SRI LAKSHMI MEDICAL CENTRE AND HOSPITAL

18/121 MTP Road,

Thudiyalur, Coimbatore 641 034.

Document Name :

POLICIES & PROCEDURES ON

RESPONSIBILITIES OF MANAGEMENT

Document No. :

E / NABH / SMCH / ROM / 01

No. of Pages :

14

Date Created :

01/11/2014

Date of Implementation :

01/11/2014
Designation : Management Representative

Prepared By :

Name : Ms.Anandhalakshmi
Signature :
Designation :Chairman

Approved By :

Name :Dr.D.Suresh Kumar

Signature :
Designation : NABH Coordinator

Responsibility of Updating :

Name : Mrs.Usha Nandhini.N.B

Signature :

AMENDMENT SHEET

S.No.

Section
no &
page no

Details of the amendment

Reasons

Signature of
the
preparatory
authority

Signature
of the
approval
authority

CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a
readily identifiable and retrievable.
The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and
when the amended versions are received.
Management Representative is responsible for issuing the amended copies to the copyholders; the copyholder
should `acknowledge the same and he /she should return the obsolete copies to the Management Representative.
The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.
The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review
and amendment can happen also as corrective actions to the non-conformities raised during the self-assessment
or assessment audits by NABH.
The authority over control of this manual is as follows:
Preparation
Management Representative

Approval
Chairman, Sri Lakshmi Medical
Centre & Hospital.

Issue
Accreditation coordinator

The procedure manual with original signatures of the above on the title page is considered as Master Copy,
and the photocopies of the master copy for the distribution are considered as Controlled Copy.
Distribution List of the Manual:
S.No.

Designation

Chairman

Management Representative

Accreditation Coordinator

CONTENTS
S.No.

Topics

Page Number

1.0

Purpose

2.0

Scope

3.0

Responsibility

4.0

Abbreviations

5.0

Reference

6.0

Policy

7.0

Procedures

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1.0 PURPOSE:
1.1

To define the responsibilities of those responsible for governance.

1.2

To ensure that the organization is managed in an ethical manner.

1.3

To define responsibilities of multi-disciplinary committees for overseeing specific aspects of

quality and patient safety

2.0 SCOPE:
2.1

Hospital-wide.

3.0 RESPONSIBILTY:
3.1

Top Management.

3.2

Chairman, Assistant Manager, Infection Control Nurse, Nursing Superintendent, HR Manager,

Accounts Manager, All functional Heads.

4.0 ABBREVIATION:
4.1

NABH

: National Accreditation for Hospitals and Healthcare Providers

4.2

ROM

: Responsibilities of Management

5.0 REFERENCE:
5.1

Pre Accreditation Entry Level Standards for Hospitals, First Edition, April 2014.

6.0 POLICY:
6.1

The hospital shall have a documented Organogram, defining clearly the responsibilities of key
personnel

6.2

The persons responsible for management shall support the quality improvement and patient
safety plans of the organization

6.3

The organization is registered with (appropriate authorities) Indian Medical Association as

Multi-specialty Hospital with 110 beds

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The Hospital has identified Mrs.Usha Nandhini.N.B (HR Manager) as the NABH co-ordinator
to oversee the hospital wide quality and safety programme.

6.5

The hospitals Board of Directors shall define, document and establish the following in the
organization:

6.6

a)

Mission

b)

Vision

c)

Values

d)

Quality policy and initiatives

The organization shall display the following:

a)

Its ownership

b)

The services it provides

c)

Standard billing tariff and billing

6.7

The leaders / Management guide the Hospital to function in an ethical manner.

6.8

The organization shall document agreements for all the outsourced services such as those given
below and monitor them periodically:

6.9

a)

Security

b)

Diagnostic tests

c)

Investigations

d)

Maintenance Air-conditioning, electrical, lifts, etc.

The Hospital shall set up multi-disciplinary committees covering Quality & Safety, Infection
Control, Pharmacy & Therapeutics, Blood Transfusion and Medical Records and the
membership, responsibilities and periodicity of meetings of each shall be defined.

7.0 PROCEDURES:
7.1 Sri Lakshmi Medical Centre &Hospital has identified its Organogram as below:

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7.2 The Roles & Responsibilities of staff at various levels are defined as below:

7.2.1.

CHAIRMAN:
a) As Head of the Organization, is responsible for all the managerial and clinical activities.
b) He brings in necessary resources in the form of manpower, equipment, etc. towards
efficient running of the Hospital
c) He continuously audits all departments for the efficient functioning of the hospital.
d) Periodically analyses various services in the hospital in order to provide quality care and
patient friendly environment.

7.2.2.

Residential Medical Officer (RMO):

a) RMO takes care of all the patients admitted under emergency and Inpatient department.

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b) Complete a brief admission, examination on each patient with appropriate documents and
clinical findings.
c) Attend ward rounds with consulting staff, as required, and be available to discuss patient
treatment plans.
d) Provide a 24-hour medical service within the hospital on an on-call basis permanently.
e) Follow the instructions of consultants for their specific regime for each individual patient.
f) To initiate emergency treatments for patients, staff and visitors and complete appropriate
documentation.
g) Can initiate emergency medical care as required within the hospital for medical and surgical
emergencies.
7.2.3.

Managing Representative :

a) Ensuring that processes needed for the quality management system are established,
implemented and maintained.
b) Reporting to top management on the performance of the quality management system and any
need for improvement.
c) Ensuring the promotion of awareness of customer requirements throughout the organization.

7.2.4 HR Manager :

a) Frame a clear and easily implementable HR Policies

b) Plan and execute suitable interventions to keep the employees motivated
c) Provide employee development and counselling / training assistance to employees /team
members to enhance employee performance and productivity
d) Identifies hiring need, develops the position description, Recruitment Plan, organizational
chart and other recruitment related documents
e) Works with the Head of Management to prepare the job description and ensures proper
procedures for review and approval are met at the department level.

1.

Administrative Manager:

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a) The Administrative Assistant/Office Manager is responsible for the general administration of

day to day operations of the hospital.
b) Administer and perform administrative and clerical functions of the hospital.
c) Consult with department heads and medical staff on their administrative needs.
d) Maintaining and repairing the physical facilities of hospital.
2.

Nursing Superintendent :

e) The Nursing Superintendent is responsible of Nursing Services in the hospital.

f) Analysing /Evaluating the kind and amount of nursing services required in the hospital.
g) Rotation of the nursing staff in various departments to ensure good nursing care.
h) To plan and implement a proper orientation for all new nursing staff.
i) To organise periodic training programs for the nursing staff, to continuously upgrade various
clinical practices.
3.

Accounts Manager:
a) Responsible for all areas relating to financial reporting.
b)

Monitor and analyze the department work to develop more efficient procedures and use of
resources while maintaining a high level of accuracy.
c) Handling funds and analyses / solves the accounts related problems.

Sri Lakshmi Medical Centre & Hospital has established the following Vision, Mission and
Quality Policy:

Vision:
Quality Modern Ethical Healthcare.

Mission:
To provide patient friendly environment.

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To provide quality healthcare to the patients, confirming to scientific and ethical

standards.
To constantly upgrade the quality of medical practice and education in the hospital.
Continuously audit and improve services.

Our Quality Policy:

We hereby assure quality healthcare to patients through reliable healthcare services, available
medicines and maintainable equipments.
We shall ensure efficiency of operations and effectiveness of treatment through our competent
human resources.
We shall review this policy for continuing suitability, adequacy and effectiveness.
We shall achieve this through the quality objectives and targets set for various departments.

Sri Lakshmi Medical Centre & Hospital provides the following services:

a) General & Laparoscopic Surgery

b) Gastro Enterology
c) Cardiology
d) Cardio thoracic Surgery
e) Obstetrics , Gynecology & Infertility
f) Orthopaedic and Traumatology
g) Spine Surgery
h) Neurology
i) Neuro Surgery
j) Pediatrics
k) Urology
l) Nephrology
m) Oncology

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n) Vascular Surgery
o) Pulmonology
p) Plastic and Micro Vascular Surgery
q) ENT
r) Dermatology & Cosmetology
s) Radiology
t) Physiotherapy
u) Master Heath Check Up
v) Diet Counseling
w) 24 hrs Computerized Lab
x) Ambulance Service.

Sri Lakshmi Medical Centre & Hospital has designated The Infection Control Nurse to oversee the hospital
wide safety program.

The Hospital has identified the following committees towards ensuring quality of patient care and towards
patient safety:
a.
i.

Quality & Safety Committee:

Members:
Chairman
Quality Manager
HR Manager
RMO
Radiologist
Pathologist
Anaesthesiologist
Obstetrics &Gynaecologist
Safety Officer

ii.

Responsibilities:

a. Issue Quality Policy

Dr.D.Suresh Kumar
Mrs.SindhuVishwanath
Mrs.Usha Nandhini.N.B
Dr.Silambarasan
Dr.Thayanandhar
Dr.Moorthy
Dr.AshokHariharan
Dr.Deepa
Mr.C.Vignesh

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b. Documentation of policy
c. Define scope of services
d. Deal with all matters concerning quality management system, quality improvement,
accreditation of the health care service
e. Function as apex committee for monitoring performance indicators .
f. Standardization of procedures and systems
g. Plan and act for Continuous Quality improvement of hospital
h. Quality assurance activities in Laboratory, Radiology, OT and ICU.
iii.

b.
i.

Frequency of meetings: Once in a month or as and when required

Infection Control Committee:

Members:
Residential Medical Officer
Lab Incharge
Infection Control Nurse
Nursing Superintendent
Pathologist
Purchase In-Charge
Maintenance In-Charge
Housekeeping In-Charge

ii.

Dr.Silambarasan
Ms.Nisha
Ms.Kavitha.J.
Ms.Kavitha.J
Dr.Moorthy
Ms.Ananthalakshmi
Mr.GnanaAgnel Dias
Ms.Arokia Angelin.J

Responsibilities:
a. Document and issue infection control manual including policies
b. Conduct training for infection control
c. Surveillance and monitoring for compliance with policies
d. Issue antibiotic policy
e. Monitor Hospital acquired infection

iii.
c.
i.

Frequency of meetings: Quarterly /As and when required

Pharmaco-Therapeutics Committee:
Members:

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Chairman
Pharmacist
Assistant Manager
Physician
Pediatrician
Purchase In-Charge
ii.

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Dr.Suresh Kumar
Ms.Unnamalai
Mr.Krishna Kumar
Dr.Uvaraj
Dr.Sukumar
Ms.Ananthalakshmi

Responsibilities:

a. Develop and issue policy on Formulary and medication management

b. Supervise purchases and procurement
c. Supervise and management of pharmacy
d. Monitor and evaluate adverse drug reactions
e. Manage the control of drugs
f. Supervise drug information service
iii.

d.
i.

Frequency of meetings: Quarterly or as and when required

Blood Transfusion Committee:

Members:
Chairman
Infection Control Nurse
Anaesthetist
Gynaecologist
Lab Incharge
OT Incharge

ii.

Dr.Suresh Kumar
Ms.Kavitha
Dr.AshokHariharan
Dr.Deepa
Ms.Nisha
Mr.Sabarigiri

Responsibilities:
a. To ensure the OT asepsis and optimum utilization.
b. To monitor the quality indicators of OT.
c. To monitor any critical incidents in OT.
d. To monitor the transfusion reactions.
e. To ensure the compliance of the statutory requirements.

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iii.

e.
i.

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Frequency of meetings: Once in 3 months / Quarterly or as and when required

Medical Records Committee:

Members:
Chairman
Assistant Manager
Medical Records Incharge
Residential Medical Officer
EDP In-Charge
Nursing Superintendent

ii.

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Dr.Suresh Kumar
Mr.Krishna Kumar
Ms.Vimala
Dr.Silambarasan
Mr.Mohan
Ms.Kavitha.J

Responsibilities:

a. Develop guidelines for medical care and medical records maintenance

b. Review and evaluate patient records for quality, adequacy of patient care, monitor staff for
compliance with policies
c. Evaluate medical record keeping, quality, content, format, accuracy, staff compliance with
documentation policies
d. Review, evaluate and monitor adverse drug reaction
e. Implementation of Right to Information
iii.

Frequency of meetings: Quarterly /As and when required