meetings and helping in implementing the actions planned in the committee meetings.
• Planning, communicating and conducting Internal Quality Audits on a regular basis. Discussing the Non Conformances with the Auditee and helping in planning and implementing corrective and preventive action.
• Conducting Quality Core Committee meetings with all the departmental and functional heads and providing them the suggestions and helping them implementing the same.
• Collecting data on Quality Indicators and analyzing them. Planning and implementing corrective/ preventive actions wherever deviations observed. Whenever targeted results achieved enhancing the target or establishing new indicators.
• Planning, executing, monitoring, measuring and following up the Continuous Improvement Projects at the organizational level and also at departmental levels.
• Assigning projects to Interns related to Quality Department.
• Communicating and coordinating with the accreditation board and other concerned external personnel for the accreditation process

Role of Chairperson

• Acts as a liaison between the Quality Improvement Committee and the apex committee chairperson
• Receives all the information pertaining to PTC and initiate necessary action as required.
• Keep oneself abreast with the recent developments in the field.

Role of secretary (Member secretary)

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of meeting shall be prepared by the secretary
• Get the approval of minutes by the chairperson
• Circulate the agenda approved by the chair person to the members and the concerned persons
• To maintain all records ( as per list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting signature from all the concerned members

Agenda

Agendas for the meeting shall be prepared by the secretary in consultation with the chair person and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.

A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.

Minutes

• Shall be prepared by secretary.
• MoM is send to the chairperson for the approval within three days of the meeting.
• After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation.
• A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary

Decision making

• A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.
• The decision of the committee will be finally taken by a majority vote and that shall be implemented.

Records to be maintained

1. List and details of all members
2. The TOR of the committee
3. Copy of all agendas, minutes of all meeting
4. Attendance sheet
5. Copy of any other correspondence to the committee members or non-members
6. Copy of any study conducted for the sake of the committee