Hospital Committees

SVIMS Hospital is committed to promote patient centeredness and ensure patient safety through continuous quality
improvement. The hospital committees are multi-plural and are formed with care to include the many facets that are
needed for an integrative service approach. The safety of the patient and the health care workers is the primary
objective of the hospital committees.

Constituted Committees:

Sl. No. Chapter Name

01. COP CPR Analysis Committee (CPRA).
02. COP Blood Bank Committee
03. MOM Pharmaco Therapeutics Committee (PTC)
04. HIC Infection Control Committee
05. HIC AMS Committee
06. PSQ Patient Safety Committee
07. PSQ Quality Improvement Committee
08. PSQ Sentinel Events Analysis Committee
09. HRM Internal Complaints Committee
10. HRM Disciplinary & Grievance Committee
11 IMS Medical Records Review Committee
 1. CPR ANALYSIS COMMITTEE:

S.No. Name Role Responsibility

1. Medical Superintendent Chairperson Head & approving authority for Code Blue
committee related matters. Supervise the
committee functioning. Reconstitute the
committee whenever required. Take actions for
resolution of issues/problems identified by other
committee members. Continuous monitoring of
the quality of the committee functions.
2. RMO Member Head & approving authority for Code Blue
committee related matters. Supervise the
committee functioning. Reconstitute the
committee whenever required. Take actions for
resolution of issues/problems identified by other
committee members. Continuous monitoring of
the quality of the committee functions.
3. Dr. A.N. Sowmya (EMD Member • Convene the meeting s with prior approval
Physician) from Chairperson
4. Dr. Sameraja, (General Member • Conduct Mock drills, audits & debriefing
Physician) sessions.
5. Dr. Rama, (General • Attend CPRA monthly BLS & ACLS training
Physician) programmes. Follow the instructions given
6. Dr. Vinay, (Anaesthesiology) Member and/or responsibilities assigned by the
Chairperson.
7. Dr. Rajamani , (General • Identify the deficiencies and problems to be
Physician) rectified to improve the quality of the work.
8. Dr. Akila , (Obstretics)
9. Dr. Kiran, (Cardiology)
10. Dr. Sreedevi
(Anaesthesiology)
11. Smt. S. Sunitha (NS-I) Member Attend CPRA monthly meetings. Arrangements
Smt. J. Sarada Devi (NS-II) for training programs. Resource arrangements for
Smt. G. Indiramma (NS-II) Code Blue activities. CAPA analysis and
Smt. I. Kanthamma (NS-II) implementation.
Smt. E. Bhuvaneswari(NS-II)
12. Smt. Y. Nirmala Member Attend CPRA monthly meetings. Arrangements
(Head Nurse) for training programs. Resource arrangements for
13. Smt. T. Suseela Member Code Blue activities. CAPA analysis and
(Head Nurse) implementation. Follow the instructions given
and/or responsibilities assigned by the
14. Smt. L. Haritha Member Chairperson. Identify the deficiencies and
(Head Nurse) problems to be rectified to improve the quality of
15. Smt. N. Ravanamma Member the work.
(Head Nurse)
16. B. Divyavani Member • Attending the Code Blue calls.
(Code Blue Nurse) Secretary • Maintaining the Code Blue data base.
17. P. Geetha Member Collection and documentation of Code Blue
(Code Blue Nurse) census.
18. G.Ramasri Member • Follow-up of the Code Blue survivors.
(Code Blue Nurse) • Attend CPRA review meetings.
 S.No. Name Role Responsibility
19. P. Chandana Member • Identifying the shortfalls in resources and
(Code Blue Nurse) address them to the Nursing Superintendent /
CPRA committee.
20. P. Haritha Member
• Participate in Mock drills and audits.
(Code Blue Nurse)
21. G. Sunil Member
22. D. Manjusha
23. G. Praveen Kumar
24. Mr. B. Prasad (IT Member Coordinate the members of the committee.
Department) Making arrangement for the meetings.
Documentation minutes of the meetings. Records
maintenance. Follow the instructions given and /or
responsibilities assigned by the Chairperson.
25. Mr. N.VS. Prasad MSW Counselling the patient attendants during Code
Blue. Follow the instructions given and/or
responsibilities assigned by the Chairperson.
26. Mr. Prakash Security Attend all Code Blue calls & provide support for
the Code Blue Team. Assist with way finding for
staff, and other patients/visitors. Cordon off the
area to ensure the Code Blue Team is unimpeded.
Controlling the attendants during Code Blue.
Follow the instructions given and/or
responsibilities assigned by the Chairperson.

Meeting schedule and quorum of the meeting

• CPRA committee review meetings are being conducted once in a month preferable on second Monday of
every month.
• Quorum: requires at least 50% of the total committee members i.e., minimum of 10 members.
• Presence of Cardiologist/General Physician, Anaesthesiologist, Nursing Superintendent, Head Nurse,
Nurse from Code Blue team, MSW, Security officer during the review meetings is mandatory to fulfil the
quorum.
 2. INFECTION CONTROL COMMITTEE:

S.No Name Role Responsibility

1 Director cum Vice- Chairman • Head & approving authority for committee related matters.
Chancellor Supervise the committee functioning.
2 Dr Ram Co- • Reconstitute the committee whenever required. Take actions
chairman for resolution of issues/problems identified by other
committee members. Continuous monitoring of the quality of
the committee functions.
3 Dr B. Venkata Member • Senior Microbiologist. Monitors the activities of Infection
Ramana secretary control team.
4 Dr A. Mohan Member • Take actions for resolution of issues/problems identified by
other committee members. Continuous monitoring of the
quality of the committee functions.
5 Dr Pranabandhu Member • Take actions for resolution of issues/problems identified by
Das other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
6 Dr G. Swetha Rao Member • Take actions for resolution of issues/problems identified by
other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
7 Dr Chaitanya Member • Take actions for resolution of issues/problems identified by
other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
8 Dr C. Konda Member • Take actions for resolution of issues/problems identified by
Reddy other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
9 Dr D. Satyavathi Member • Take actions for resolution of issues/problems identified by
other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
10 Dr Prajakta Member • Take actions for resolution of issues/problems identified by
other committee members.
• Attend monthly review meetings. Follow the instructions
given and/or responsibilities assigned by the Chairperson/Co-
chairperson
11 Dr R. Jayaprada HICO • Coordinate with the Medical Superintendent (Co-Chairman)
in planning infection control program and measures.
12 Dr N. Ramakrishna HICO • ICO is responsible for surveillance and supervision of
hospital acquired infection as well as preventive and
13 Dr S. Yamini HICO corrective programmes in the hospital.
14 Dr V. Harika HICO
15 Mrs. T. Member • Attend monthly review meetings.
Prabhavathi • Follow the instructions given and/or responsibilities assigned
by the Chairperson / Co-chairperson
16 Mrs. M. Member • Environmental surveillance.
Lakshmidevi • Surveillance of air in OT’s/ICUs.
S.No Name Role Responsibility
17 Mrs. V. Karpugam Member • To check for sterilization & dis-infection practices.
• In-use test of disinfectants.
18 Mrs. D. Redemma Member • Autoclave checks, Water testing.
• Continuous surveillance of HAI infections.
19 Mrs. A. Shobharani Member • Educating of HCWs.
20 Mrs. Shakira Member • Monitor OT related IPC practices, Attend monthly review
meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson / Co-chairperson.
21 Mrs. C. Sunitha Member • Monitor CSSD related IPC practices, Attend monthly review
meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
22 Mrs. A. Member • Monitor sanitation & disinfection activities in all areas,
Umamaheswari Attend monthly review meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
23 Dr P. Member • Monitor Antimicrobial prescriptions for high end antibiotics
Subramanyam and antimicrobial prescription audit.
• Attend monthly review meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
24 Mrs.C. Sunitha Member • Monitor Laundry & linen related IPC practices, Attend
monthly review meetings.
25 Mrs. D. Indiramma Member • Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
26 Mrs.M. Sunitha Member • Monitor Kitchen sanitation & vaccination of food handlers.
Attend monthly review meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
27 Dr V. Member • Monitor any outbreaks if infections & MDR bugs.
Chandrasekar • Attend monthly review meetings.
• Follow the instructions given and/or responsibilities assigned
by the Chairperson/Co-chairperson.
28 Mr. T.V.P.Kumar Member • Monitor water tanks disinfection including RO plants.
• Attend monthly review meetings.
• Follow the instructions given and/or 28responsibilities
assigned by the Chairperson/Co-chairperson.
29 Mr. P. Yashodhar Member • Air and surface surveillance culture for OT, ICU’s and other
high risk areas
30 Mr. V. Venkatesh Member • Performing water surveillance to test the quality for drinking
water
• Performing disinfectant testing of a range disinfectant
• Sterility checking of blood and blood product
31 Mr. Sai Jagadeesh Secretarial • Documentation of minutes of the meetings.
Assistant

Meeting schedule and quorum of the meeting

• HICC committee review meetings are being conducted once in a month preferably on FIRST TUESDAY
of every month.
• Quorum: Requires at least 50% of the total committee members i.e., minimum of 15 members.
• Presence of Chairperson/Co-chairperson, member secretary, Physicians, surgeons, HICOs, ICNs, Nursing
superintendent, health inspector, CSSD, engineering dept., OT and ICUs in charges during the review
meetings is mandatory to fulfil the quorum.
 3. PHARMACO THERAPEUTICS COMMITTEE:

S. Name Role Responsibility

No
1 Dr.Ram Chairman Advising medical, administrative and pharmacy
(Medical Superintendent) departments on pharmaceutical related issues.
Monitor and Supervise the committee functioning.
Reconstitute the committee whenever required.
2 Dr.K.Uma Maheswara Executive Developing drug policies and procedures.
Rao Secretary Evaluating and selecting medicines for the formulary and
(Prof & HOD, providing for its periodic revision. Promoting &
Pharmacology) conducting effective interventions to improve medication
use. Monitoring ADRs & Medication errors. Conducting
audits and training programmes for improving medication
safety.
3 Dr.P.Subramanyam Member Attend PTC monthly meetings. Following the instructions
(Sr.Pharmacist) assigned by the chair person and executive secretary.
Checking whether medications are stored appropriately and
are available when required. Checking whether
medications are dispensed in safe manner. Checking
whether medical supplies and consumables are stored
appropriately and are available when required. Identifying
deficiencies to improve the quality of medication safety.
4 Dr. Aloka Samantaray Member Attend PTC monthly meetings. Reviewing the minutes of
(Prof & HOD, meetings. Checking for the proper maintenance of crash
Anaesthesiology) cart.
5 Dr.Vinod Bhan Member Attend PTC monthly meetings. Reviewing the minutes of
(Prof., CT Surgery) meetings. Checking whether implantable prosthesis and
medical devices are used in accordance with laid down
criteria.
6 Dr.Chandramalitheswaran Member Attend PTC monthly meetings. Reviewing the minutes of
(Assoc. Prof, Surgical GE) meetings. Advising for surgical items and their storage.
7 Dr.Malathi Member Attend PTC monthly meetings. Reviewing the minutes of
(Assoc.Prof, OBG) meetings.
8 Dr.Venkata Naveen Member Attend PTC monthly meetings. Reviewing the minutes of
Prasad meetings.
(Assoc Prof, Neurology)
9 Dr.Bhargavi Member Attend PTC monthly meetings. Reviewing the minutes of
(Assoc Prof., Medical meetings. Checking whether narcotic drugs and
Oncology) psychotropic substances, chemotherapeutic agents are used
safely.
10 Dr.M.C.R.Rama Member Attend PTC monthly meetings. Reviewing the minutes of
(Asst.Prof.,of Medicine) meetings.
11 Dr.Harini Devi Member Attend PTC monthly meetings. Reviewing the minutes of
(Asso.Prof.,Biochemistry) meetings. Advising regarding lab chemicals, reagents and
their storage
12 Dr.Sujith Kumar Member Attend PTC monthly meetings. Reviewing the minutes of
(Assoc.Prof,Community meetings.
Medicine)
13 Dr.Akhila Member Attend PTC monthly meetings. Reviewing the minutes of
(Asst.Prof.,OBG) meetings.
14 Dr.C.Pallavi, (Asst.Prof., Member Attend PTC monthly meetings. Attending clinical audits
Pharmacology) and training programmes related to medication safety.
Monitoring medication errors and CAPA. Reviewing the
minutes of meetings.
S. Name Role Responsibility
No
15 Dr.G.Ravindra Kumar Member Attend PTC monthly meetings. Attending clinical audits
(Asst.Prof., and training programmes related to medication safety.
Pharmacology) Monitoring medication errors and CAPA. Reviewing the
minutes of meetings.
16 Dr.Ramya Priya Member Attend PTC monthly meetings. Reviewing the minutes of
(Asst.Prof., Nuclear Med) meetings.
17 Dr.Jayaprda Member Attend PTC monthly meetings. Reviewing the minutes of
(Assoc.Prof. meetings. Monitoring Antibiotic audit Committee and
Microbiology) developing policies concerning usage of antibiotics.
18 Dr.M.Yerram Reddy Member Attend PTC monthly meetings. Reviewing the minutes of
(A.D Purchase) meetings. Monitoring for improved medicine procurement
and inventory management.
19 Mr.L.Sateesh Member Attend PTC monthly meetings. Following the instructions
(A.D Stores) assigned by the chair person and executive secretary.
Checking whether medications are stored appropriately and
are available when required. Checking whether
medications are dispensed in safe manner. Checking
whether medical supplies and consumables are stored
appropriately and are available when required. Identifying
deficiencies to improve the quality of medication safety.
20 Mrs.Prabhavathi Member Attend PTC monthly meetings. Reviewing the minutes of
(A.D. Nursing) meetings. Checking for the safe dispensing and
administration of medications. Monitoring the patients
after administration. Advising medication administration
staff to minimise medication errors and take necessary
CAPA for enhancing patient safety.
21 Mrs.C.Sunitha Member Attend PTC monthly meetings. Reviewing the minutes of
(Nursing Superintendent meetings. Checking for the safe dispensing and
Gr-I) administration of medications. Advising medication
administration staff to minimise medication errors and take
necessary CAPA for enhancing patient safety.
22 Mr.Subramanyam Raju Member Attend PTC monthly meetings. Reviewing the minutes of
(Pharmacist Gr-I) meetings. Checking for the safe dispensing of medicines.
23 Mr.Babu Suresh Member Attend PTC monthly meetings. Reviewing the minutes of
(Pharmacist Gr-I) meetings. Checking for the safe dispensing of medicines.
24 Dr.A.Sai Kiran Member Attend PTC monthly meetings. Reviewing the minutes of
(Clinical Pharmacist) meetings. Attending clinical rounds and monitoring
medication use. Identifying and reporting ADRs
medication errors along with CAPA.
25 Dr.P.Anuhya Member Attend PTC monthly meetings. Reviewing the minutes of
(Clinical Pharmacist) meetings. Checking whether medication orders are written
in uniform manner or not. Attending clinical rounds and
monitoring medication use. Identifying and reporting
ADRs medication errors along with CAPA.

Meeting schedule and quorum of the meeting

• PTC meeting is scheduled once in a month i.e. every 1st Friday of month
• Quorum: Requires at least 50% of the total committee members
 4. QUALITY IMPROVEMENT COMMITTEE:

S.No. Name & Designation of the Position in the Roles and Responsibilities of the
Member committee member
01 Director cum Vice-Chancellor Chairman
02 Dr. Y. Mutheeswaraiah, Professor Member Implementation of AAC standards
& Head, Dept. of Surgery through out the hospital.
03 Dr. K. UmamaheswarRao, Member Implementation of MOM chapter through
Professor & Head, Dept. of out the hospital and PSQ3 standard.
Pharmacology
04 Mrs. K. Bhavana, IT Manager Member Implementation of IMS chapter through
out the hospital
05 Mrs. GP. Manjula, AD Member Implementation of HRM chapter
Establishment Section II
06 Dr. Vinod Bhan, Professor, Member–Patient Implementation of Patient safety
Dept. of C.T. Surgery Safety programmes through out the hospital and
PSQ 1, & FMS 3 (e) ( f)
07 1. Dr. A. Surekha, Assoc. Prof., Member– Implementation Clinical Safety measures
Dept. of DVL – I/c for Medical Clinical safety through out the hospital & PSQ 4
Departments standard.
2. Dr. B. Manilal, Assoc. Prof.,
Dept. of SO – I/c for Surgical
Departments
3. Dr. V. Sivakumar, Asst. Prof,
Dept. of Pathology – I/c for Lab
Departments
08 Dr. Pranabandu Das, Assoc. Member In charge for Sentinel events Analysis &
Professor, Dept. of Radiotherapy Implementation of PSQ 7 standard
09 Dr.H.Narendra Prof. & Head, Member In charge for clinical audits and
Dept. of SO Implementation of PSQ 5 standard
10 Dr. R. Jayaprada Member from Implementation of HIC programme
Assoc. Professor, HIC through out the hospital and
Dept. of Microbiology Implementation of PSQ3, FMS 1 (e),
FMS 7 (c), standard elements.
11 Mr. Elango Reddy Member from Implementation of FIRE SAFETY, Mock
Fire Safety Officer support services drills for CODE RED &
FMS 4 (e) & FMS 7 standard elements.
12 Mr. B. Prakesh Member from FMS 3 (b)
Security Officer Support services
13 Dr V.S.Kiranmayi Member from Implementation of PSQ, chapter through
Assoc. Professor, Lab services out the hospital and PSQ 3 standard in
Dept. of Biochemistry detail.
14 Dr. V. Vanajakshama, Professor, Member from Implementation of mock drills for code
Dept. of Cardiology CPR committee blue FMS 7 (c)
15 Dr. J. Malathi, Assoc. Professor, Member from Implementation of mock drills for CODE
Dept. of OBG OBG services PINK , FMS 7 (c) & COP 10 standard
elements.
16 Dr. PunithPatak, Assoc. Professor Member from Implementation of mock drills for CODE
& Ho Di/c, Dept. of Paediatrics Paediatric PINK, FMS 7 (c) & COP 11
services Standard elements.
17 Dr. P. JanakiSubhadhra Member from Implementation of PSQ3 standard
Professor, Dept. of ICU services through out the hospital.
Anaesthesiology
S.No. Name & Designation of the Position in the Roles and Responsibilities of the
Member committee member
18 Dr. S. Sarala Member from Implementation of RADIATION
Professor, Dept. of Radiology Imaging SAFETY PRACTICES ACROSS
Services IMAGING SERVICES - AAC 9,
AAC10, & AAC 11 standards.
19 HoD EMD Services Member from Implementation of PSQ3, COP 2,
Emergency COP3, COP 4 & FMS 7 (c) standards
Services and elements
20 Mr. K. Kantha Rao Member – Implementation of HIC 4(c) through out
Sanitary Supervisor Support the hospital.
Services

21 Mrs. M. Prasanna Lakshmi Member – Implementation of FMS 2 (g), FMS 3 (e),

Deputy Director (GM) Facility FMS 6 standards and elements through
Management out the hospital.
22 Asst. Engneer, Civil, TTD SVIMS Member – Implementation of FMS 1 (a, b, e) FMS
Facility 2 (b, g) FMS 3 (a) FMS 4 (f) standards
Management and elements through out the hospital.
23 Mr. K. Narasimha Reddy, Member – Implementation of FMS 2 (b) (d), (e), ( g)
Asst. Engineer (Electrical) Facility FMS 3 (c), FMS 4 (a,), (b), (c), (d), (e),
Management (f), (g), (h) standards and elements
through out the hospital.
24 Mr. T.V.P. Kumar Member – Implementation of FMS 1 b, FMS 2(d, e,
Asst. Engineer, Technical Facility f, g)& FMS 4 (c, f, g, h)
Management
25 Mr. Dorai Swamy Member from Implementation of FMS 5
Sr. Biomedical Engineer Facility
Management

26 Account Officer Member from PSQ6(e) & ROM 4 (c)

Finance/Accoun
ts
27 Mr NVS. Prasad Member from PSQ 3 (e) & FMS 7 (c)
Medico social Worker Patient Reported
Outcome
Measures
(PROM)
28 Patient Safety Committee Implementation of PSQ1
Leader (a,b,c,d,e,f,g,g,i) FMS 1 (b, d)
29 Mr. R. Nagaraja Member Implementation of FMS 2 (c)
Sr. Artist
30 Mrs. T. Prabhavathi Member from Implementation of FMS 3 (e), FMS 4 (d)
Asst. Director (Nursing) Nursing Services

Meeting schedule and quorum of the meeting

• The quality improvement meeting is scheduled twice in a month i.e. on 2nd & 4th Tuesday of every
month.
• The meetings are held by involving limited departments to discuss and review the quality improvement
activities in patients oriented areas and in the organization oriented standards.
 5. PATIENT SAFETY COMMITTEE:

S. No Name & Role Responsibility

1. Facility Management Team
1.1 Principal, College of Provision of Grab Bars, Special Toilets for differently able persons,
Physiotherapy wheel chairs, External and Internal signage’s and bed rails.
1.2 Deputy Executive Before commencement of expansion or maintenance of any work, risk
Engineer, Civil assessment shall be done with the help of HIC coordinator and this shall
be covered noise, vibration and infection control. Built and updated
drawings are to be maintained as per statutory requirements, Check the
swing doors unsafe for people passing through it. Leakages/seepages in
the area rendering it prone to infection. Height of the ceiling can cause
injury to head to people with long height. Unwanted or unnoticed holes,
breaks in the floor/ground that can be hazardous while walking.
Terrace/higher floors lack of grills at the border making it unsafe.
1.3 Radiation Safety To follow AERB guidelines.
Officer
1.4 AE, SVIMS Potable water testing, overhead storage cause accidents, Is placement of
furniture can cause any fall.
1.5 Assistant Engineer, Electricity Back up, Elevators movements to avoid sudden stoppage and
Electrical, TTD jerks, unprotected electrical wirings, lack of adequate lighting can cause
which can be reason for accidents or errors.
1.6 Security Officer Restricted entry into OTs, ICUs and CC TV coverage of the entire
hospital and monitoring.
1.7 Deputy Director(GM) As per FMS 7 standard
1.8 Deputy Director(GM) As per FMS 6 standard
2. Dr. Vinod Bhan, Professor, Department of CT Surgery, Patient Safety Officer

1.Environmental Safety
2.Lab Safety
3.Equipment risk Eg. Fire/Injury risk from use of LASER
4.Risk resulting from long term conditions
5.Internal and External reporting system on process failure
6.Fire accidents
7.Leakage of radiation source
8.Incidents covering from “no harm” to “sentinel events”
9.Pro-active risk analysis of patient safety risks shall be done through
HIRA and FMEA.
10. At minimum one patient safety related risk shall undergo proactive
risk analysis every year.
11. Avoid Lack of continuity of manpower during surgery due to shift
duties
12. Avoid Patient Fall from trolley to bed and bed to Trolley
13. Avoid Cautery burns
14. Avoid Delay in availability of surgical material in middle of surgery
15. Connecting all critical equipments to UPS
16. Continuous medical gas supply
17. Patient safety officer shall report directly to the top management
Clinical Safety Officer 1. Radiation Safety – ALARA (As low as reasonably achievable) Eg.
X-ray for all ICU, Pediatric or neonatal, patients. CT Scan
protocols to be modified to use the lowest exposure. Parameters to
maintain the image quality appropriate for clinical indication. Eg.
CT for ureteric calculi can be done with low dose where as renal
tumor will require high dose.
S. No Name & Role Responsibility
2. Appropriate screening of the patients before imaging.
3. Patients in the child bearing age group who need to be exposed to
radiation should be scanned for pregnancy. MRI patients screened
for Magnetic substance. Screening also shall be applicable to the
accompanying patient/child into the imaging area.
4. Shielding of body parts of the patients, attendants shall be adhered to
using appropriately.
5. To identify various risk, record for action taken for risk alleviation
of each of these risk and the mechanism for informing the staff
regarding the same.
6. Medication Management covering the issues of Patient/Service user,
allergies and antibiotic resistance.
7. Implementation of current national patient safety/International
patient safety goals.
8. SBAR communication for patients handover
9. Two identifiers for patients identification
10. Implement evidence based medicine/ clinical practice guidelines
(STGs) Standard Treatment Guidelines bought by GoI.
11. To define list of high risk medication, Look alike sound alike,
different concentrations of the same drug to be stored far away, High
risk medications are to be verified before dispensing, Inadvertent
administration of drug through wrong route shall be avoided.
12. Medication orders shall be checked at transition points of the
patients.
13. Hand Hygiene guidelines at all locations of hand washing areas.
14. One Needle, one syringe and only one time policy. To implement
CDC recommendations.
15. Retained missing instruments and gauze
Paramedical staff 1. Follow HIC practices while attending patients.
2. Avoid to storing of listed hazardous material in unsafe condition
3. Maintain MSDS sheets
Clinicians 1. Implementation National/International patient Safety Goals
2. Implement the Clinical Safety Officer guidelines pertaining to the
respective Clinical and Diagnostic departments as suggested by the
Clinical Safety Officer.
3. Implement evidence based medicine/ clinical practice guidelines
(STGs) Standard Treatment Guidelines bought by GoI.
Nurses 1. Implement the guidelines pertaining to the respective clinical
departments as suggested by the Clinical Safety Officer.
2. Follow HIC practices while attending patients.
3. Fall risk assessment of the patients and to take pro-active risk
management.
Support Services 1. Slippery floor and probable to cause slip falls.
2. Rodents and pests in the area which can cause harm to patients, staff
and equipments.
Meeting schedule and quorum of the meeting

• The Patient safety committee meeting is scheduled once in a month i.e. on 4th Saturday of every month.
• Quorum: Requires at least 50% of the total committee members
• Patient safety aspects like development, implementation and monitoring of the safety plans and policies
to provide as safe and secure facility and environment. Proactive risk assessment, FEMA, HIRA, facility
inspection rounds, patient safety incident, risk management and analysis of key-safety indicators and
sentinel events.
 6. INTERNAL COMPLAINTS COMMITTEE:

S.No. Name of the Member Designation & Department Status in Internal

Complaints Committee
01 Dr Aparna R Bitla Professor, Department of Presiding Officer
Biochemistry
02 Dr.V.Venkatarami Reddy Professor & HOD, Department Member
of Surgical G.E.
03 Dr.K.Prathiba Associate Professor, Department Member
of Anatomy
04 Sri. Ashok Kumar Advocate & Standing Counsel, Member-External (legal)
SVIMS

The respective HoD’s /College Principals/Administrative HoD’s shall be co-opted on case to case basis
depending upon the need.
Roles & Responsibilities
The Internal Committee, SVIMS plays an important role in the functioning of the provisions of the Act and to
ensure the fulfillment of its objectives of the Internal Committee Policy thus the main function of the Internal
Committee is:

• Implementation of the Internal Committee Policy relating to the prevention of sexual harassment.
• Resolving complaints by the aggrieved based on the guidelines of the Internal Committee Policy.
• Recommending actions to be taken by the Employer.
As per Section 11(3) the internal Committee enjoys the powers same as that of a civil court and therefore:
• It is empowered to initiate an inquiry into a complaint of sexual harassment at the workplace according to
the Internal Committee Policy.
• IC has the power to summon witnesses and parties to state the committee.
• It enjoys the discretion of summoning evidence to be examined if it may be deemed necessary to do so by
the members of the committee.
• All the members thus have an active role in each of the above. The external legal advisor shall give
opinion related to the legal issues pertaining to the case. Inclusion of the external member ensures
transparency and authenticity to the entire process and gives an outside perspective.

Responsibilities of Internal Complaints Committee:

SVIMS is bound by Prevention of Sexual Harassment Act and displays the names and details of the current IC
members on the premises at prominent places as well as in the official website.

• Receive complaints of sexual harassment at the workplace

• Initiate and conduct an inquiry as per the policy
• Submit findings and recommendations of all such inquiries
• Maintain strict confidentiality throughout the process as per established guidelines of the Internal
Committee Policy
• Submit annual report in the prescribed format as prescribed.

Meeting schedule and quorum of the meeting

• Once in a month and as and when a case is registered, the committee shall meet immediately.
• Quorum: Requires 100% of the total committee members.
7. DISCIPLINARY & GRIEVANCE COMMITTEE:

S. Name of the Status in Disciplinary & Roles & Responsibility

No. Member Grievance Committee
01 Dr. D. Rajasekhar Chairperson The Grievance Committee shall be
responsible to ensure that grievances
02 Dr. A. Mohan Member-Ex-Officio-Dean are dealt with effectively in
accordance with the Grievance
03 Dr. K.V. Sreedhara Member– Ex-Officio– Procedures set out for the
Babu Registrar implementation of this Policy.
In doing so, the Committee shall
04 Dr. K. Nagaraj Member – Secretary adhere to the following principle

05 Dr. Dr. Chandramal Member • Take grievances seriously taking

Theswaran on board why the employee feels
aggrieved, unhappy or dissatisfied
06 Dr. K. Prathiba Member • Investigate the facts and
07 Dr. A. Surekha Member surrounding circumstances, and
showing the employees that this
08 Dr. M. Ganesh Member been done thoroughly and
Kumar sensitively.
• Actively look for a solution that
09 Dr. V. Srikumari Member will satisfy the employee, where
practical without causing
10 Mrs. G.P. Manjula Convener & Coordinator disproportionate difficulty for the
organization or the Employee’s
colleagues.
• Provide feedback to the employee
about what can, and cannot be
done to resolve the grievance
• Take necessary follow-up action
• All the members thus have an
active role in each of the above.

Meeting schedule and quorum of the meeting

• The disciplinary & Grievance Committee meeting shall be held on 1st Saturday of every month
between 3 and 4 pm in the committee hall.
• Quorum requires at least 50% of the total committee members.
 8. MEDICAL RECORDS REVIEW COMMITTEE:

S. No. Name of the Status in Disciplinary Roles & Responsibility

Member &
Grievance Committee
01 Medical Chairperson • Responsible or overall supervision of the
Superintendent Committee activities.
• Responsible for sending lacunas for CAPA
to the concerned HoD’s.
02 Medical Record Coordinator • Co-ordinate the Medical Record Review
Officer Committee Meeting.
• Prepares the minutes of the meeting.
• Dispatches the minutes to the concerned
and inform the deficits to the concerned.
• Responsible for sample bases review
03 Resident Medical Member • Address the members in the meeting,
Officer discuss with the concerned members to
complete the lacunas at the earliest.
04 HoD, Dept. of Member • Responsible to conduct audit for complete
Anaesthesiology consent form, anaesthesia record &
operation record.
05 HoD, Dept. of Member • Responsible to conduct audit for
Pharmacology medication chart, regarding administered
drug properly, legibility of author name,
signature time and to write in capitals,
using no short forms, dosage.
06 Prof. Dept. of Member • To audit the medical cases.
Medicine
07 Assoc. Prof Dept. Member • To audit the surgical cases.
of General Surgery
08 AD Nursing & Member • To audit the nursing assessment / Nurses
Nursing Group notes and various consent forms used at the
time of admission.

Meeting schedule of the Medical Record Review Committee meeting

The Medical Record Review committee shall meet once in a month i.e. on 3rd Thursday at 10:30 am in the
committee hall to review the medical records of current patients.
9. AMS COMMITTEE

Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials
(including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of
infections caused by multidrug-resistant organisms.

THE FOLLOWING ARE THE MEMBERS OF ANTIMICROBIAL STEWARDSHIP COMMITTEE:

1. Dr R. Ram (Medical superintendent) - Chairman

2. Dr R. Jayaprada (Microbiology) - Member
3. Dr N. Ramakrishna (Microbiology) - Member
4. Dr C. Sunil Kumar (GM) - Member
5. Dr M.C.R. Rama (GM) - Member
6. Dr C.V.S.Manasa (GM) - Member
7. Dr V. Manolasya, (GM) - Member
8. Dr Surekha.A (Dermatology) - Member
9. Dr B.Hari Prasad (GS) - Member
10. Dr V. Nagateja (Plastic surgery) - Member
11. Dr K. Venkat (Neurosurgery) - Member
12. Dr B. Manilal (SO) - Member
13. Dr J. Malathi (OBG) - Member
14. Dr D. Bhargavi (MO) - Member
15. Dr A. Naga Sowmya (EMD) - Member
16. Dr Jonnakuti Rani (EMD) - Member
17. Dr P. Hemalatha (Anaesthesiology) - Member
18. Dr C. Sumadhu (Anaesthesiology) - Member
19. Dr V. Chandra sekhar (PSM) - Member
20. Dr K. Vijaya Chandra Reddy (Pharmacology) - Member
21. Dr J.P. Joshi Sowmya (Pharm D) - Member
22. Dr C. Pallavi (Pharmacology) - Member
23. Dr Peta subramanyam (Pharmacist) - Member
24. Mr V. Babu suresh (Pharmacist) - Member
25. K.V. Kishore Tangella - Member
26. AMS & HIC Link nurses (All ICU and RR) - Member
27. Nursing Superintendents (Mrs Indiramma & Mrs Sharada devi) - Member

Meeting schedule of the Medical Record Review Committee meeting

 The committee shall meet once in a month as per Medical Superintendent orders.
• Quorum requires at least 50% of the total committee members.