Legal & Compliance Policies
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Clinical Establishment Compliance Policy
Sri Lakshmi Multi Speciality Hospital is committed to operating in compliance with all applicable healthcare laws, statutory requirements, licensing conditions and regulatory standards governing clinical establishments in India and the State of Tamil Nadu.
This Clinical Establishment Compliance Policy has been developed with reference to the Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable), the Tamil Nadu Clinical Establishments (Regulation) Act, 1997 and applicable Rules, the National Medical Commission Act, 2019, applicable public health laws, and the quality principles promoted by the National Accreditation Board for Hospitals & Healthcare Providers (NABH).
The Hospital is committed to maintaining all applicable registrations, licences, approvals and statutory records, while continuously improving compliance systems to support safe, ethical and high-quality healthcare services.
Purpose of this Policy
The purpose of this policy is to establish a structured framework for ensuring that Sri Lakshmi Multi Speciality Hospital complies with applicable legal, regulatory and professional requirements governing the establishment, licensing and operation of healthcare institutions.
This policy also promotes transparency, accountability, patient safety, ethical healthcare delivery and continuous quality improvement through effective regulatory compliance.
Legal Compliance
Compliance with applicable healthcare laws and regulations.
Licensing
Maintaining valid statutory registrations, approvals and licences.
Patient Safety
Supporting safe, ethical and quality healthcare services.
Quality Standards
Promoting continuous compliance and readiness for future NABH accreditation.
Scope of this Policy
This policy applies to all departments, clinical services, healthcare professionals, administrative personnel, support staff and management of Sri Lakshmi Multi Speciality Hospital who are responsible for maintaining compliance with statutory, regulatory and professional requirements.
The policy covers Hospital registration, licensing, statutory approvals, inspections, documentation, regulatory reporting, internal compliance monitoring and continuous improvement activities.
"Regulatory compliance is an essential component of safe, ethical and accountable healthcare delivery."
Our Commitment to Regulatory Compliance
Sri Lakshmi Multi Speciality Hospital is committed to maintaining full compliance with applicable statutory requirements governing healthcare establishments. We strive to ensure that all necessary registrations, licences, approvals and certifications are obtained, maintained and renewed in accordance with applicable legal requirements.
Our Compliance Commitment
We believe that legal compliance is fundamental to delivering safe, ethical and patient-centred healthcare. Sri Lakshmi Multi Speciality Hospital is committed to maintaining transparent governance, regulatory accountability and continuous improvement while meeting applicable healthcare laws and recognised quality standards.
Registration & Licensing Compliance
Sri Lakshmi Multi Speciality Hospital shall obtain and maintain all registrations, licences, permits and statutory approvals required for the lawful establishment and operation of a healthcare institution under applicable Central and State Government laws.
The Hospital shall regularly review the validity of all licences and statutory approvals to ensure uninterrupted compliance with applicable legal and regulatory requirements.
Regulatory Compliance Includes
- Hospital Registration.
- Applicable Clinical Establishment Registration.
- Local Authority Licences.
- Fire & Safety Approvals.
- Biomedical Waste Authorisation.
- Other statutory approvals required by law.
Regulatory Responsibility
Hospital Management shall ensure that regulatory approvals remain valid and are renewed in accordance with applicable legal requirements before their expiry.
Statutory & Regulatory Compliance
Sri Lakshmi Multi Speciality Hospital shall conduct its operations in accordance with applicable healthcare laws, regulatory notifications, professional standards and government guidelines governing the provision of medical services in India and the State of Tamil Nadu.
Compliance includes adherence to licensing conditions, maintenance of statutory records, reporting obligations, patient safety requirements and other legal responsibilities applicable to healthcare establishments.
"Regulatory compliance supports patient safety, ethical healthcare delivery and public confidence in healthcare institutions."
Licence Renewal & Compliance Monitoring
Hospital Management shall establish systems for monitoring the validity of licences, registrations and statutory approvals to ensure timely renewal and continued compliance with applicable legal requirements.
Internal reviews may be conducted periodically to identify compliance gaps, implement corrective actions and minimise regulatory risks.
Display of Statutory Certificates
Sri Lakshmi Multi Speciality Hospital shall display applicable statutory registrations, licences and certificates at appropriate locations within the Hospital, wherever required by law or regulatory authorities, to promote transparency and public confidence.
Copies of relevant approvals and certificates shall be maintained securely by the Hospital and made available to authorised regulatory authorities during inspections or audits, in accordance with applicable legal requirements.
Transparency & Accountability
Displaying applicable registrations and licences demonstrates the Hospital's commitment to lawful operation, transparency and responsible healthcare governance while supporting public trust and regulatory compliance.
Regulatory Inspections & Internal Audits
Sri Lakshmi Multi Speciality Hospital shall cooperate with inspections conducted by authorised government authorities, statutory bodies and regulatory agencies in accordance with applicable laws and regulations. The Hospital recognises that regulatory inspections contribute to patient safety, service quality and legal compliance.
In addition to external inspections, the Hospital shall conduct periodic internal compliance audits to assess adherence to statutory requirements, identify compliance gaps and implement appropriate corrective measures.
Compliance Audits
Regular compliance audits help verify that Hospital policies, statutory records, licences and operational practices continue to meet applicable legal and professional requirements.
Statutory Record Maintenance
Sri Lakshmi Multi Speciality Hospital shall maintain statutory records, registers, licences, certificates, inspection reports and other regulatory documents in an organised, accurate and secure manner in accordance with applicable legal requirements and recognised record management practices.
Records shall be retained for the period prescribed under applicable laws or Hospital policy, whichever is longer, unless otherwise required by law.
Records Maintained
- Hospital registration certificates.
- Statutory licences and approvals.
- Inspection and audit reports.
- Renewal documentation.
- Regulatory correspondence.
- Compliance reports and corrective actions.
Secure Record Management
Statutory records shall be protected against loss, unauthorised access or damage while remaining readily available for authorised inspections and regulatory review.
Roles & Responsibilities of Hospital Staff
Compliance with statutory and regulatory requirements is a shared responsibility. All Hospital employees, healthcare professionals, department heads and administrators are expected to understand and comply with policies relevant to their roles and responsibilities.
Compliance Reporting & Corrective Actions
Sri Lakshmi Multi Speciality Hospital encourages the timely reporting of actual or potential compliance concerns, regulatory deficiencies or statutory non-conformities. Reports shall be reviewed by the appropriate Hospital authority, and corrective actions shall be implemented where necessary.
Corrective and Preventive Actions (CAPA) may include policy revisions, staff education, process improvements, additional monitoring or other measures designed to strengthen compliance and reduce future regulatory risks.
"Effective compliance management requires timely identification of issues, transparent reporting and continuous improvement through corrective and preventive action."
Hospital Responsibilities
Sri Lakshmi Multi Speciality Hospital is committed to maintaining a culture of legal compliance, ethical governance and accountability. Hospital Management shall ensure that all applicable statutory requirements are identified, implemented and regularly monitored to support safe and lawful healthcare delivery.
Hospital Commitments
- Maintain valid registrations, licences and statutory approvals.
- Ensure compliance with applicable healthcare laws and regulations.
- Maintain accurate statutory records and documentation.
- Provide compliance education and awareness to employees.
- Support regulatory inspections and authorised audits.
- Promote transparency, accountability and ethical governance.
Governance Commitment
Compliance is integrated into the Hospital's governance framework to strengthen patient safety, regulatory accountability and organisational excellence through responsible healthcare management.
Continuous Compliance Improvement
Sri Lakshmi Multi Speciality Hospital continually evaluates its compliance systems through internal audits, management reviews, staff training, regulatory updates and quality improvement initiatives. Lessons learned from inspections, audits and operational experience are used to strengthen governance and minimise compliance risks.
Our Improvement Strategy
Continuous review of regulatory requirements, employee awareness programmes and corrective actions helps ensure sustained compliance and supports the Hospital's ongoing journey towards future NABH accreditation.
Policy Review
This Clinical Establishment Compliance Policy shall be reviewed periodically by Hospital Management to ensure continued alignment with applicable Central and State Government healthcare laws, regulatory requirements, recognised professional standards and organisational governance objectives.
"Strong regulatory compliance promotes patient confidence, organisational integrity and sustainable healthcare excellence."
Contact Information
Questions relating to regulatory compliance, statutory approvals or this policy may be directed to the Hospital Administration using the contact details below.
Sri Lakshmi Multi Speciality Hospital
Address:
No. 5/91, Near Apollo Hospital OMR,
Church Road, Perungudi,
Chennai – 600096, Tamil Nadu, India.
Phone: +91 98407 92932
Email: contactus@slmsh.com
Regulatory & Standards Reference
This Clinical Establishment Compliance Policy has been developed with reference to applicable Indian healthcare laws, regulatory requirements, professional standards and recognised quality frameworks that support lawful, accountable and patient-centred healthcare delivery.
Applicable Indian Laws
- Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
- Tamil Nadu Clinical Establishments (Regulation) Act, 1997 and applicable Rules.
- National Medical Commission Act, 2019.
- Consumer Protection Act, 2019.
- Applicable Central and State Government healthcare regulations.
- Other statutory licences and approvals required for lawful Hospital operations.
Quality & Governance Standards
- NABH Standards – Governance & Leadership.
- NABH Standards – Patient Rights & Education.
- NABH Standards – Continuous Quality Improvement (CQI).
- NABH Standards – Facility Management & Safety (FMS).
- Clinical Governance & Risk Management Principles.
- Ethical Healthcare Administration Practices.
Hospital Compliance Declaration
Sri Lakshmi Multi Speciality Hospital is committed to maintaining compliance with applicable healthcare laws, statutory requirements, licensing conditions and recognised professional standards. We continually strengthen our governance framework through effective compliance management, staff education, quality improvement and responsible healthcare administration.
The Hospital endeavours to operate with integrity, transparency and accountability while maintaining registrations, statutory approvals and operational practices in accordance with applicable Indian laws and recognised healthcare standards. As part of our commitment to excellence, we continue to enhance our systems and processes in support of our future goal of achieving National Accreditation Board for Hospitals & Healthcare Providers (NABH) accreditation.
"Compliance is not merely a legal obligation—it is a commitment to ethical healthcare, patient safety, organisational accountability and continuous excellence."