Lesson 4.2: Responsibilities of Quality & Safety Committees

Описание: Lesson 4.2: Responsibilities of Quality & Safety Committees
Module 4: Organization-Centered Standards

🧭 Introduction
To ensure sustained quality and patient safety, NABH mandates the formation of dedicated Quality and Safety Committees in hospitals. These committees serve as the nerve center for monitoring, reviewing, and improving the institution's clinical and operational performance.
This lesson outlines the roles, structure, and responsibilities of these crucial governance bodies.

🏛️ What Are Quality & Safety Committees?
These are multidisciplinary teams responsible for implementing and overseeing quality assurance and patient safety programs in the hospital. The committees help create a culture of accountability and continuous improvement, aligned with NABH standards.
Most hospitals have multiple sub-committees working under a Central Quality Council or Quality Steering Committee.

🧑‍⚕️ Composition of Committees
Committee Type
Key Members
Quality Steering Committee
CEO/Medical Director (Chair), Quality Head, Nursing Head, Dept. Heads
Infection Control Committee (ICC)
Microbiologist, Nursing In-Charge, Housekeeping, Clinicians
Clinical Audit Committee
Senior Clinicians, Department Auditors, Quality Team
Pharmacy & Therapeutics
Pharmacist, Physician, Quality Representative
Patient Safety Committee
Nursing Staff, Clinicians, Quality Lead, Incident Review Officer

Note: Membership should be reviewed annually and documented.

🧩 Key Responsibilities
1. Establishing Quality & Safety Policies
Define goals and KPIs for clinical and administrative quality.


Ensure alignment with NABH standards and hospital vision.


2. Monitoring Quality Indicators
Review data trends (e.g., infection rates, readmissions, patient complaints).


Take corrective and preventive actions (CAPA) based on findings.


3. Incident Reporting & Analysis
Ensure adverse events are reported, investigated, and acted upon.


Lead Root Cause Analysis (RCA) for serious events.


4. Internal Quality Audits
Schedule and conduct departmental audits.


Track compliance and initiate improvement plans.


5. Policy Reviews & Updates
Regularly update SOPs and protocols in line with clinical guidelines and regulations.


6. Staff Training & Sensitization
Plan regular training on infection control, documentation, safety practices.


Conduct mock drills and awareness programs.


7. Feedback & Patient Satisfaction
Analyze patient feedback and complaints.


Use insights to improve service delivery and patient communication.



🗂️ Documentation Expectations (As per NABH)
Hospitals must maintain:
Committee meeting minutes with agenda and attendance


Action taken reports and follow-ups


Audit and RCA documentation


Training calendars and attendance logs



📌 Best Practices
Monthly Committee Meetings with timely follow-ups


Use of Dashboards to visualize quality metrics


Cross-functional Collaboration between departments


Patient Involvement in safety initiatives wherever feasible



🧠 Key Takeaways
Quality & Safety Committees are the backbone of a hospital’s quality ecosystem.


Their effectiveness depends on data-driven decision-making, timely reviews, and staff involvement.


Strong committee functioning significantly enhances NABH preparedness and day-to-day hospital performance.