Quality Council

The Quality Council is a critical body within the hospital dedicated to driving and maintaining high standards of care and operational excellence in line with national and international healthcare standards. As part of the commitment to provide safe, effective, and compassionate care to all patients, the Quality Council plays a pivotal role in ensuring continuous improvement and compliance with the guidelines set forth by the Quality Council of India (QCI).

The Quality Council will serve as the backbone for all quality management initiatives, focusing on improving patient outcomes, enhancing safety and optimizing the overall healthcare delivery process. This council will oversee the implementation of quality improvement strategies, monitor performance metrics and ensure that our hospital meets the rigorous standards required for a tertiary care hospital.

Role of the Quality Council

  1. Policy Formulation and Strategic Planning:

    The Quality Council will be responsible for developing and updating policies related to patient safety, clinical practices, and quality management. It will work to align these policies with national and international standards.

  2. Quality Improvement Initiatives:

    The Council will actively promote and monitor quality improvement programs across departments. These initiatives will be designed to address patient care, clinical outcomes, patient satisfaction, and operational efficiency.

  3. Monitoring and Evaluation:

    Regular audits, performance evaluations, and internal assessments will be conducted by the Quality Council to track progress against established quality indicators. This data-driven approach will ensure accountability and transparency.

  4. Accreditation Readiness:

    The Council will ensure that the hospital is consistently prepared for NABH assessments and other accreditation processes. It will facilitate compliance with all quality standards and prepare the organization for successful re-accreditation.

  5. Staff Education and Training:

    A key responsibility of the Quality Council is to ensure that all staff members are well-trained on quality standards, patient safety protocols, and best practices. Regular training and workshops will be organized to cultivate a culture of continuous learning.

  6. Patient-Centered Care:

    The Quality Council will ensure that patient safety and satisfaction are at the core of every decision made. It will develop strategies to gather patient feedback and use this information to refine care processes.

  7. Risk Management:

    The Council will identify, assess, and mitigate potential risks within the hospital, including clinical risks, operational risks, and regulatory risks. Proactive risk management will minimize adverse events and ensure patient safety.

  8. Reporting and Communication:

    The Quality Council will establish clear communication channels for reporting quality issues, incidents, and patient concerns. It will ensure that there is transparency in all quality-related matters and encourage open feedback from staff and patients alike

Below is the detail of quality council and framework for the roles and responsibilities (Annexure-A & B) of members of quality council to ensure optimal patient care and safety:

Quality Council (For both Patient Care Quality & Patient Safety)
S. No. Name Designation Appointment
1 Lt Gen Dr. Daljit Singh (Retd.) Executive Director Head of Quality Council
2 Prof. (Dr.) Dinesh Kumar Verma Medical Superintendent Chairperson
3 Lt Col Vishwas Pradeep Paranje Deputy Director (Admin.) Co-Chairperson
4 Prof. (Dr.) Rupali Parlewar Dean (Academics) Co-Chairperson
5 Prof. (Dr.) Anupam Prashar Dean (Research) Co-Chairperson
6 Prof. (Dr.) Nidhi Puri Dean (Examination) Co-Chairperson

Quality Cell

S. No. Name Designation Appointment
7 Prof. (Dr.) Narvir Singh Chauhan HoD, Radiology Co-ordinator/Head of Quality Cell
8 Prof. (Dr.) Sriram Pothapregada Additional Medical Superintendent Chairperson, Patient Safety
9 Prof. (Dr.) Yatiraj Singi Additional Medical Superintendent Chairperson, Patient Care Quality

Members

S. No. Name Designation Appointment
10 Prof. (Dr.) Sanajy Vikrant Professor & HoD Nephrology
11 Prof. (Dr.) Nidhi Puri Professor & HoD Anatomy
12 Prof. (Dr.) Deepti Chopra Professor & HoD Pharmacology
13 Prof. (Dr.) Sadhna Sharma Professor Biochemistry
14 Dr. Muninder Kumar Additional Professor & HoD Radiation Oncology
15 Dr. Ashish Sharma Additional Professor & HoD Neurology
16 Dr. Sudesh Kumar Additional Professor & HoD ENT
17 Dr. Poojan Dogra Marwaha Additional Professor & HoD OBG
18 Dr. Vijayalakshmi Sivapurapu Additional Professor & HoD Anaesthesia
19 Dr. Manu Priya Additional Professor & HoD Pathology
20 Dr. Ajay Jaryal Additonal Professor, Faculty Coordinator General Medicine
21 Dr. Vikas Kumar Associate Professor, Faculty Coordinator CTVS
22 Dr. Bijaya Sethi Associate Professor, Faculty Coordinator Paediatrics Surgery
23 Dr. Pravesh Dhiman Additonal Professor, Faculty Coordinator Medical Oncology
24 Dr. Sumita Sharma Additional Professor, Faculty Coordinator Biochemistry
25 Dr. Chitresh Kumar Additional Professor, Faculty Coordinator Surgical Oncology
26 Dr. Neelam Verma Additional Professor, Faculty Coordinator Ophthalmology
27 Dr. Nalini A Additional Professor, Faculty Coordinator Neonatology
28 Dr. Preyander Thakur Associate Professor, Faculty Coordinator Endocrinology
29 Dr. Mohim Thakur Associate Professor, Faculty Coordinator General Surgery
30 Dr. Ranjeet Coudhary Associate Professor, Faculty Coordinator Orthopaedics
31 Dr. Yogesh Preet Singh Assistant Professor, Faculty Coordinator Clinical Immunology & Rheumatology
32 Dr. Navdeep Singh Sidhu Assistant Professor, Faculty Coordinator Cardiology
33 Dr. Umakant Dutt Associate Professor, Faculty Coordinator Urology
34 Dr. Manju Daroch Associate Professor, Faculty Coordinator Dermatology
35 Dr. Navneet Sharma Associate Professor, Faculty Coordinator Burn & Plastic Surgery
36 Dr. Arjun Dhar Associate Professor, Faculty Coordinator Neurosurgery
37 Dr. Jyoti Gupta Associate Professor, Faculty Coordinator Psychiatry
38 Dr. Anshul Sharma Assistant Professor, Faculty Coordinator Nuclear Medicine
39 Dr. Rakesh Kumar Associate Professor, Faculty Coordinator Transfusion & Blood Bank
40 Dr. Vikrant Kanwar Assistant Professor, Faculty Coordinator Hospital Administration
41 Ms. Kiran Mishra Nursing Superintendent -
42 Nominated Member - Engineering Section
43 Manager - Sanitation Services
44 Manager - Security Services

 

QC Co-ordinator
↓
Quality Cell Office (Block-C, 2nd Floor)
↓
↓ ↓
Head, Patient Safety 
(Quality Cell Office – 2nd Floor)
↓
Head, Patient Care 
(Quality Cell Office – 2nd Floor)
↓

Program Responsibility
Surgical Safety OT Committee
Lab Safety Lab Committee
Radiology Safety HOD Radiology
Nuclear Safety FI/C Nuclear Medicine
Ambulance Safety Ambulance Committee
Transfusion Safety FI/C Transfusion
Obstetrics Safety HOD OBG
Paediatric & Neonatology Safety HOD Paediatric
Anaesthesia Safety HOD Anaesthesia
Medication Safety HOD Pharmacology
Fire Safety Fire Safety Committee
Spill Management DMS Emergency
Needle Stick Injury DMS Emergency
MGPS Safety SE Civil
Environmental Safety SE Civil
Engineering Safety SE Civil
Incident Reporting PCRC
HIC HIC Committee member Secretary
Disaster Preparedness Working Group for Disaster SOP preparation
Program Responsibility
Emergency KPI Emergency
OT KPI DMS OT
Surgeries KPI All Surgical Depts. FI/C
ICU KPI DMS ICU
Wards KPI DMS Ward
Scope of Services FI/C department
Registration and Admission manual DMS OPD
Patient Transfer manual DMS Emergency, DMS IPD
Lab + QA manual Lab NABL Committee
Radiology + QA manual HOD Radiology
Emergency manual Emergency Committee
Ambulance manual Ambulance Committee
Ambulance manual Ambulance Committee
Nursing Services manual NS
Transfusion Services manual FI/C Transfusion
ICU manual DMS ICU
Internal Audits Internal Audit Committee
   

 

Roles & Responsibilities

S. No. Appointment Designation Responsibility
1 Head of Quality Council Executive Director Monitoring, Mentoring & Implementation
2 Chairperson Medical Superintendent Monitoring & Implementation
3 Co-Chairperson-1 Dean (Academics) Education, Training of all for PCQ & PS
4 Co- Chairperson -2 Dean (Research) Ensuring PS for patients under research project
5 Co- Chairperson -3 Deputy Director (Administration) Aligning administrative process regarding PCQ & PS
6 Co- Chairperson - 4 Nursing Superintendent Monitoring & Implementation
7 Co-Ordinator QC (Head of Quality Cell)   Guiding & Co- ordinating operations with various groups, Committees
8 Chairperson, Patient Care (Quality)   Implementation of patient care Quality goals
9 Chairperson, Patient Safety   Implementation of Patient Safety related Goals
  Members    
10 Committees and working groups   Implementation of Patient Care Quality and Patient Safety Goals
11 HODs and Faculty In-charges   Implementation of Patient Care Quality and Patient Safety Goals
12 Nominated Members from Engineering Section   Implementation of Patient Care Quality and Patient Safety Goals
13 Manager, Sanitation Services   Implementation of Patient Care Quality and Patient Safety Goals
14 Manager, Security services   Implementation of Patient Care Quality and Patient Safety Goals