JJM HOSPITAL, KASHIPUR
HOSPITAL ORGANIZATIONAL STRUCTURE & CLINICAL GOVERNANCE FLOW CHART
Accreditation Framework: NABH 6th Edition Standards (Core Governance, Continuous Quality Improvement & Patient Safety)
MEDICAL DIRECTOR / MANAGING DIRECTOR
Designated: Dr. Abhishek Goel
Executive Leadership, Resource Allocation & Clinical Quality Accountability
MEDICAL SUPERINTENDENT
Designated: Dr. Ashok Goel
Clinical Governance, Credentialing & Patient Care (AAC, COP)
CLINICAL SPECIALTIES (COP, AAC)
Nephrology & Dialysis
Dr. Abhishek Goel
Consultant Nephrologist
(NABH: COP, AAC)
Anaesthesiology & ICU
Dr. Yamini Goel
Consultant Anaesthesiologist
(NABH: COP, MOM)
General & Lap. Surgery
Dr. Pradeep Raj Rastogi
Consultant Surgeon
(NABH: COP, PRE)
Emergency & Casualty
Duty CMOs / EMOs
Casualty Medical Officers
(NABH: AAC, COP)
General Medicine
Dr. S. P. Gupta
Consultant Physician
(NABH: COP, AAC)
Paediatrics
Dr. Arun Prakash Pancholi
Consultant Paediatrician
(NABH: COP, AAC)
Obs & Gynaecology
Dr. Ruchi Devendra Mehta
Consultant Gynaecologist
(NABH: COP, PRE)
Orthopaedics
Dr. A. K. Sirohi
Consultant Orthopaedic Surgeon
(NABH: COP, PRE)
DIAGNOSTICS (PAC)
Radiology & Imaging
Dr. B. M. Goel
Consultant Radiologist
(NABH: PAC, HRM)
Clinical Pathology
Dr. A. K. Goel
Consultant Pathologist
(NABH: PAC, HIC)
Diagnostic Techs
Senior Techs
Lab & X-Ray Technicians
Blood Storage Centre
Medical Officer / Tech
Cold Chain & Crossmatch
(NABH: PAC, COP)
NURSING SERVICES
Nursing Supdt.
Designated: NS
Staffing & Ratios (HRM)
Infection Control Nurse
Designated: ICN
Surveillance & Audits
AUDIT
Ward / ICU Incharges
Senior Staff Nurses
OT, ICU, Dialysis, Wards
Bedside Care Staff
Staff Nurses & Techs
Dialysis Techs & GDA
QUALITY & PATIENT SAFETY
Designated: Quality Manager
NABH 6th CQI Indicators, Risk Assessment, Incident Audits (PSQ)
NABH 6th EDITION QUALITY & PATIENT SAFETY SECRETARIAT
Headed by: Quality Manager | Supported by: Quality Coordinator & NABH Champions
Key Functions: Incident Management (Sentinel Events / Near Misses), Clinical Audits, Quality Indicator Tracking
1. Hospital Infection Control (HICC)
[HIC]
Chair: Med. Supdt. | Sec: ICN | Surveillance: ICN
HAI Surveillance (CAUTI, CLABSI, SSI, VAP), BMW, Disinfection
4. Quality & Patient Safety (CQI)
[CQI, PSQ]
Chair: Dr. Abhishek Goel | Sec: Quality Manager
Hospital KPIs, Sentinel Event RCA, CAPA Implementation
2. Pharmaco & Materiovigilance
[MOM]
Chair: Dr. Yamini Goel | Sec: Chief Pharmacist
High-risk meds, LASA compliance, ADR reporting, implant vigilance
5. Facility Management & Safety (FMS)
[FMS]
Chair: Head - Admin | Sec: Safety Officer
Fire drills, HAZMAT safety, BMS calibrations, HVA disaster plan
3. Resuscitation & Code Blue Committee
[COP]
Chair: Dr. Yamini Goel | Lead: ICU Shift In-charge
Resuscitation audits, Crash Cart readiness, ACLS/BLS training
6. Patient Rights & Grievance Committee
[PRE]
Chair: Med. Supdt. | Sec: Patient Care Executive
Grievances, informed consent, billing audits, privacy rights
HEAD - OPERATIONS & ADMIN
Designated: Hospital Administrator / GM
Infrastructure, Biomedical Safety, Non-Clinical Ops & HR (FMS, HRM)
ALLIED SUPPORT
Pharmacy (24x7)
Chief Pharmacist
Medication Safety (MOM)
CSSD Department
CSSD In-charge
Sterilization & Autoclave
Dietary & Nutrition
Dietitian / Kitchen Head
Patient Diets & Hygiene
Ambulance & Transport
Transport In-charge
24x7 BLS / ALS Transfer
(NABH: COP, AAC)
Central Stores & Purchase
Stores In-charge
Supplies & Inventory
(NABH: MOM, FMS)
FACILITY SAFETY (FMS)
Safety & Fire Officer
Designated: Safety Officer
Fire Drills, Evac, Security
Bio-Medical Engg. (BME)
Biomedical Engineer
PPM, Calibration & Logs
Housekeeping & BMW
Housekeeping Supervisor
BMW Barcoding & Maint
Security & Surveillance
Security In-charge
CCTV & Access Control
(NABH: FMS, PSQ)
Maintenance & Utilities
Engineering Lead
MGPS, HVAC & Power Backup
(NABH: FMS)
CORPORATE / ADMIN
MRD / Medical Records
MRD / HIM Officer
Archiving, ICD-10 (IMS)
Human Resources
HR Manager / Executive
Credentialing, BLS Training
Front Office & Billing
Billing / TPA In-charge
Tariff, Billing Transparency
IT & Systems (HIS)
IT Systems Admin
HIS, EMR & Data Security
(NABH: IMS)
Statutory Compliance
Compliance Officer
AERB, Fire NOC & Licenses
(NABH: FMS, HRM)