HRM 1: The organisation has a documented system of human resource planning

HRM 1: The Organisation Has a Documented System of Human Resource Planning

This standard fundamentally focuses on ensuring that hospitals approach human resource management strategically, not reactively. It mandates a proactive and systematic approach to planning for the people who deliver care and support hospital operations. The emphasis is on documentation, which signifies a formal, structured, and auditable process.

Objective Elements and Detailed Explanation:

HRM 1a: Human resource planning supports the organisation's current and future ability to meet the care, treatment and service needs of the patient. (C)

• Objective Element Text: Human resource planning supports the organisation's current and future ability to meet the care, treatment and service needs of the patient.

• Compliance Level: Commitment (C)

• Detailed Explanation: This Objective Element underscores the patient-centric nature of HR planning in a hospital setting. It's not just about filling positions; it's about strategically ensuring that the hospital has the right workforce now and in the future to effectively deliver safe and quality patient care. It moves HR planning from a purely operational function to a strategic one directly linked to patient outcomes.

• Key Points for Implementation:

  • Plan in a structured manner: This implies a move away from informal or reactive hiring practices. Hospitals must establish a formal, documented HR planning process. This process should have defined steps, responsibilities, and timelines. It needs to be repeatable and consistent.

    • Practical Implication: Hospitals should have a written HR planning policy or procedure. This document would outline the entire process, from needs assessment to plan implementation and review.

  • Involve various stakeholders: HR planning cannot be confined to the HR department alone. A collaborative approach is crucial to understand the diverse needs across the hospital.

    • Practical Implication: This means including representatives from various departments (e.g., Nursing, Medical, Support Services, Administration) in the planning process. This could be through committees, working groups, or consultations to gather input and perspectives.

  • Use recognised methods for determining levels of staffing: Subjective guesswork is not acceptable. Staffing levels must be based on data-driven, recognized methodologies. This ensures a more objective and justifiable approach to workforce sizing.

    • Practical Implication: Hospitals need to implement and utilize methods like workload analysis, patient acuity systems, benchmarking data from similar hospitals, or workforce planning models to scientifically determine staffing needs. Simply relying on past staffing levels may not be sufficient if patient volumes, acuity, or service offerings change.

  • Take corrective action on variances found during the year: A static plan created at the beginning of the year is insufficient. Hospitals operate in a dynamic environment, and HR plans must be flexible and responsive to changes.

    • Practical Implication: Hospitals need to establish a system to monitor staffing levels and patient needs regularly (e.g., monthly, quarterly). If variances occur between planned staffing and actual needs (due to increased patient load, unexpected departures, etc.), the hospital must have mechanisms to take corrective actions, which could include hiring, temporary staffing, or re-deployment of existing staff.

  • Incorporate in subsequent plan: HR planning is a continuous cycle of improvement. The experience and data gathered from the current planning cycle should inform and enhance future plans.

    • Practical Implication: After each planning cycle, the hospital should conduct a review and evaluation of the effectiveness of the HR plan. This review should identify successes, challenges, and areas for improvement. These learnings should be systematically documented and incorporated into the next iteration of the HR plan, making it more robust and effective over time.

• Points to Remember (Practical Guidance):

  • Plan - For all staff categories: The HR plan must be comprehensive and cover all types of personnel essential for hospital operation. This includes:

    • Medical Professionals: Doctors, specialists, residents, consultants.

    • Nursing Professionals: Registered Nurses, Nurse Practitioners, Nursing Assistants.

    • Para-clinical Professionals: Physiotherapists, Dieticians, Pharmacists, Technologists, etc.

    • Administrative and Support Staff: Receptionists, Clerks, HR staff, IT personnel, Housekeeping, Security, Maintenance, etc.

    • Outsourced Staff and Volunteers: The plan's scope, while primarily for direct employees, should consider the impact and management of outsourced and volunteer personnel as they are part of the overall workforce.

  • Plan - Based on hospital's mission, volume, mix of patients, services and medical technology: HR planning must be contextual and tailored to the unique characteristics of the hospital. Key factors to consider:

    • Hospital's Mission: The hospital's stated purpose and goals. A specialty hospital (e.g., oncology) will have different staffing needs than a general hospital.

    • Volume of Patients: Patient census, occupancy rates, and anticipated patient load fluctuations (seasonal variations, etc.) directly impact staffing requirements.

    • Mix of Patients: Patient acuity, complexity of conditions, and demographic factors (age, co-morbidities) influence the skill mix needed in the workforce. A hospital with a higher proportion of critical care patients requires a different skill set than one primarily focused on outpatient services.

    • Services Offered: The range of clinical and support services provided by the hospital (e.g., cardiology, surgery, radiology, rehabilitation) dictates the specific types of staff and expertise required in each area.

    • Medical Technology: The level of technology utilized in the hospital (advanced diagnostic equipment, robotic surgery, EMR systems) influences the training, skills, and potentially the number of staff needed to operate and maintain these technologies effectively and support patient care.

  • Staffing - Match with strategic and operational plans: HR planning is not an isolated activity. It must be integrated with the overall strategic direction and day-to-day operations of the hospital.

    • Strategic Alignment: The HR plan should enable the hospital to achieve its long-term strategic goals. For example, if the hospital aims to expand a particular specialty service, the HR plan must address the staffing needs for that expansion.

    • Operational Alignment: The HR plan should support the smooth functioning of daily operations. It should address short-term and day-to-day staffing needs to ensure service delivery is not disrupted and patient care is consistently provided.

HRM 1b: The organisation maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient. (CO)*

• Objective Element Text: The organisation maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.

• Compliance Level: Commitment Core OE (CO)

• Detailed Explanation: This OE focuses on the implementation of the HR plan. It's not enough to have a plan; the hospital must actively maintain staffing levels and skill sets that are truly "adequate" to meet patient needs. The "Core OE" designation highlights its criticality for patient safety and service quality. "Adequate" is a dynamic concept, not a fixed number, and depends on various factors. "Mix of staff" is as important as the "number" ensuring the right skills are available.

• Key Concepts:

  • Staffing Commensurate with Workload: Staffing is not static. It should fluctuate with the actual demands placed on the hospital.

    • Practical Implication: Hospitals need to have systems to monitor workload indicators (e.g., patient census, bed occupancy, procedures performed, emergency room visits). Staffing levels should be adjusted based on these indicators. For example, during peak seasons or outbreaks, staffing may need to be temporarily increased. Flexibility in staffing models (part-time staff, float pools, agency staff) becomes essential to manage workload fluctuations efficiently.

  • Staffing Commensurate with Clinical Requirement of patients: Staffing decisions should be driven by the complexity of patient care and the specific clinical needs of the patient population.

    • Practical Implication: Hospitals need to consider patient acuity when determining staffing ratios, particularly in specialized units like ICUs, CCUs, and specialized surgical departments. Acuty assessment tools may be used to categorize patients based on their care needs, and staffing is adjusted accordingly. Skill mix is vital – ensuring the presence of appropriately qualified and experienced staff (e.g., critical care nurses, specialized doctors) for the patient mix.

  • Staffing Norms (Focus on Nurses): Nurses are a central component of patient care, and their staffing levels are often subject to specific guidelines or regulatory requirements.

    • Practical Implication: Hospitals should be aware of and adhere to published staffing guidelines for nurses. This may be from regulatory bodies, nursing associations, or research-based best practices. The World Health Organization's (WHO) "Workload Indicators of Staffing Need (WISN)" method is specifically mentioned as an example of a recognized, systematic approach to calculate nurse staffing needs based on objective workload data. Utilizing such methodologies demonstrates a commitment to evidence-based staffing.

  • Addressing Shortage of Staff: Staff shortages are a persistent challenge in healthcare. Hospitals must be prepared for them.

    • Practical Implication: Hospitals need to develop and implement contingency plans to mitigate the impact of staff shortages. These plans should not just be reactive, but proactive, outlining strategies to manage shortages before they critically impact patient care. Contingency plans are further detailed in OE HRM 1c.

HRM 1c: The organisation has contingency plans to manage long-and short-term workforce shortages, including unplanned shortages. (A)

• Objective Element Text: The organisation has contingency plans to manage long-and short-term workforce shortages, including unplanned shortages.

• Compliance Level: Achievement (A)

• Detailed Explanation: This OE expands upon the "Shortage of staff" point in HRM 1b. It mandates that hospitals have formal, written contingency plans to deal with workforce shortages across different timeframes and circumstances, acknowledging that shortages are inevitable. Being at the "Achievement" level signifies a proactive and well-prepared approach.

• Key Questions & Management Strategies:

  • Defining Workforce Shortage: It's important to have a clear understanding of what constitutes a "workforce shortage" in the hospital's context.

    • Definition: "Non-availability of mix of skills required for the organisation to function at its peak efficiency." This definition emphasizes that shortage isn't just about headcount. It's about having the right skills and skill mix necessary to deliver services optimally. A hospital might have enough total staff but lack staff with specific critical skills (e.g., experienced ICU nurses during a pandemic surge), leading to a workforce shortage.

  • When Shortages Occur: Contingency plans need to be relevant to different types of shortages.

    • Shift-by-shift basis: Daily, even hourly, fluctuations due to sudden illnesses, unexpected leaves, or surges in patient arrivals.

    • Short-term basis: Lasting days or weeks, often predictable (e.g., planned leaves, seasonal illnesses) or semi-predictable (e.g., localized disease outbreaks).

    • Long-term basis: More prolonged shortages due to difficulty in recruitment, high turnover, or broader workforce issues in the healthcare sector. These may be less predictable in their exact timing but are often anticipated trends.

  • Managing Staff Crises: Contingency plans are the key tool to manage staff crises. The presentation outlines common elements of effective contingency plans:

    • Reprioritising tasks: In a shortage situation, hospitals must focus on essential patient care tasks and potentially postpone or delegate less critical activities.

      • Practical Implication: Develop protocols to identify essential versus non-essential tasks during staff shortages. Streamline workflows to maximize efficiency with fewer staff.

    • Allocating tasks to different staff members (Cross-training and Task Delegation): Maximizing the use of the existing workforce is crucial.

      • Practical Implication: Invest in cross-training staff so they can perform duties in multiple areas, increasing flexibility. Implement clear guidelines for task delegation (e.g., between nurses and nursing assistants, or among different levels of nurses) ensuring patient safety and scope of practice are maintained.

    • Relying on pool of filler staff (previous employees): Building a reserve workforce can be highly effective.

      • Practical Implication: Maintain a database of former employees (retirees, those on leave, etc.) who are willing to work on a temporary or "as-needed" basis. Establish agreements for quick and efficient onboarding when needed.

    • Sourcing casual staff from agencies (Temporary Staffing Agencies): Utilizing external agencies is a common, albeit often more expensive, method for addressing immediate shortages.

      • Practical Implication: Establish relationships with reputable temporary staffing agencies. Have pre-established contracts or framework agreements to expedite the process of bringing in temporary staff when needed. Ensure proper vetting and orientation for agency staff to maintain quality and safety standards.

HRM 1d: The job specification and job description are defined for each category of staff. (C)*

• Objective Element Text: The job specification and job description are defined for each category of staff.

• Compliance Level: Commitment Core OE (CO)

• Detailed Explanation: This OE emphasizes the fundamental HR practices of clearly defining roles and requirements for every position in the hospital. These documents are not just for recruitment; they are essential tools for performance management, training, and ensuring clarity of responsibilities. "Core OE" highlights their fundamental importance for effective HR management and patient safety indirectly, as clear roles lead to more effective teamwork and less ambiguity in patient care delivery.

• Key Components of Defined Job Documentation:

  • Job Description: This is the core document that outlines what the job is.

    • Purpose: To "Define content of each job." It's a narrative description of the job's purpose, main duties, responsibilities, reporting relationships, and working conditions.

    • Typical Content: Job title, department, reporting structure, summary of purpose, list of key responsibilities and tasks, working conditions, equipment used, etc. It should be written in clear, concise, and understandable language.

  • Job Specification (Person Specification): This document defines who is best suited for the job, outlining the essential criteria for a successful candidate.

    • Purpose: To "Lay down criteria to perform job." It sets the minimum acceptable standards for knowledge, skills, abilities, and other attributes needed to fulfill the job description requirements.

    • Key Criteria:

      • Qualifications: Formal educational degrees, diplomas, certifications, professional licenses required for the role. For clinical positions, these are often mandated by regulatory bodies (e.g., MBBS for doctors, GNM/BSc Nursing for nurses).

      • Skills: Specific competencies (both technical and soft skills) needed to perform job tasks effectively. Examples include clinical skills, communication skills, problem-solving, technical skills related to equipment operation, etc.

      • Experience required: Type and level of relevant prior work experience that is essential or desirable. This specifies the kind of background that best prepares a candidate for the role. Years of experience, specific settings, and types of patients handled can be relevant.

• Points to Remember (Context and Exceptions):

  • Job Description Commensurate with Staff's Qualification: There must be a direct link between the requirements in the job description and the necessary qualifications. The qualification requirements specified in the job specification should logically enable an individual to perform the duties described in the job description.

    • Example Provided: For jobs requiring the skills of a "doctor/nurse," the minimum qualification must be MBBS (for doctor) and GNM degree (for nurse) respectively. This emphasizes that for clinical roles, professional qualifications are fundamental and non-negotiable in most cases.

  • Exception for Government/Statutory Body Exemption: Recognizes that there may be legally permitted exceptions or alternative pathways to qualification in specific circumstances.

    • Practical Implication: Hospitals need to be aware of and adhere to relevant laws and regulations regarding qualifications. If there are officially recognized exemptions or alternative qualifications allowed by government or statutory bodies, these must be clearly documented and justified if utilized for any positions. This is a reminder to comply with all applicable legal frameworks.

HRM 1e: The organisation performs a background check of new staff. (C)

• Objective Element Text: The organisation performs a background check of new staff.

• Compliance Level: Commitment (C)

• Detailed Explanation: This OE addresses the critical aspect of staff safety and patient safety through pre-employment verification. It's a fundamental step in risk management and building trust within the hospital environment. It is set at the Commitment level, reflecting its essential nature.

• Key Implementation Aspects:

  • Background check of new staff: The core requirement is that all new staff members undergo a background check. This applies to all categories of staff (clinical, non-clinical, permanent, contractual) who will be working within the hospital, as they all potentially interact with patients or sensitive hospital resources.

  • Use suitable methodology: The background check process should be formalized and reliable. It cannot be a casual or superficial process. "Suitable methodology" means employing established and effective methods to verify information.

    • Practical Implication: Hospitals should have a documented procedure for conducting background checks. This procedure should specify the types of checks to be conducted (e.g., reference checks, qualification verification, criminal record checks - where legally permissible and relevant, address verification, etc.) and the sources used for verification (e.g., previous employers, educational institutions, licensing bodies, law enforcement agencies - again, within legal boundaries). The methodology should be consistent and applied to all new hires.

  • Timing of Background Check: The background check needs to be timely to be effective.

    • Timing: "Perform either before the person joins/within one month of joining the organisation." Ideally, the background check should be completed before the staff member begins working in the hospital to minimize any potential risks. However, recognizing practical constraints, it's acceptable for the process to be initiated and completed within the first month of employment. But, best practice is to complete it pre-employment.

HRM 1f: Reporting relationships are defined for each category of staff. (C)*

• Objective Element Text: Reporting relationships are defined for each category of staff.

• Compliance Level: Commitment Core OE (CO)

• Detailed Explanation: Clear organizational structure and defined reporting lines are vital for effective communication, accountability, and efficient workflow in a complex hospital environment. Ambiguity about who reports to whom can lead to confusion, duplicated effort, and breakdowns in communication, potentially impacting patient care and safety. "Core OE" highlights the fundamental importance of organizational clarity.

• Implementation Strategies:

  • Use an organisation structure/chart (Organogram): The primary tool for visually representing reporting relationships is an organizational chart or organogram. This is a graphical depiction of the hospital's hierarchy and reporting structure.

    • Practical Implication: Develop and maintain a comprehensive organogram that accurately reflects the hospital's current structure. Ensure it is regularly updated to reflect any organizational changes (restructuring, department creation, etc.).

  • Document hierarchy, line of control and functions at various levels: The organogram needs to be informative and clearly communicate essential organizational information.

    • Key Information to Document:

      • Hierarchy: The levels of management and authority within the organization. Showing the different tiers of positions from top leadership down to entry-level staff.

      • Line of control (Chain of Command): Who reports directly to whom. Showing the direct reporting relationships through connecting lines in the organogram. This clarifies the flow of authority and accountability.

      • Functions at various levels: Broadly indicating the main responsibilities or departments associated with different positions or organizational units. This provides context and understanding of the roles and responsibilities at each level. For example, labeling departments like "Nursing Department," "Surgical Services," "Administrative Services," etc.

• Note - Transparency and Dissemination:

  • "An organogram should transparent. It should be disseminated to all stakeholders." An organogram is only effective if it is accessible and understood by those who need to use it.

    • Practical Implication: The organogram should not be a hidden document only for senior management. It should be readily available to all staff members (employees, volunteers, outsourced staff, etc.). Dissemination can be through the hospital intranet, employee handbooks, departmental notice boards, or during induction programs. Transparency helps to ensure everyone understands their place in the organization, their reporting lines, and who they can approach for guidance or escalation of issues.

HRM 1g: Exit interviews are conducted and used as a tool to improve human resource practices. (A)

• Objective Element Text: Exit interviews are conducted and used as a tool to improve human resource practices.

• Compliance Level: Achievement (A)

• Detailed Explanation: This OE emphasizes continuous improvement in HR practices through feedback from employees who are leaving the organization. Exit interviews provide a valuable, often candid, perspective on what works well and what could be improved from the employee's viewpoint. Being at the "Achievement" level shows a proactive commitment to learning and development.

• Key Aspects of Effective Exit Interview Processes:

  • Obtain feedback from employee leaving organisation: The core purpose of exit interviews is to systematically collect feedback. This feedback is valuable because departing employees often feel more comfortable providing honest opinions and constructive criticism as they are no longer directly dependent on the organization for their career progression.

  • Exit interviews: It mandates the conduct of exit interviews as a routine HR practice.

  • Conduct personal interview: Recommends personal, face-to-face interviews as the preferred method. While written surveys can also be used, personal interviews allow for richer, qualitative data to be gathered. They allow for follow-up questions, clarification, and a deeper understanding of the employee's perspective. This suggests a more invested and thoughtful approach to gathering exit feedback.

• Note - Voluntary Participation:

  • "This should be a voluntary exercise." Exit interviews must always be voluntary. Employees should have the choice whether to participate or not.

    • Practical Implication: Make it clear to departing employees that participation is voluntary and their responses will be confidential and used for organizational improvement, not for any negative repercussions. Respect their decision if they choose not to participate. Forcing participation can lead to insincere or incomplete feedback, undermining the purpose of the exit interview.

In conclusion, HRM 1 is a comprehensive standard focusing on the foundational elements of human resource planning. It emphasizes strategic thinking, documentation, data-driven approaches, clear roles, organizational clarity, risk management, and continuous improvement through feedback. Each Objective Element within HRM 1 builds upon this foundation, ensuring that hospitals have a robust and well-managed human resource system that ultimately supports the delivery of safe and effective patient care. The levels of compliance (Commitment and Achievement), along with Core OE designations, guide hospitals in prioritizing implementation efforts and understanding the relative criticality of different aspects of HR planning.

HRM 2: The organisation implements a defined process for staff recruitment

Overall Standard HRM 2 Summary:

• Standard Text: HRM2: The organisation implements a defined process for staff recruitment.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard itself. Similar to HRM 1, the core standard remains consistent. However, the interpretation for HRM 2c (code of conduct) has been modified in the 6th edition to offer further clarity or emphasis.

• Objective Elements: There are 4 Objective Elements under HRM 2 in both the 5th and 6th editions. These OEs detail the key components of a robust and well-defined recruitment process.

Detailed Breakdown of Objective Elements under HRM 2 

HRM 2a: Written guidance governs the process of recruitment. * (CO)

• Objective Element Text: Written guidance governs the process of recruitment. * (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment Core OE (CO) - As a Core OE at the Commitment level, this emphasizes that having documented recruitment policies and procedures is a critical and fundamental requirement for accreditation, mandating system documentation as evidence.

• Detailed Explanation: This Objective Element mandates that the hospital's recruitment process is not ad-hoc or based on individual preferences, but rather is guided by formal, written documentation. This ensures consistency, transparency, and fairness in recruitment practices across the organization. "Written guidance" serves as the blueprint for all recruitment activities.

• Key Components of Written Guidance:

  • Staff (Left Blue Box - "Written Guidance" area): This section focuses on the criteria used to select staff during recruitment.

    • "Recruit based on defined criteria (Necessary registration, qualifications, skills and experience).": This is the core principle of criterion-based recruitment. Hiring decisions should be based on pre-determined and documented criteria that are directly relevant to the job and the needs of the hospital. These criteria must include:

      • Necessary Registration: For clinical roles (doctors, nurses, pharmacists, etc.), professional registration with the relevant statutory bodies (Medical Council, Nursing Council, Pharmacy Council, etc.) is often a legal requirement and a critical criterion. The written guidance should specify which registrations are mandatory for each role.

      • Qualifications: Formal educational degrees, diplomas, certifications specified as essential for the job. The level and type of qualification must be clearly defined for each position (e.g., MBBS, BSc Nursing, Diploma in Medical Technology).

      • Skills: Specific technical and soft skills required to perform the job effectively. The written guidance might list out the essential skills or refer to competency frameworks for different roles. Examples: clinical skills, communication skills, technical skills for equipment, IT skills, etc.

      • Experience: Relevant prior work experience needed for the role. The level and type of experience should be defined (e.g., years of experience in a specific specialty, experience with certain patient populations, experience in a leadership role).

  • Recruitment process (Right Blue Box): This section focuses on the steps and principles governing the entire recruitment procedure.

    • "Recruit adequate number and skill mix of staff to provide organisation's service.": The overall goal of the recruitment process is to ensure the hospital can meet its service delivery needs by hiring the right number of people with the appropriate skills. This links recruitment directly back to the strategic HR planning principle outlined in HRM 1a and 1b.

      • Practical Implication: The recruitment process should be aligned with the hospital's HR plan. It should be designed to attract and select candidates who will contribute to achieving the hospital's goals and meeting patient care needs effectively.

    • "Adhere to statutory requirements, where applicable.": Recruitment must be conducted in compliance with all relevant laws and regulations. This is a critical principle of ethical and legal recruitment.

      • Practical Implication: Hospitals must ensure their recruitment processes are compliant with labor laws, equal opportunity employment laws, anti-discrimination laws, and any other relevant statutory requirements specific to their jurisdiction. This might include regulations related to advertising positions, interviewing practices, background checks, terms of employment, etc

• Note:

  • "Recruitment should be carried out in a transparent manner. And, the process should be documented." These two principles underpin the entire Objective Element:

    • Transparency: The recruitment process should be open and understandable to both candidates and internal stakeholders. Criteria for selection, steps in the process, timelines, and decision-making should be clear and accessible. Transparency builds trust and fairness perception.

    • Documented Process: Every stage of the recruitment process, from advertising the vacancy to making the final offer, should be formally documented. This documentation serves as evidence of adherence to policies, criteria, and statutory requirements. Documentation is crucial for auditability and accountability.

HRM 2b: A pre-employment medical examination is conducted on the staff. (C) 

• Objective Element Text: A pre-employment medical examination is conducted on the staff.

• Compliance Level: Commitment (C) - At the Commitment level, this highlights pre-employment medical exams as a standard, essential practice for employee and patient safety.

• Detailed Explanation: This Objective Element mandates that all new staff undergo a pre-employment medical examination. This is primarily aimed at ensuring that new hires are medically fit for the job they are being offered and to protect both the employee's health and the health of patients. It's a proactive step in occupational health and infection control.

• Key Aspects of Pre-employment Medical Examination:

  • Check staff fitness: The main purpose is to assess the overall health status of the new employee and determine if they are fit to perform the essential functions of their job without risk to themselves or others.

    • "Ensure staff is fit to provide safe patient care.": This directly connects the medical exam to patient safety. It ensures that individuals in healthcare roles do not have health conditions that could compromise patient safety (e.g., untreated infectious diseases, physical limitations that prevent them from performing essential care duties safely).

  • Conduct diagnostics tests: The medical examination should include appropriate diagnostic tests. The nature of these tests should be relevant to the job and the context of the hospital.

    • "Based on the nature of the job.": The specific tests required may vary depending on the job role. For example, staff in high-risk areas (operating rooms, infection control) might require more extensive testing than administrative staff.

    • "In accordance with law of land.": The tests conducted must be legally compliant and ethical.

      • "For example: Pre-employment HIV testing without consent is illegal.": This example provides a crucial ethical and legal boundary. Mandatory pre-employment HIV testing without informed consent is generally considered illegal and unethical in many jurisdictions. It highlights the need for medical examinations to be conducted within legal and ethical frameworks, respecting individual rights and privacy. Any testing should be justified, relevant to the job, and with informed consent.

• Note:

  • "The organisation should bear the cost of pre-employment medical examination." Ethically and practically, the cost of the pre-employment medical examination should be borne by the hospital (the employer), not the prospective employee. This ensures that financial constraints do not prevent individuals from undergoing necessary medical assessments and promotes equitable access to employment opportunities.

HRM 2c: The organisation defines and implements a code of conduct for its staff. (CO) 

• Objective Element Text: The organisation defines and implements a code of conduct for its staff.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, emphasizing the fundamental importance of ethical behavior and professional conduct in healthcare with mandatory system documentation.

• Detailed Explanation: This Objective Element requires hospitals to have a formal, written code of conduct that outlines expected behaviors and ethical standards for all staff members. It goes beyond just job descriptions and administrative rules, setting out the values and ethical principles that should guide staff interactions and professional responsibilities. "Implementation" is as crucial as "definition" - the code needs to be actively used and reinforced within the organization.

• Key Components of a Code of Conduct:

  • "Outline do's and don'ts for staff behaviour.": The code of conduct should be practical and actionable, providing clear guidance on acceptable and unacceptable behaviors in the workplace. It should define both positive expectations (do's) and prohibited actions (don'ts). Examples:

    • Do's: Respect patient dignity and privacy, maintain confidentiality, provide courteous service, adhere to professional ethics, report errors and incidents, maintain a safe work environment, etc.

    • Don'ts: Bullying or harassment, discrimination, misuse of hospital resources, unauthorized disclosure of patient information, unprofessional behavior, conflict of interest, etc.

  • "Align with organisation's values and ethics framework.": The code of conduct should be rooted in the hospital's core values and ethical principles. It's not just a list of rules; it should reflect the organization's fundamental commitments to ethical conduct, patient well-being, and professional integrity. This ensures the code is meaningful and resonates with the organizational culture.

  • "Include protection of patient confidentiality.": Patient confidentiality is a paramount ethical and legal obligation in healthcare. The code of conduct must explicitly address and emphasize the importance of protecting patient information, privacy, and data. It should detail the responsibilities of staff in maintaining confidentiality under all circumstances.

• Note:

  • "It is preferable that the staff sign the code of conduct at the time of joining." To ensure accountability and demonstrate understanding and commitment, it is highly recommended that staff members formally acknowledge the code of conduct. Having staff sign the code of conduct upon joining is a common practice. This signifies that they have read, understood, and agree to abide by the code. It reinforces the importance of the code from the very beginning of their employment.

HRM 2d: Administrative procedures for human resource management are documented. (C) *

• Objective Element Text: Administrative procedures for human resource management are documented.* (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment (C) - Core OE at the Commitment level, highlighting the need for documented administrative procedures for smooth HR operations and compliance.

• Detailed Explanation: This Objective Element emphasizes that the routine administrative functions of the HR department should also be governed by documented procedures. This ensures consistency, efficiency, and minimizes errors in HR operations. Documented administrative procedures make HR processes transparent, auditable, and less dependent on individual knowledge. "Core OE" status indicates their essential role in the effective functioning of HR management.

• Key Administrative Procedure Areas Highlighted (Examples - Blue Boxes):

  • Attendance: Procedures for recording, monitoring, and managing staff attendance. This includes policies on punctuality, leave application processes, sick leave, etc.

  • Leave: Procedures for different types of leave (annual leave, sick leave, maternity/paternity leave, etc.) - application process, approvals, record-keeping, encashment policies (if applicable).

  • Replacement: Procedures for managing staff replacements when employees are on leave or when positions become vacant. This could include internal job postings, temporary staffing arrangements, or initiating the full recruitment process.

  • Conduct: Administrative procedures related to staff conduct (beyond the code of conduct itself). This might include processes for handling minor disciplinary issues, performance improvement plans, issuing warnings, managing employee grievances, etc.

• Note:

  • "The administrative procedures for HRM should be documented." The core message is that the entire range of routine HR administrative tasks should be covered by documented procedures. The examples given are just illustrative. Hospitals should identify all significant HR administrative processes and ensure they are documented. Other areas that might require documented procedures include:

    • Payroll processing

    • Benefits administration

    • Training administration (scheduling, attendance tracking)

    • Performance appraisal processes (timelines, forms, review meetings)

    • Grievance handling procedures (steps, timelines, escalation)

    • Separation processes (resignation, termination, retirement procedures, exit formalities)

    • Record-keeping procedures for personnel files and HR data.

In summary, HRM 2 is centered on the establishment of a defined, documented, and ethical recruitment process. It moves beyond simply "hiring people" to a more structured and strategic approach to acquiring talent. The Objective Elements emphasize the need for written guidance, criterion-based selection, pre-employment health checks, a code of conduct, and documented administrative procedures – all essential components for ensuring that the hospital recruits competent, ethical, and fit-for-purpose staff, ultimately contributing to patient safety and quality care. The designation of HRM 2a, 2c, and 2d as Core OEs underlines the fundamental importance of these documented systems within the overall NABH accreditation framework.

HRM 3: Staff are provided induction training at the time of joining the organisation

Overall Standard HRM 3 Summary :

• Standard Text: HRM3: Staff are provided induction training at the time of joining the organisation.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard. The core requirement for induction training remains the same. However, interpretations for certain Objective Elements have been modified to provide more clarity. Significantly, HRM 3j is a new Objective Element introduced in the 6th Edition.

• Objective Elements: The number of Objective Elements has increased from 9 in the 5th Edition to 10 in the 6th Edition, reflecting an expanded scope of induction training.

Detailed Breakdown of Objective Elements under HRM 3:

HRM 3a: Staff are provided with induction training. (CO)

• Objective Element Text: Staff are provided with induction training.

• Compliance Level: Commitment Core OE (CO) - As a Core OE at the Commitment level, this emphasizes that providing induction training is a foundational and critical requirement for all staff, and system documentation is mandatory to prove compliance.

• Detailed Explanation: This Objective Element is the cornerstone of HRM 3. It mandates that all new staff joining the hospital must receive induction training. Induction is not optional; it's a fundamental organizational process to effectively integrate new personnel. "Core OE" status highlights its essential role in setting the stage for staff competency and integration.

• Key Questions Addressed & Implementation Details:

  • Who should attend induction training?

    • "All staff including doctors, consultants (including visiting) and outsourced staff.": The scope is comprehensive. Everyone who works within the hospital, regardless of their role, employment type, or duration of engagement, should receive induction. This includes:

      • All Employee Categories: Permanent, temporary, part-time, contractual employees.

      • Medical Professionals: Doctors (at all levels, including Heads of Departments), consultants, visiting consultants, residents, fellows.

      • Nursing and Para-clinical Staff: Nurses, technicians, therapists, pharmacists, dieticians, etc.

      • Administrative and Support Staff: All non-clinical personnel who are part of the hospital's workforce.

      • Outsourced Staff: Staff provided by external agencies who work regularly within the hospital premises (e.g., housekeeping, security, certain clinical support roles). This is a significant inclusion in the 6th edition's intent of HRM.

    • Practical Implication: The hospital needs a system to ensure no new staff member is missed for induction. This could involve automated triggers from HR systems upon onboarding, departmental checklists, and clear responsibilities for induction scheduling and follow-up.

  • When should it be conducted?

    • "It should be conducted within 1 month of staff joining. But, the organisation can determine the date of training programme.": Induction should be timely, happening soon after joining. A window of one month is given for flexibility.

    • Practical Implication: Hospitals should aim to conduct induction training as soon as practically possible after a staff member joins, ideally within the first few days or week. While a one-month window is permitted, delaying induction for too long can negatively impact a new staff member's initial adjustment and performance. The hospital should set a schedule for induction programs and ensure new staff are enrolled in the next available session.

  • What should be covered in the training programme?

    • "Objective elements “b” to “h” of this standard. And, all requirements of this standard.": The content of the induction program is defined by the subsequent Objective Elements (HRM 3b through 3h), and broadly, all aspects relevant to this entire HRM 3 standard.

    • Practical Implication: The content should be comprehensive, addressing all the topics outlined in HRM 3b to 3h (Vision, Mission, Values, Rights & Responsibilities, Safety, CPR, Infection Control, Service Standards, Administrative Procedures). The program should also address any other organization-specific requirements or information essential for new staff.

• Points to Remember (Best Practices):

  • "Organisation could provide contents of training to staff in form of a booklet.": Providing a handbook or booklet summarizing the key information covered in induction is a good practice.

    • Practical Implication: Develop a well-structured induction booklet (physical or digital) that serves as a takeaway resource for new staff. It should contain key policies, procedures, contact information, overviews of topics covered, and links to further resources. This reinforces learning and provides a reference guide for new staff.

  • "Separate induction training can be held at organisation level and for respective departments.": Induction can be structured in levels. A general organization-wide induction followed by more specific departmental induction is often effective.

    • Practical Implication: Design a tiered induction program. The organizational level induction can cover hospital-wide topics (vision, mission, values, general policies, safety, rights). Departmental induction should focus on department-specific procedures, job roles, team introductions, department-specific safety aspects, and practicalities of the work environment. This ensures both a broad organizational understanding and job-specific orientation.

  • "Records of the training should be maintained.": Documentation of induction training is essential for compliance and quality assurance.

    • Practical Implication: Maintain formal records of induction training for each staff member. This should include dates of training, content covered, attendance records, and potentially assessments or feedback forms. These records serve as evidence of compliance and help track who has received induction and when.

HRM 3b: The induction training includes orientation to the organisation's vision, mission and values. (C)

• Objective Element Text: The induction training includes orientation to the organisation's vision, mission and values.

• Compliance Level: Commitment (C) - Commitment level, highlighting the importance of aligning staff with the organizational direction from the outset.

• Detailed Explanation: This OE specifies that induction must include orientation to the hospital's Vision, Mission, and Values. These are the guiding principles and foundational identity of the organization, and it's crucial for new staff to understand and internalize them. This creates a sense of belonging and shared purpose.

• Key Aspects:

  • Staff orientation: Induction is about orienting staff not just to their job, but also to the overarching organizational direction.

  • Be aware: New staff should be made aware of the hospital's vision, mission, and values. This involves clear communication and presentation of these statements.

  • Correctly interpret: It's not enough just to present the statements; staff should be helped to understand what they mean in practice and how they translate into daily work behaviors and patient interactions. Interpretation ensures the vision, mission, and values are not just abstract words, but living principles that guide actions.

• 
  

• Practical Implementation:

  • Clearly communicate the Vision, Mission, and Values: Present these statements in a clear, accessible format during induction (e.g., slides, videos, handouts in the induction booklet). Explain what each statement means in simple terms.

  • Provide examples of how Vision, Mission, and Values translate into practice: Use real-life examples or scenarios to illustrate how these principles guide decision-making and behavior within the hospital. For example, if "Patient-Centered Care" is a core value, explain how this translates into specific actions staff are expected to take in patient interactions.

  • Interactive sessions: Use interactive sessions, discussions, or Q&A to ensure new staff understand and can ask questions about the vision, mission, and values.

  • Reinforce in ongoing communication: Vision, Mission, and Values should not be mentioned only in induction. They should be consistently reinforced in internal communications, staff meetings, and organizational culture-building activities to keep them top-of-mind.

• Note:

  • "The induction training should be provided to the outsourced staff as well." It's reiterated that even outsourced staff, who may not be direct employees, are an integral part of the hospital environment and should receive this organizational orientation to understand and align with the hospital's core direction and values.

HRM 3c: The induction training includes awareness on staff rights and responsibilities and patient rights and responsibilities. (C)

• Objective Element Text: The induction training includes awareness on staff rights and responsibilities and patient rights and responsibilities.

• Compliance Level: Commitment (C) - Commitment level, highlighting the importance of mutual understanding of rights and responsibilities in the hospital setting.

• Detailed Explanation: This OE mandates that induction training covers both staff rights and responsibilities as well as patient rights and responsibilities. This ensures that new staff understand their entitlements, obligations, and equally importantly, are aware of the rights of the patients they will be serving. It promotes a respectful and rights-based approach to healthcare.

• Key Aspects:

  • Staff awareness: Induction is about building awareness and understanding of these important rights and responsibilities frameworks.

  • Understand implications of staff rights and responsibilities: New staff need to be informed about their rights as employees (fair treatment, safe working conditions, etc.) and their responsibilities as healthcare professionals or hospital staff (professional conduct, adherence to policies, ethical obligations, duty of care, etc.).

  • Identify and report violation of patient rights: Crucially, staff must be trained to recognize and report any potential violations of patient rights. This promotes a culture of patient advocacy and ensures mechanisms are in place to protect patient rights.

• Practical Implementation:

  • Clearly present Staff Rights and Responsibilities: Outline key staff rights (e.g., right to a safe working environment, right to fair treatment, rights as per labor laws) and responsibilities (e.g., duty of care, professional conduct, adherence to policies, confidentiality obligations). This can be presented through handouts, presentations, or in the induction booklet.

  • Clearly present Patient Rights and Responsibilities: Explain the organization's charter of patient rights, detailing patient entitlements (e.g., right to information, right to consent, right to privacy, right to quality care, right to redressal). Also briefly touch upon patient responsibilities (e.g., providing accurate information, following treatment plans, respecting hospital staff).

  • Reporting Mechanisms for Patient Rights Violations: Clearly explain the process for reporting suspected violations of patient rights. This should include who to report to, how to report (formal channels), and assurances of confidentiality and no retaliation for reporting.

  • Case studies and scenarios: Use case studies or scenarios to illustrate examples of both staff and patient rights and responsibilities in practice. This can make the concepts more relatable and understandable.

HRM 3d: The induction training includes training on safety. (C)

• Objective Element Text: The induction training includes training on safety.

• Compliance Level: Commitment (C) - Commitment level, emphasizing safety as a fundamental component of induction for all staff.

• Detailed Explanation: Safety is paramount in a healthcare setting. This OE mandates that safety training is a core component of induction. This ensures all new staff are aware of safety protocols, procedures, and potential hazards from day one, contributing to a safer environment for staff, patients, and visitors.

• Key Safety Aspects:

  • Safety measures: Induction training must focus on practical safety measures relevant to the hospital environment.

  • Aspects of patient, visitor and staff safety: Safety training should encompass the safety of all stakeholders in the hospital environment: patients, visitors, and staff themselves. This holistic approach to safety is essential.

  • Training on 'codes': 'Codes' in hospital context often refer to emergency codes (e.g., Code Red for fire, Code Blue for cardiac arrest, Code Yellow for bomb threat). Induction training should introduce staff to these codes and the procedures associated with each code.

• Practical Implementation:

  • Comprehensive Safety Training Content: Safety training should cover a range of relevant topics, including:

    • General safety rules and regulations of the hospital.

    • Fire safety (prevention, evacuation procedures, use of fire extinguishers, emergency exits).

    • Basic emergency response procedures.

    • Infection control basics (hand hygiene, PPE, waste disposal – though infection control is also a separate OE - HRM 3f).

    • Security protocols, including access control and visitor management.

    • Safe patient handling techniques (if relevant to their role).

    • Hazardous materials handling and spill management (if relevant).

  • Practical Demonstrations and Drills: Go beyond just theoretical presentations. Include practical demonstrations (e.g., fire extinguisher use, proper hand hygiene) and drills (e.g., fire evacuation drills) to reinforce learning and ensure staff know how to respond in real-life situations.

  • Code Familiarization: Clearly explain the hospital's emergency codes (Code Red, Code Blue, etc.) - what each code signifies, how staff should respond to each code, their individual roles in code response, and emergency contact numbers. Provide a code quick reference guide (perhaps in the induction booklet).

HRM 3e: The induction training includes training on cardio-pulmonary resuscitation for staff providing direct patient care. (C)

• Objective Element Text: The induction training includes training on cardio-pulmonary resuscitation for staff providing direct patient care.

• Compliance Level: Commitment (C) - Commitment level, reflecting the crucial life-saving skill of CPR for direct patient care staff.

• Detailed Explanation: This OE mandates that staff who are involved in direct patient care receive training in cardio-pulmonary resuscitation (CPR) as part of their induction. CPR is a fundamental life-saving skill in healthcare, and ensuring direct care staff are trained is critical for patient safety in emergency situations.

• Target Staff Categories and Training Levels:

  • "All staff (Doctors, nursing staff and rehabilitation staff)": Specifies the primary categories of staff who should receive Basic Life Support (BLS) training. This is the fundamental level of CPR training suitable for a wide range of healthcare professionals.

    • Basic life support (BLS): Induction training for these staff should include BLS training, covering techniques for chest compressions, rescue breathing, and managing airway obstruction in adults, children, and infants.

  • "ICU/High-dependency unit staff": Staff working in intensive care units and high-dependency units, where patients are at higher risk of critical events, require a more advanced level of CPR training.

    • Advanced cardiac life support (ACLS): For ICU/HDU staff, induction should include Advanced Cardiac Life Support (ACLS) training, which builds upon BLS and includes advanced airway management, use of medications in cardiac arrest, ECG interpretation in emergencies, and algorithms for managing cardiac arrest and other critical conditions.

    • Paediatric advanced life support (PALS): For ICU/HDU staff who care for children, Paediatric Advanced Life Support (PALS) training is essential. PALS focuses on resuscitation in infants and children, considering age-specific differences in physiology and techniques.

    • Neonatal advanced life support (NALS): For ICU/HDU staff who care for newborns, Neonatal Advanced Life Support (NALS) or equivalent training is needed. NALS focuses on the unique aspects of neonatal resuscitation.

    • Or Any other equivalent/similar programme: Acknowledges that there may be other equivalent advanced resuscitation training programs that meet the intent of ACLS, PALS, or NALS. Organizations can use other recognized and equivalent certifications.

• Points to Remember (Implementation Guidance):

  • "Staff - With valid certificate need not undergo training.": If a new staff member already holds a valid and recognized certification in BLS, ACLS, PALS, or NALS (depending on their role), they do not need to repeat the training during induction. Recognizing prior valid certifications avoids unnecessary redundancy. However, verification of the certificate validity is important.

  • "Trainers - From within/outside organisation can impart training.": CPR training can be conducted by internal trainers within the hospital who are certified CPR instructors, or the hospital can utilize external certified CPR training providers. The choice depends on internal capacity and resources.

  • "Training - Can be given using established evidence-based protocols.": CPR training must adhere to current, evidence-based guidelines and protocols.

    • Practical Implication: Training programs should be based on the latest resuscitation guidelines from recognized bodies like the American Heart Association (AHA), European Resuscitation Council (ERC), or similar nationally recognized organizations. This ensures that staff are trained in the most up-to-date and effective techniques.

HRM 3f: The induction training includes training in hospital infection prevention and control. (C)

• Objective Element Text: The induction training includes training in hospital infection prevention and control.

• Compliance Level: Commitment (C) - Commitment level, emphasizing the crucial role of infection control training from day one for all staff.

• Detailed Explanation: Hospital-acquired infections (HAIs) are a significant patient safety concern. This OE mandates that infection prevention and control (IPC) training is a core component of induction for all staff. This emphasizes that everyone in the hospital has a role to play in preventing infections.

• Key IPC Areas to Cover:

  • Infection prevention and control: Induction training should provide a foundational understanding of IPC principles and practices within the hospital.

  • Policies: Training must cover the hospital's infection control policies. These policies are the formal guidelines and rules established by the hospital to prevent and manage infections. Staff need to be aware of these policies and their obligations under them.

  • Procedures: Training must cover key infection control procedures. These are the step-by-step methods and techniques staff need to follow in their daily work to minimize infection risks. Examples: hand hygiene procedures, PPE procedures, waste disposal procedures, cleaning and disinfection procedures.

  • Practices: Training should focus on practical IPC practices that staff need to adopt in their routine activities. This reinforces the practical application of policies and procedures. Examples: appropriate hand washing techniques, correct use of PPE, safe injection practices, cough etiquette, proper handling of linen and waste, etc.

• Practical Implementation:

  • Core IPC Training Content: Induction training on IPC should, at minimum, cover:

    • Basics of microorganisms and infection transmission.

    • Standard Precautions (hand hygiene – detailed technique, when to perform; PPE – types, when to use, donning and doffing; respiratory hygiene; safe injection practices; safe handling of sharps and contaminated waste; cleaning and disinfection of equipment and environment).

    • Transmission-Based Precautions (brief overview of when and why used – Contact, Droplet, Airborne).

    • Hospital's specific infection control policies and procedures.

    • Reporting procedures for suspected infections or breaches in IPC protocols.

  • Hands-on Demonstrations and Practice: Include practical demonstrations of key techniques like hand washing, PPE donning and doffing. Allow staff to practice these skills under guidance during the induction session.

  • Role-Specific IPC: Tailor some aspects of IPC training to be relevant to different staff roles. For example, direct patient care staff might need more detailed training on catheter care or wound care infection prevention, while administrative staff might need more focus on environmental cleanliness and hand hygiene.

HRM 3g: The induction training includes orientation to the service standards of the organisation. (C)

• Objective Element Text: The induction training includes orientation to the service standards of the organisation.

• Compliance Level: Commitment (C) - Commitment level, emphasizing the importance of aligning staff with the hospital's service quality expectations from the beginning.

• Detailed Explanation: This OE highlights the importance of orienting new staff to the hospital's Service Standards. Service standards define the level of service quality that the hospital aims to provide to patients and visitors. These standards are about the patient experience and how staff interactions contribute to that experience. Induction is the ideal time to introduce these standards and instill a service-oriented mindset.

• Key Aspect:

  • Service standards: Induction must focus on making staff aware of the specific service standards that the hospital has defined. These are the benchmarks for service quality.

  • Orient staff to implement service standards of organisation: The goal is not just awareness, but to orient staff to actively implement these service standards in their daily work. This means staff understanding what the standards are and how to consistently meet or exceed them.

• Practical Implementation:

  • Clearly define and communicate Service Standards: Hospitals need to have clearly documented service standards that cover various aspects of the patient experience (e.g., communication, responsiveness, empathy, respect, cleanliness, waiting times, information provision). Present these standards during induction.

  • Provide examples of service standard behaviors: Illustrate what meeting service standards looks like in practice. Use scenarios or case studies to show examples of staff behaviors that demonstrate excellent service and those that fall short.

  • Train on communication skills: Effective communication is often a core component of good service. Include training on communication skills (active listening, clear and empathetic communication, handling patient queries and concerns) in the induction program.

  • Role-playing and practical exercises: Use role-playing exercises to allow staff to practice applying service standards in simulated patient interaction scenarios. This makes the training more engaging and practical.

  • Reinforce service standards in ongoing training and performance feedback: Service standards should be consistently reinforced beyond induction. Include them in ongoing training programs, performance appraisal criteria, and internal communication to create a service-oriented culture.

HRM 3h: The induction training includes an orientation on administrative procedures. (C)

• Objective Element Text: The induction training includes an orientation on administrative procedures.

• Compliance Level: Commitment (C) - Commitment level, ensuring new staff are quickly oriented to essential administrative aspects for smooth functioning within the organization.

• Detailed Explanation: In addition to clinical and patient-focused training, new staff also need to be oriented to the hospital's essential administrative procedures. This helps them navigate the organizational processes efficiently, understand their administrative responsibilities, and ensures smooth day-to-day operations.

• Key Administrative Areas to Cover:

  • Administrative procedures: Induction training should include an overview of key administrative procedures that staff will need to be aware of.

  • Attendance: Explain the hospital's attendance policies and procedures. How to record attendance, rules regarding punctuality, shift timings, and procedures for reporting absences.

  • Leave: Explain the different types of leave available (annual leave, sick leave, etc.) and the procedure for applying for leave. Approval processes, leave balances, and relevant leave policies should be covered.

  • Conduct: Orientation on general workplace conduct expectations and basic administrative rules that are not covered by the more formal Code of Conduct (HRM 2c). This might include dress code, use of hospital resources, personal phone use during work hours, general workplace etiquette, etc.

• Note:

  • "Induction training should also include staff awareness of organisation-wide polices and procedures." This broadens the scope beyond just attendance, leave, and conduct. Induction should also cover other relevant organization-wide policies and procedures that all staff need to be aware of, regardless of their specific department. This ensures consistent understanding and adherence to hospital-wide rules. Examples of other policies and procedures:

    • IT usage policies, data security and privacy policies (beyond patient confidentiality, covering all organizational data).

    • Communication policies (internal and external communication protocols).

    • Policy on workplace harassment and discrimination (beyond Code of Conduct, detailing reporting procedures).

    • Policy on conflict of interest.

    • Procedure for raising grievances or complaints.

    • Access control and security procedures for the hospital premises.

HRM 3i: The induction training includes an orientation on relevant department/unit/service/programme's policies and procedures. (C)

• Objective Element Text: The induction training includes an orientation on relevant department/unit/service/programme's policies and procedures.

• Compliance Level: Commitment (C) - Commitment level, emphasizing the need for job-specific orientation within departments or units, in addition to general hospital induction.

• Detailed Explanation: Building upon the organization-wide induction, this OE stresses the importance of department-specific or unit-specific induction. While hospital-wide policies and procedures provide a general framework, individual departments, units, services, or programs often have their own specific policies and procedures tailored to their unique functions and workflows. New staff need to be oriented to these localized rules and processes as well. This ensures smooth integration into their specific work environment.

• Key Aspect:

  • Department/unit/service/programme orientation: This emphasizes the need for localized induction beyond the general organizational induction.

  • Train staff on relevant policies and procedures: The departmental or unit induction should focus on training new staff on the specific policies and procedures that are relevant to their particular area of work. These are often more detailed and operationally focused than the broader organizational policies.

• Practical Implementation:

  • Departmental/Unit Induction Modules: Departments or units should design their own induction modules in addition to the hospital-wide induction program. These modules should be tailored to the specific needs of the department.

  • Examples of Department-Specific Content:

    • Nursing Department: Departmental nursing procedures, charting protocols, medication administration guidelines specific to the unit, unit-specific safety protocols, introduction to the nursing team, unit layout.

    • Operating Room: OR-specific protocols (surgical attire, infection control in OR, equipment operation), flow of procedures, introduction to surgical team.

    • Radiology Department: Departmental safety protocols (radiation safety), equipment-specific procedures, reporting protocols.

    • HR Department (for new HR staff): HR department-specific procedures (recruitment processes, payroll procedures, employee relations protocols), software and systems used by HR.

  • Departmental Induction Checklist: Use a checklist to ensure all essential department-specific induction topics are covered for each new staff member joining the department.

  • Departmental Mentorship or Buddy System: Assign a mentor or buddy within the department to guide the new staff member, answer questions, and facilitate their integration into the team and departmental processes in the initial days and weeks.

HRM 3j: Staff is trained on information systems, information security, information use and management. (C) - NEW OBJECTIVE ELEMENT

• Objective Element Text: Staff is trained on information systems, information security, information use and management.

• Compliance Level: Commitment (C) - Commitment level, reflecting the growing importance of information systems and data management in modern healthcare.

• Detailed Explanation: This is a new Objective Element in the 6th Edition, reflecting the increasing reliance on digital information systems in hospitals. It mandates induction training on various aspects of information technology, data security, and responsible data management. This is a critical addition in the digital age to ensure data integrity, patient privacy, and effective use of hospital information systems.

• Key Focus Areas:

  • Information systems: Induction must include training on the information systems used in the hospital. This means familiarizing staff with the digital tools and platforms they will be using for their work.

  • Information security: Training must cover information security protocols and procedures. Data breaches and cyber threats are major concerns in healthcare, so training on data security is crucial to protect patient information and hospital systems.

  • Information use and management: Training should also address responsible information use and management. This encompasses ethical data handling, data privacy, data quality, and appropriate use of information systems for patient care and operational purposes.

• Practical Implementation:

  • Information Systems Training (Tailored to Role): Provide role-based training on the specific information systems staff will use in their jobs. This could include:

    • Electronic Medical Records (EMR): If the hospital uses EMR, provide training on accessing patient records, documenting care, navigating the system, order entry, and relevant EMR functionalities.

    • Hospital Information System (HIS): Training on any other HIS modules relevant to their role (e.g., billing, lab information system, radiology information system).

    • Other Software/Applications: Training on any other specific software or applications staff will be using (e.g., scheduling software, communication platforms, quality reporting systems).

  • Information Security Training: Cover essential information security topics:

    • Data privacy and confidentiality principles (beyond just patient confidentiality, covering all sensitive hospital data).

    • Password security and best practices.

    • Safe use of computers and networks (avoiding phishing, malware, etc.).

    • Protocols for data access and authorization.

    • Policies on data sharing and data handling.

    • Reporting procedures for security breaches or suspected security incidents.

  • Data Use and Management Training: Emphasize responsible data practices:

    • Data accuracy and integrity.

    • Ethical use of patient data.

    • Compliance with data privacy regulations (e.g., HIPAA, GDPR, or local equivalents).

    • Proper documentation and record-keeping practices in digital systems.

  • "Also if EMR is being used, training given to staff who need to access, document or review in EMR": Specifically highlights EMR training as a critical component if the hospital utilizes an EMR system. Training must enable staff to effectively access, document, and review patient information within the EMR, depending on their role and authorized access levels.

In summary, HRM 3 on Induction Training is a comprehensive standard covering a wide range of essential topics. It ensures that new staff are not only oriented to their job but also to the organization's values, policies, safety protocols, service standards, administrative procedures, and increasingly importantly, information systems. The addition of HRM 3j and the detailed breakdown of the OEs demonstrate NABH's emphasis on a robust, multi-faceted induction program that sets the stage for competent, safe, and well-integrated staff who contribute to quality patient care and efficient hospital operations. The designation of HRM 3a as a Core OE reinforces the fundamental nature of induction training within the accreditation framework.

HRM 4: There is an on-going programme for professional training and development of the staff

Overall Standard HRM 4 Summary (Page 31 equivalent):

• Standard Text: HRM4: There is an on-going programme for professional training and development of the staff.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard, signifying consistent emphasis on continuous professional development. However, interpretations for HRM 4a & HRM 4b have been modified for clarity. HRM 4e has had its objective element level changed from Excellence to Achievement.

• Objective Elements: There are 6 Objective Elements under HRM 4 in both the 5th and 6th editions, detailing the components of an effective on-going training and development program.

Detailed Breakdown of Objective Elements under HRM 4 (Pages 32-37 equivalent):

HRM 4a: Written guidance governs training and development policy for the staff. (CO)*

• Objective Element Text: Written guidance governs training and development policy for the staff.* (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment Core OE (CO) - As a Core OE at the Commitment level, this emphasizes that a documented training and development policy is foundational and critically important, mandating system documentation to demonstrate compliance.

• Detailed Explanation: This Objective Element is fundamental to ensuring that staff training and development is not haphazard but rather a systematic and planned activity. It mandates the existence of written guidance - essentially a formal policy and procedures document - that governs how training and development are approached within the hospital. This ensures consistency, clarity, and a strategic approach to staff development.

• Key Components of Written Guidance:

  • Training manual (Left Blue Box): This refers to the detailed operational document that outlines how training will be conducted and managed.

    • "Identify training needs.": The training manual must describe the process for identifying training needs. This is the starting point. Training should not be generic; it needs to address specific gaps in knowledge, skills, or competencies required for staff to perform their roles effectively and to support the hospital's objectives.

      • Practical Implication: Needs assessment can be done through various methods: performance appraisals (identifying areas for improvement), job descriptions (identifying required competencies), changes in technology or procedures (necessitating new training), feedback from staff and supervisors, incident reports (revealing knowledge gaps), quality improvement initiatives (identifying training needs related to quality issues), and strategic planning (identifying future skill requirements).

    • "Devise training methodology.": The manual must outline the training methodologies that will be used. This is about how training will be delivered. Effective training uses a variety of methods, not just lectures.

      • Practical Implication: Consider different training methodologies suitable for different topics and learning styles. Examples include: lectures, workshops, hands-on training, simulations, e-learning modules, on-the-job training, mentorship programs, journal clubs, case study discussions, webinars, external conferences/workshops. The manual should explain which methods are typically used for different types of training.

    • "Document training.": The manual must describe how training activities will be documented. This is crucial for record-keeping, tracking staff training history, and demonstrating compliance with NABH standards.

      • Practical Implication: Establish a system for documenting all training activities. This could involve maintaining training records (electronic or paper-based) for each staff member, detailing: training title, date, duration, trainer, content covered, training methodology used, and attendance records (preferably with signatures). This documentation should be easily retrievable for audits and reporting.

    • "Perform training assessment.": The manual should outline how training effectiveness will be assessed. Assessment is vital to determine if training has achieved its objectives and if staff have acquired the intended knowledge or skills.

      • Practical Implication: Define assessment methods to be used before, during, and after training. Examples: pre- and post-tests to measure knowledge gain, practical demonstrations to assess skills, observation of performance on the job after training, feedback forms from participants, evaluation of incident reports or quality metrics post-training to see if training has led to improvements in practice. The assessment methods should be appropriate for the type of training and learning outcomes.

    • "Analyse impact of training.": The manual should describe how the impact of training will be evaluated. This goes beyond just immediate assessment; it's about understanding the broader effect of training on staff performance, patient outcomes, and organizational goals.

      • Practical Implication: Establish metrics to measure the impact of training over time. This might involve tracking changes in key performance indicators (KPIs) related to quality, safety, efficiency, or patient satisfaction before and after training initiatives. Analyze incident reports, audit findings, patient feedback, and performance data to see if training has led to tangible improvements in relevant areas.

    • "Prepare training calendar.": The manual must include the process for preparing an annual training calendar. A calendar is a practical tool for planning, scheduling, and communicating training activities throughout the year.

      • Practical Implication: Develop an annual training calendar based on identified training needs and organizational priorities. This calendar should list planned training programs, target audience, dates, venues, and trainers. The calendar should be communicated to all staff well in advance to facilitate planning and participation. The calendar should be flexible enough to accommodate urgent or emerging training needs throughout the year.

  • Staff training (Right Blue Box): This section specifies the minimum areas that staff training should cover. It's about the content of the training program.

    • "At a minimum, staff should be trained on:": This phrase indicates these are essential topics and not an exhaustive list. Hospitals may need to include other training topics relevant to their specific needs and context.

      • "Occupational safety aspects.": All staff need to be trained on aspects related to their occupational safety in the workplace. This is crucial for staff well-being and creating a safe work environment.

        • Practical Implication: Occupational safety training should cover: hazard identification and risk management in their specific work areas, safe handling of equipment and materials, ergonomic principles, emergency procedures related to occupational hazards (e.g., chemical spills, needle stick injuries), reporting procedures for occupational safety incidents, and relevant safety regulations (e.g., OSHA guidelines).

      • "Soft skills.": Training on soft skills is increasingly recognized as vital in healthcare. These are interpersonal and behavioral skills essential for effective communication, teamwork, and patient-centered care.

        • Practical Implication: Soft skills training might include: communication skills (active listening, empathy, effective verbal and non-verbal communication), interpersonal skills, teamwork and collaboration, conflict resolution, customer service skills (patient interaction skills), stress management, and leadership skills (for staff in leadership roles).

      • "Aspects of patient-centred care.": Training on patient-centered care is fundamental in modern healthcare. It emphasizes putting the patient at the heart of care delivery, respecting their preferences, and ensuring their active involvement in their care.

        • Practical Implication: Training on patient-centered care should cover: principles of patient-centered care (respect, dignity, empathy, responsiveness, shared decision-making), communication skills for patient interaction, cultural competence and sensitivity to diverse patient needs, patient rights and responsibilities, techniques for eliciting patient preferences and involving patients in care planning, and strategies to improve patient experience and satisfaction.

• Points to Remember Box:

  • Patient-centred care includes: This box elaborates on what "patient-centered care" practically means in a training context, emphasizing specific components:

    • Respecting patient preferences: Tailoring care to align with individual patient values, beliefs, and choices.

    • Shared decision-making: Involving patients actively in decisions about their treatment and care, providing them with information and options, and respecting their choices.

    • Provision of integrated care: Ensuring care is coordinated and seamless, considering the patient's holistic needs across different services and providers.

• Note:

  • "All staff including doctors and outsourced staff (wherever applicable) should undergo training." The scope of the training program is broad. It should encompass all staff categories, including doctors, consultants, nurses, allied health professionals, administrative staff, support staff, and even outsourced staff where relevant to their roles and responsibilities within the hospital. This reinforces the idea that continuous professional development is important for everyone contributing to hospital operations and patient care.

HRM 4b: The organisation maintains the training record. (C)

• Objective Element Text: The organisation maintains the training record.

• Compliance Level: Commitment (C) - Commitment level, highlighting the basic necessity of maintaining records of training activities for each staff member.

• Detailed Explanation: This Objective Element mandates that the hospital must maintain a training record for each staff member. This record serves as a history of the training and professional development activities undertaken by the individual. Accurate and accessible training records are essential for tracking staff competencies, identifying training gaps, planning future training, and demonstrating compliance.

• Key Components of a Training Record (Blue Box - "Training record"):

  • Title of training: Clearly state the name or title of the training program or session. This provides identification of the specific training activity.

  • Trainer(s): Record the name(s) of the trainers or facilitators who conducted the training. This helps in identifying who delivered the training and for any follow-up questions or quality assessment.

  • List of trainees (with signature): Maintain a list of staff members who attended the training session. Ideally, this list should include signatures from attendees as evidence of their participation. Signatures provide a more formal and verifiable record of attendance.

  • Contents of training: Briefly describe the key topics or content covered in the training session. This provides context and helps understand what the training entailed. It doesn't need to be exhaustive, but a summary of the main subjects.

• Note:

  • "The human resources department maintains a training record." Clarifies the responsibility for maintaining these training records. Typically, the Human Resources department is the central repository for staff training records. HR is best positioned to track training across the organization and ensure consistency in record-keeping. However, departmental training records might also be kept and then consolidated by HR, depending on the organizational structure.

HRM 4c: Training also occurs when job responsibilities change/new equipment is introduced. (C)

• Objective Element Text: Training also occurs when job responsibilities change/new equipment is introduced.

• Compliance Level: Commitment (C) - Commitment level, emphasizing that training is not just routine, but also responsive to changes in job roles and technology.

• Detailed Explanation: This Objective Element stresses that training is not limited to annual calendars or routine programs. It must be triggered by significant changes in the workplace, specifically: changes in job responsibilities and the introduction of new equipment or technology. This ensures staff are always adequately prepared for any shifts in their roles or the tools they use.

• Training Triggers:

  • Revised job responsibilities: When an employee's job duties or scope of work are significantly altered, training is required to equip them with the new skills and knowledge needed for the changed responsibilities.

    • Practical Implication: When job descriptions are updated or roles are redefined, HR and department managers should assess the training implications. If significant new skills or knowledge are required, specific training programs should be designed and delivered to affected staff before the new responsibilities are implemented.

  • Newly introduced equipment and technology: When new equipment or technology is introduced in the hospital (clinical equipment, IT systems, etc.), staff who will be using or interacting with this new technology must receive training. This is essential for safe and effective use and to prevent errors.

    • Practical Implication: Before rolling out new equipment or technology, plan and deliver comprehensive training to all staff who will be using it. Training should cover: operation of the equipment, safety features and protocols, troubleshooting, basic maintenance, and integration with existing workflows.

• Note:

  • "When a new equipment is introduced, the operating staff should be trained on operational and daily maintenance aspects of the equipment." Specifically highlights that training for new equipment should not just focus on operation, but also on basic daily maintenance. This empowers staff to keep equipment functioning properly, prevent minor issues from escalating, and ensure equipment longevity. Daily maintenance training could include: cleaning procedures, basic checks, lubrication (if applicable), reporting minor malfunctions, and understanding preventive maintenance schedules.

HRM 4d: Feedback mechanisms are in place for improvement of training and development programme. (C)

• Objective Element Text: Feedback mechanisms are in place for improvement of training and development programme.

• Compliance Level: Commitment (C) - Commitment level, emphasizing the need for continuous improvement of training programs using feedback.

• Detailed Explanation: This Objective Element stresses the importance of continuous improvement of the training and development program itself. Training programs should not be static; they need to evolve and become more effective over time. Feedback mechanisms are essential tools for gathering information on how to improve training programs. This ensures that training remains relevant, effective, and meets the needs of staff and the hospital.

• Feedback Process:

  • Obtain feedback (Central Blue Box): The core action is to actively seek and collect feedback about training programs.

  • For all training programmes (Internal and external): Feedback collection should be systematic and apply to all types of training, whether conducted internally within the hospital or if staff attend external training programs. This ensures a comprehensive view of training quality.

  • Collect relevant information: The feedback sought should be focused and relevant to program improvement.

• Points to Remember Box - Focus Areas for Feedback:

  • Feedback should be obtained on the: This box lists key aspects on which feedback should be specifically sought:

    • Appropriateness of course material: Is the training content relevant to the staff's job roles and needs? Is the level of information appropriate? Is the content up-to-date and accurate?

    • Facilities provided: Were the training facilities adequate? Was the venue comfortable and conducive to learning? Were necessary resources (equipment, materials) available?

    • Capability of the trainer: Was the trainer knowledgeable, engaging, and effective in delivering the training? Were they able to answer questions and facilitate learning effectively?

• Practical Implementation:

  • Feedback Forms: Use structured feedback forms or questionnaires to collect feedback from training participants immediately after each training session. These forms should cover the aspects listed in "Points to Remember" and other relevant questions about training delivery, organization, and value.

  • Verbal Feedback Sessions: Conduct brief verbal feedback sessions at the end of training sessions, allowing participants to share their immediate thoughts and suggestions.

  • Post-Training Surveys (Delayed Feedback): Send out follow-up surveys some time after the training (e.g., 1-3 months later) to assess the longer-term impact and relevance of the training to their work.

  • Trainer Feedback and Self-Reflection: Trainers should be encouraged to self-reflect on their training delivery and seek feedback from participants and colleagues on how to improve their training skills.

  • Regular Review of Feedback Data: HR or the training department should systematically collect, analyze, and review the feedback data gathered from various sources. Identify trends, recurring themes, and areas for improvement in the training program.

  • Use Feedback to Make Improvements: Critically, the feedback should be used to actually make changes to the training program. Revise course content, update training materials, improve training methodologies, select different trainers, enhance facilities based on the feedback received. Demonstrate a feedback loop where feedback leads to tangible improvements.

HRM 4e: Evaluation of training effectiveness is done by the organisation. (A)

• Objective Element Text: Evaluation of training effectiveness is done by the organisation.

• Compliance Level: Achievement (A) - Changed from Excellence to Achievement in 6th Edition. At the Achievement level, this signifies a step beyond basic commitment, requiring a more in-depth and demonstrable effort in evaluating training effectiveness.

• Detailed Explanation: This Objective Element goes beyond just assessing if training was well-delivered (as in HRM 4d feedback). It focuses on evaluating the actual effectiveness of the training in achieving its intended learning outcomes and impacting staff competency and performance. Evaluation is more about measuring outcomes rather than just gathering feedback on the process. The change from "Excellence" to "Achievement" suggests that while rigorous evaluation was previously seen as a best practice, it is now considered a more emphasized expectation for accreditation.

• Evaluation Timeframes and Methods:

  • Immediately after training (Left Blue Box): Evaluation should be conducted immediately after the training session to assess immediate learning and initial reactions to the training.

    • Why should it be done? "To find immediate effectiveness of training." - To gauge if participants have grasped the key concepts and if the training was perceived as useful right after the session.

    • How can it be done? "By conducting pre and post-tests." - Using pre-tests (before training) and post-tests (after training) to objectively measure knowledge gain. This is particularly useful for knowledge-based training.

  • After a certain period (Right Blue Box): Evaluation should also be conducted some time after the training (weeks or months later) to assess the longer-term impact of the training on staff performance and competency in their actual work settings.

    • Why should it be done? "To ensure that the training has helped in improving staff's competency." - To determine if the training has translated into real-world changes in staff behavior, skills, and performance on the job.

    • How can it be done? "With the help of incident reports and non-conformities pointed during assessment." - Using practical indicators to measure impact:

      • Incident reports: Analyzing incident reports after training to see if there is a reduction in incidents related to the training topic. For example, if training was on medication safety, track medication errors reported after training.

      • Non-conformities pointed during assessment: Reviewing findings from quality audits, performance appraisals, or other assessments conducted after training to see if staff demonstrate improved competency in areas addressed by the training. For example, if training was on infection control practices, assess hand hygiene compliance rates post-training.

• Points to Remember Box - Evaluation Focus:

  • Evaluation should focus on: Evaluation should be multi-dimensional and not just limited to knowledge tests. It should aim to assess changes in:

    • Knowledge: Has the training improved staff's factual understanding of the subject matter? (Measured through tests, quizzes)

    • Skills: Has the training enhanced staff's practical abilities and competencies? (Measured through skill demonstrations, practical assessments, observation of job performance)

    • Attitude: Has the training influenced staff's attitudes, behaviors, or commitment to best practices? (Measured through feedback, surveys, observation of workplace behaviors, patient satisfaction data)

• Note:

  • "The organisation can determine the time frame for capturing effectiveness of training based on the type of training." Recognizes that the appropriate timeframe for evaluating training effectiveness may vary depending on the type of training, its objectives, and the nature of the skills or knowledge being taught. For some training (e.g., equipment operation), immediate assessment and short-term follow-up might be sufficient. For others (e.g., leadership development, complex clinical skills), a longer-term evaluation timeframe is needed to observe sustained changes in behavior and performance. The hospital has flexibility in setting evaluation timeframes, but needs to justify them based on the training's goals.

HRM 4f: The organisation supports continuing professional development and learning. (A)

• Objective Element Text: The organisation supports continuing professional development and learning.

• Compliance Level: Achievement (A) - Achievement level, highlighting a proactive organizational commitment to fostering a culture of lifelong learning and professional growth for staff.

• Detailed Explanation: This Objective Element goes beyond mandatory training requirements. It emphasizes the hospital's broader role in supporting and encouraging ongoing professional development (CPD) and lifelong learning for its staff. It's about fostering a culture of continuous growth, skill enhancement, and career development. Being at the "Achievement" level shows a commitment to staff growth beyond basic compliance.

• Organizational Support and Staff Benefits:

  • Staff benefits (Top Blue Box): Describes why continuing professional development is beneficial for staff:

    • "Be familiar with advancements in their field.": CPD helps staff stay current with the latest knowledge, research, best practices, and technological advancements in their respective fields. Healthcare is constantly evolving, and continuous learning is crucial to provide up-to-date care.

    • "Develop skills.": CPD opportunities allow staff to develop new skills and enhance existing ones. This could be technical skills, clinical skills, soft skills, or leadership skills, expanding their capabilities and career potential.

    • "Improve skill sets and competency.": Ultimately, CPD leads to an improvement in staff skill sets and overall competency. This benefits both individual staff members in their career progression and the hospital through a more skilled and capable workforce, leading to better patient care.

  • Organisation benefits (Bottom Blue Box): Describes how the hospital can actively support CPD:

    • "Encourage staff to attend courses/conferences.": Actively encourage staff to participate in external courses, workshops, seminars, conferences, and professional development events. This could involve promoting such opportunities, providing time off for attendance, or offering financial support.

    • "Provide resources.": The hospital should allocate resources to support CPD. This could include:

      • Financial resources: Training budgets, scholarships, subsidies for course fees or conference registration.

      • Time resources: Allocating protected time for staff to attend training, participate in online learning, or engage in self-study.

      • Learning resources: Access to online learning platforms, e-libraries, journals, professional development materials within the hospital.

    • "Provide access to distance learning/e-learning resources.": Recognizes the growing importance of flexible and accessible learning formats. Hospitals should provide access to distance learning platforms, e-learning modules, online courses, webinars, and other digital learning resources. This makes CPD more convenient and accessible for staff with busy schedules.

• Note:

  • "The organisation should specify minimum mandatory hours of training that every staff should undergo in a year." To reinforce the commitment to CPD, it's recommended that hospitals establish a minimum number of mandatory training hours that all staff (or certain categories of staff) should undertake annually. This creates a culture of learning and sets a baseline expectation for CPD engagement. The specific number of hours can be determined by the hospital based on roles, needs, and resources. This is a key mechanism for driving a culture of continuous learning within the organization.

In summary, HRM 4 focuses on establishing a systematic, continuous, and supportive framework for staff training and professional development. It emphasizes documented policies, structured training programs, diverse methodologies, rigorous evaluation, feedback mechanisms, and organizational support for lifelong learning. The objective elements move from foundational requirements (written guidance, record-keeping) to more advanced practices (evaluation of effectiveness, organizational support for CPD), reflecting a progression towards a learning organization that invests in its staff and promotes a culture of continuous improvement.

HRM 5: Staff are appropriately trained based on their specific job description

Overall Standard HRM 5 Summary (Page 38 equivalent):

• Standard Text: HRM5: Staff are appropriately trained based on their specific job description.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard, indicating a consistent emphasis on job-role specific training. However, interpretations for HRM 5e & HRM 5f have been modified for clarity.

• Objective Elements: There are 6 Objective Elements under HRM 5 in both the 5th and 6th editions. These OEs detail specific areas of training that should be provided based on the staff's roles and responsibilities within the hospital.

Detailed Breakdown of Objective Elements under HRM 5 (Pages 39-44 equivalent):

HRM 5a: Staff involved in blood transfusion services are trained on the handling of blood and blood products. (C)

• Objective Element Text: Staff involved in blood transfusion services are trained on the handling of blood and blood products.

• Compliance Level: Commitment (C) - At the Commitment level, highlighting the essential safety training for staff working with blood and blood products.

• Detailed Explanation: This Objective Element directly targets staff who work in blood transfusion services. These individuals have a critical role in the safe handling, processing, and administration of blood and blood products. Training is crucial to minimize risks associated with transfusion and ensure patient safety. The focus is on job-specific training relevant to blood transfusion processes.

• Key Training Areas for Handling Blood and Blood Products (Blue Box - "Handling blood and blood products"):

  • "Safe transport of blood.": Training must cover procedures for the safe and appropriate transportation of blood and blood products within the hospital premises and potentially even from external blood banks. This is critical to maintain blood quality and prevent damage or contamination during transport.

    • Practical Implication: Training on proper packaging, temperature control during transport (maintaining cold chain), use of validated transport containers, protocols for transporting different types of blood products, procedures for documenting transport, and emergency procedures in case of transport delays or issues.

  • "Obtaining informed consent.": Training must include the process of obtaining informed consent from patients prior to blood transfusion. Informed consent is a fundamental ethical and legal requirement for any medical procedure, including transfusion.

    • Practical Implication: Training on the elements of informed consent for blood transfusion (risks, benefits, alternatives, right to refuse), communication skills to explain this information clearly to patients, documentation of informed consent in patient records, addressing patient questions and concerns about transfusion, and procedures for obtaining consent in emergency situations.

  • "Maintenance of various documents.": Training must cover the accurate maintenance of all relevant documentation related to blood transfusion services. Meticulous record-keeping is essential for traceability, auditability, and patient safety in blood transfusion.

    • Practical Implication: Training on proper documentation practices at each step of the blood transfusion process: blood request forms, blood component tracking records, pre-transfusion testing records, transfusion records, adverse reaction reporting forms, inventory management records, equipment maintenance logs, and archival procedures for blood transfusion documents.

  • "Identification of transfusion reactions.": Training must equip staff to recognize and identify potential transfusion reactions. Early detection of a reaction is critical for timely intervention and managing patient safety.

    • Practical Implication: Training on the signs and symptoms of different types of transfusion reactions (e.g., febrile, allergic, hemolytic, TRALI, TACO), recognizing both immediate and delayed reactions, procedures for monitoring patients during and after transfusion, and emergency response protocols for managing transfusion reactions.

  • "Handling transfusion reactions.": Training must include protocols and procedures for handling and managing transfusion reactions once they are identified. This is about effective response and minimizing patient harm.

    • Practical Implication: Training on step-by-step procedures for managing transfusion reactions: stopping the transfusion immediately, maintaining IV access, notifying a physician, managing symptoms based on the type of reaction, completing adverse reaction reporting forms, investigating the cause of the reaction, and follow-up care for patients who have experienced a reaction.

  • "Educating patient and family on donation.": Training should also cover how to educate patients and their families about blood donation. This is about promoting voluntary blood donation and ensuring a sufficient blood supply. While not directly related to immediate patient care, it's important for the broader blood transfusion service.

    • Practical Implication: Training on providing information to patients and families about the importance of blood donation, eligibility criteria for donation, the donation process, addressing common concerns and myths about blood donation, promoting voluntary donation drives, and directing interested donors to appropriate blood donation centers or hospital blood banks.

• Points to Remember Box (Contextual Guidance):

  • "Relevant staff should be trained on various aspects of transfusion services." Emphasizes that the scope of training should be broad and cover all aspects of blood transfusion services that are relevant to their job roles. It's not just about the technical act of transfusion itself.

  • "Relevant staff include:": Specifies the categories of staff who are considered "relevant" for this training:

    • Doctors: Prescribe blood transfusions, manage transfusion reactions, oversee transfusion services.

    • Nurses: Administer blood transfusions, monitor patients during transfusion, identify and manage reactions, document transfusion details.

    • Technicians: Lab technicians in blood banks, blood storage unit personnel involved in blood processing, testing, storage, and issuing of blood products.

    • Staff involved in transporting blood from blood bank/blood storage unit. Even staff whose primary role is transport need training on safe handling and transport procedures to maintain blood integrity.

HRM 5b: Staff are trained in handling vulnerable patients. (C)

• Objective Element Text: Staff are trained in handling vulnerable patients.

• Compliance Level: Commitment (C) - Commitment level, highlighting the need for specialized training to care for vulnerable patient populations.

• Detailed Explanation: This Objective Element emphasizes the need for specialized training for staff who interact with vulnerable patients. Vulnerable patient populations have specific needs and risks that require staff to have particular skills and sensitivities to provide appropriate and ethical care. It's about adapting care delivery to meet the unique needs of these groups.

• Key Training Areas for Handling Vulnerable Patients (Blue Circle - "Vulnerable patients"):

  • "Identify": Training must equip staff to identify vulnerable patients. This requires understanding the characteristics and factors that make a patient "vulnerable."

    • Practical Implication: Training on defining vulnerability in the hospital context, identifying categories of vulnerable patients (e.g., children, elderly, patients with cognitive impairment, patients with disabilities, patients from marginalized communities, patients experiencing domestic violence or abuse, patients with language barriers, patients with mental health conditions), recognizing risk factors that contribute to vulnerability, and using tools or checklists (if available) to help identify vulnerable patients.

  • "Render care": Training must focus on how to render appropriate care to vulnerable patients. This goes beyond standard care and requires adaptations and specialized approaches.

    • Practical Implication: Training on specific care considerations for different vulnerable groups, communication techniques adapted for vulnerable populations (e.g., communicating with children, patients with cognitive impairment, patients with language barriers), ethical considerations in caring for vulnerable patients, safeguarding procedures and reporting mechanisms for abuse or neglect, cultural sensitivity and awareness when dealing with diverse vulnerable groups, strategies to empower vulnerable patients and involve them in their care to the extent possible, and accessing resources and support services for vulnerable patients within the hospital and in the community.

• Note:

  • "Relevant staff should be trained as per the written guidance." The specific content and scope of "handling vulnerable patients" training should be defined in written guidance (likely the overall training and development policy or specific program policies). This ensures a structured and consistent approach to training on this important topic. The written guidance would detail which staff categories are considered "relevant" (e.g., all clinical staff, patient-facing staff, social workers, counselors), the specific learning objectives of the training, and the content to be covered.

HRM 5c: Staff are trained in control and restraint techniques. (C)

• Objective Element Text: Staff are trained in control and restraint techniques.

• Compliance Level: Commitment (C) - Commitment level, highlighting the need for training on proper use of control and restraint, emphasizing ethical and safe application.

• Detailed Explanation: Control and restraint techniques (both physical and chemical restraint) are sometimes necessary in healthcare settings for patient safety (e.g., to prevent self-harm or harm to others). However, restraint is a serious intervention with ethical and safety implications. This Objective Element mandates that staff who may need to use restraint are properly trained in these techniques to ensure they are used appropriately, safely, and ethically, as a last resort.

• Key Training Area (Gold Box):

  • "Appropriate use of control and restraint techniques.": The training must focus on the appropriate and ethical application of control and restraint. It's not just about the mechanics of restraint, but the entire process of decision-making, application, monitoring, and documentation.

    • Practical Implication: Training content should cover:

      • Indications for restraint (when is it justified, criteria for use as a last resort).

      • Alternatives to restraint (de-escalation techniques, environmental modifications, verbal interventions, medication - if appropriate and less restrictive).

      • Different types of restraint (physical, chemical, environmental).

      • Safe application of restraint techniques (proper techniques to minimize risk of injury to patient and staff, safe positioning, monitoring circulation and breathing).

      • Ethical considerations in restraint use (least restrictive means principle, patient dignity, consent - if possible, justification for use without consent in emergencies).

      • Legal and policy frameworks related to restraint use in the hospital.

      • Documentation requirements for restraint use (reasons for restraint, type used, duration, monitoring parameters, alternatives tried, consent process).

      • Procedures for monitoring patients in restraint (frequency of checks, parameters to monitor – circulation, breathing, skin integrity, psychological distress).

      • Protocols for releasing restraint as soon as it is safe to do so.

• Note:

  • "Relevant staff should be trained as per the written guidance." Similar to HRM 5b, the specific content, scope, and target audience for "control and restraint techniques" training should be defined in written guidance. This written guidance would detail which staff categories need this training (e.g., nursing staff in acute psychiatric units, emergency departments, ICUs, security staff), the level of training required (basic awareness vs. advanced practical skills), the specific techniques covered (aligned with ethical and best practice guidelines), and the frequency of refresher training.

HRM 5d: Staff are trained in healthcare communication techniques. (C)

• Objective Element Text: Staff are trained in healthcare communication techniques.

• Compliance Level: Commitment (C) - Commitment level, recognizing effective communication as a core competency for all healthcare staff.

• Detailed Explanation: Effective communication is fundamental to all aspects of healthcare – patient care, teamwork, safety, and patient satisfaction. This Objective Element mandates that staff are trained in healthcare communication techniques. It's about enhancing staff's ability to communicate effectively with patients, families, colleagues, and other stakeholders in the healthcare setting.

• Key Communication Skills Training Areas (Speech Bubbles):

  • "Handling challenging situations.": Training should equip staff to manage difficult or challenging communication situations that are common in healthcare.

    • Practical Implication: Training on: de-escalation techniques for managing angry or distressed patients or family members, communication strategies for delivering bad news sensitively, conflict resolution skills for inter-professional conflicts or patient-staff conflicts, communication skills for dealing with emotionally charged situations, strategies for managing communication breakdowns, and techniques for handling complaints and feedback constructively.

  • "Adhering to good practices in health care communication.": Training should focus on general principles of good healthcare communication and best practices for effective interaction.

    • Practical Implication: Training on: active listening skills, empathetic communication, clear and concise verbal and written communication, non-verbal communication awareness, culturally sensitive communication, communication skills for building rapport with patients and families, communication skills for inter-professional teamwork, and communication techniques for shared decision-making with patients.

• Points to Remember Box (Identifying Training Needs):

  • "The training needs for communication skills can be identified by:": This box suggests methods for identifying gaps in communication skills and areas where training is needed, making the training needs-based:

    • "Analysing patient complaints.": Patient complaints often highlight communication issues. Analyzing complaints can reveal recurring themes and areas where staff communication skills need improvement.

    • "Incident reports.": Reviewing incident reports can also reveal communication breakdowns as contributing factors to errors or adverse events. Communication training can be targeted to address these identified issues.

    • "Appraisals.": Performance appraisals may identify communication skills as an area for development for individual staff members. Appraisal feedback can be used to tailor training plans.

    • "Employee feedback.": Seeking direct feedback from employees themselves about communication challenges they face and areas where they feel they need more training can provide valuable insights into training needs.

HRM 5e: Staff involved in direct patient care are provided training on cardio-pulmonary resuscitation periodically. (CO)

• Objective Element Text: Staff involved in direct patient care are provided training on cardio-pulmonary resuscitation periodically.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, emphasizing the critical and ongoing need for CPR competency for direct patient care staff with mandatory system documentation for proof of periodic training.

• Detailed Explanation: This Objective Element builds upon HRM 3e (CPR training in induction), but focuses on periodic refresher or update training in CPR. CPR skills, like many medical skills, require regular practice and updates to maintain competency, especially as guidelines evolve. This OE mandates that for staff involved in direct patient care, CPR training must be on-going and periodic. "Core OE" status emphasizes the continuous criticality of CPR competency.

• Target Staff Categories and Training Levels (Same as HRM 3e - Blue Box "Cardio-pulmonary resuscitation training"):

  • "All staff (Doctors, nursing staff, rehabilitation staff)": Should receive Basic Life Support (BLS) training periodically. This ensures foundational competency is maintained.

  • "ICU/High-dependency unit staff": Should receive Advanced Cardiac Life Support (ACLS), Paediatric Advanced Life Support (PALS), Neonatal Advanced Life Support (NALS) or equivalent training periodically to maintain advanced resuscitation skills required in critical care settings.

  • Or Any other equivalent/similar programme: Recognizes use of equivalent advanced resuscitation programs.

• Points to Remember Box (Implementation Guidance - same as HRM 3e):

  • "Trainers - From within/outside organisation can impart training.": Periodic CPR training can be delivered by internal or external certified trainers.

  • "Training - Can be given using established evidence-based protocols.": Refresher CPR training, just like initial training, must adhere to current, evidence-based guidelines and protocols (e.g., AHA, ERC).

• Note:

  • "Update on CPR is done once in 2 years or earlier if there is change in protocol": Provides a recommended frequency for CPR update training: at least once every 2 years. However, it also stresses the need for more frequent updates if there are significant changes in CPR protocols or guidelines. This ensures that staff are always trained in the most current best practices. The 2-year timeframe is a minimum; hospitals may choose to provide refresher training more frequently (e.g., annually). The key is to ensure skills remain current and competent.

HRM 5f: Staff are provided training on infection prevention and control. (C)

• Objective Element Text: Staff are provided training on infection prevention and control.

• Compliance Level: Commitment (C) - Commitment level, underscoring that infection prevention and control is an ongoing and essential training requirement for all staff.

• Detailed Explanation: Similar to CPR, infection prevention and control (IPC) is not a one-time training event. Knowledge and best practices in IPC constantly evolve. This Objective Element mandates that all staff receive periodic, in-service training on infection prevention and control. This reinforces the importance of IPC as an ongoing organizational priority and ensures that all staff remain updated on current best practices and hospital policies.

• Key Implementation Aspects (Blue Box - "In-service training sessions"):

  • "In-service training sessions": Emphasizes that IPC training should be delivered as in-service training sessions - meaning training that is integrated into the ongoing work and professional development activities of staff, not just a one-off initial training.

  • "All staff.": The scope of periodic IPC training is all-inclusive. It applies to every category of staff in the hospital, clinical and non-clinical, as everyone has a role in infection prevention, even if indirect.

  • "At least once a year.": Provides a minimum frequency for in-service IPC training: at least annually (once per year). This sets a baseline expectation for regular IPC updates. Hospitals may choose to provide more frequent IPC training sessions depending on their needs, risk assessments, or new outbreaks/concerns.

In summary, HRM 5 is centered on ensuring that training is job-role specific and relevant. It emphasizes targeted training in critical areas directly related to staff responsibilities, such as blood transfusion safety, care for vulnerable patients, restraint techniques (where applicable), communication skills, and essential life-saving skills like CPR and infection prevention and control. The Objective Elements within HRM 5 are designed to make training more practical, focused, and directly applicable to the daily work of different staff categories, contributing to enhanced competency and ultimately, better patient safety and care quality. The Core OE status of HRM 5e highlights the continuous importance of CPR competency for direct care staff, necessitating ongoing attention and documented periodic training.

HRM 6: Staff are trained in safety and quality-related aspects.

Overall Standard HRM 6 Summary (Page 45 equivalent):

• Standard Text: HRM6: Staff are trained in safety and quality-related aspects.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard, signifying a consistent emphasis on safety and quality training. However, interpretations for HRM 6a, HRM 6b, HRM 6d, HRM 6e, HRM 6f, and HRM 6g have been modified for clarity and potentially to reflect updated best practices.

• Objective Elements: There are 7 Objective Elements under HRM 6 in both the 5th and 6th editions. These OEs specify various safety and quality related training areas that staff should be trained on.

Detailed Breakdown of Objective Elements under HRM 6 (Pages 46-52 equivalent):

HRM 6a: Staff are trained on the organisation's safety programme. (C)

• Objective Element Text: Staff are trained on the organisation's safety programme.

• Compliance Level: Commitment (C) - At the Commitment level, highlighting the fundamental need for staff to be trained on the hospital's overall safety program.

• Detailed Explanation: This Objective Element mandates that staff are not only trained in general safety principles but specifically on the organization's own, tailored safety programme. This emphasizes that safety is not a generic concept, but something that each hospital must define, structure, and implement in a program format that addresses its unique risks and context. It ensures staff are aware of the hospital's specific approach to safety.

• Key Training Aspects (Blue Box - "Safety programme"):

  • "Provide regular training.": Training on the safety program should not be a one-time event, but rather regular and ongoing. This reinforces safety principles, updates staff on any changes, and maintains a safety-conscious culture.

    • Practical Implication: Develop a schedule for regular safety training sessions. This could be annually, bi-annually, or more frequently depending on the hospital's risk profile and changes in safety procedures or regulations. Regular training could be incorporated into in-service training calendars, departmental meetings, or dedicated safety awareness weeks.

  • "Give printed materials.": Providing printed materials as part of the safety program training is recommended. These materials serve as a takeaway resource for staff, allowing them to review key information, policies, and procedures after the training session.

    • Practical Implication: Develop easily understandable printed materials summarizing the key aspects of the hospital's safety program. This could include brochures, pamphlets, posters, or checklists outlining safety rules, emergency procedures, contact information, and key policies. These materials should be readily accessible to all staff.

• Note:

  • "Staff working in laboratory and imaging services should be trained in their respective safety programmes." Emphasizes the need for department-specific safety training in addition to the general organization-wide safety program, particularly for high-risk areas like laboratories and imaging services. These areas have unique safety hazards (e.g., biohazards, radiation) that require specialized training.

    • Practical Implication: Departments like Laboratory and Imaging should develop their own supplementary safety programs that address the specific risks and safety protocols relevant to their operations. Staff working in these departments should receive both the general hospital safety program training and department-specific safety training. This dual approach ensures comprehensive safety competence.

HRM 6b: Staff are provided training on the detection, handling, minimisation and elimination of identified risks within the organisation's environment. (C)

• Objective Element Text: Staff are provided training on the detection, handling, minimisation and elimination of identified risks within the organisation's environment.

• Compliance Level: Commitment (C) - Commitment level, emphasizing comprehensive risk training for all staff to identify, manage, and reduce risks in their work environment.

• Detailed Explanation: This Objective Element mandates training that goes beyond general safety and focuses on proactive risk management. Staff need to be trained not just on responding to safety issues, but also on identifying, handling, minimizing, and ideally eliminating risks in their daily work environment. This fosters a culture of risk awareness and proactive safety.

• Key Aspects of Risk Training (Left Blue Box - "Risk identification"):

  • "Define types of risks": Training must help staff understand the different categories or types of risks that can be present in a hospital setting. This provides a framework for risk awareness. The presentation provides examples of risk categories:

    • Physical: Risks related to the physical environment and infrastructure.

      • Examples: Poor lighting, slippery floors, blind corners, open electrical points and naked wires, trip hazards, improperly stored equipment.

    • Chemical: Risks related to the use, storage, and handling of chemicals.

      • Examples: Improper handling of chemicals, spills of hazardous substances, aerosolization of chemicals, exposure to cleaning agents, disinfectants, or medications.

    • Environmental: Risks related to the broader environment and working conditions.

      • Examples: Noise pollution, smoke (e.g., from construction or external sources), dampness, excessive heat or cold, poor ventilation.

    • Process-related: Risks inherent in healthcare processes and procedures.

      • Examples: Needle stick injuries, exposure to blood and body fluids, spills of blood or body fluids, handling of soiled linen or contaminated waste.

  • "Define risks related to": Training needs to be context-specific and identify risks that are relevant to different groups within the hospital environment:

    • Patient: Risks that directly threaten patient safety (e.g., medication errors, falls, infections, equipment malfunction).

    • Visitors: Risks to visitors within the hospital premises (e.g., slip and fall hazards, security risks, exposure to infections).

    • Staff: Risks that impact staff health and safety in their workplace (e.g., occupational hazards, ergonomic risks, workplace violence).

• Note:

  • "Staff should be able to demonstrate actions such as managing blood spills and handling hazardous materials." Emphasizes that the training should be practical and skills-based. Staff should not just learn about risks theoretically; they should be able to demonstrate practical skills in handling common risk scenarios. The examples given are managing blood spills and handling hazardous materials.

    • Practical Implication: Include hands-on practice and simulations in risk management training. For example, for blood spills, training should include practical steps for: using appropriate PPE, containing the spill, disinfecting the area, proper disposal of contaminated materials, and documentation. For hazardous materials, training should cover: safe handling, storage, use, and disposal of specific hazardous chemicals used in the hospital, and procedures for responding to spills or accidental exposures.

HRM 6c: Staff members are made aware of procedures to follow in the event of an incident. (C)

• Objective Element Text: Staff members are made aware of procedures to follow in the event of an incident.

• Compliance Level: Commitment (C) - Commitment level, highlighting the importance of incident awareness and preparedness for all staff.

• Detailed Explanation: This Objective Element focuses on incident preparedness and response. Hospitals are complex environments where incidents (safety events, errors, emergencies) can occur. It's crucial that all staff members are aware of the procedures to follow when an incident happens. This ensures timely and appropriate response to minimize harm and manage incidents effectively.

• Key Action (White Box):

  • "Staff should intimate sequence of events they will undertake in case of an incident." The training should make staff aware of the step-by-step procedures or the "sequence of events" that they should follow when they witness or are involved in an incident. "Intimate" implies understanding and being familiar with this sequence.

    • Practical Implication: Training should clearly outline the incident reporting process and emergency response procedures. This could include:

      • Immediate actions at the scene of an incident: First aid, securing the area, protecting patients and others from immediate danger.

      • Who to notify immediately: Supervisors, charge nurses, security, emergency response teams, etc., depending on the type of incident.

      • How to report an incident: Using incident reporting forms (paper-based or electronic), verbal reporting procedures, timelines for reporting.

      • Documentation requirements for incidents: What information to document, where and how to document it accurately and completely.

      • Emergency contact numbers and codes (already covered in HRM 3d, but reinforced here): Ensuring staff know who to call and how to use emergency codes for different situations.

      • Different procedures for different types of incidents: Tailoring procedures to specific incident types (e.g., fire, medical emergency, security breach, patient fall, medication error).

HRM 6d: Staff are trained in occupational safety aspects. (C)

• Objective Element Text: Staff are trained in occupational safety aspects.

• Compliance Level: Commitment (C) - Commitment level, emphasizing training on risks and prevention specifically related to staff's own occupational safety and health.

• Detailed Explanation: This Objective Element focuses specifically on occupational safety, which means the health and safety of staff members in their workplace. It mandates training to protect staff from work-related hazards and promote a healthy and safe working environment for them. While patient safety is paramount, staff safety is also crucial for a well-functioning hospital.

• Key Occupational Safety Training Areas (Blue Circle - "Occupational safety aspects"):

  • "Identify areas with potential occupational hazards.": Training should help staff recognize potential occupational hazards present in their specific work areas and the hospital in general. This is about hazard awareness in the workplace.

    • Practical Implication: Conduct workplace hazard assessments and share the findings with staff during training. Train staff to identify hazards specific to their roles and departments (e.g., lifting heavy objects for nurses, exposure to chemicals in labs, ergonomic risks for desk-based staff, risk of sharps injuries for phlebotomists).

  • "Be aware of possible risks involved.": Training must ensure staff are aware of the risks associated with identified hazards. This means understanding the potential harm or consequences of exposure to these hazards.

    • Practical Implication: For each identified occupational hazard, training should explain the specific risks to staff health and safety. Examples: needle stick injury risks (infection transmission), chemical exposure risks (skin irritation, respiratory problems), ergonomic risks (musculoskeletal disorders), noise hazards (hearing loss). Quantify risks where possible (e.g., statistics on needle stick injuries, common types of work-related injuries).

  • "Take preventive actions to avoid risks.": Training should empower staff to take proactive preventive actions to mitigate or eliminate occupational hazards. This is about promoting a culture of prevention.

    • Practical Implication: Training should focus heavily on preventive measures for each identified occupational hazard. Examples: for needle stick injuries - safe injection practices, use of safety-engineered devices, proper sharps disposal procedures; for chemical exposure - proper handling procedures, use of PPE, ventilation measures; for ergonomic risks - proper lifting techniques, workstation setup guidance, taking breaks and stretching exercises.

• Examples of occupational risks (Right White Box): Provides concrete examples of common occupational risks in healthcare:

  • Needle stick injury: Risk of injury from needles and other sharps, leading to potential exposure to bloodborne pathogens.

  • Blood/body fluid exposure: Risk of exposure to blood and other body fluids, again leading to potential infection risks.

  • Radiation exposure: Risk for staff working in radiology, radiotherapy, and other areas where ionizing radiation is used.

  • Chemotherapy exposure: Risk for staff handling chemotherapy drugs, which are hazardous substances.

  • Noise in utility areas: Risk of noise-induced hearing loss for staff working in utility areas with loud machinery or equipment.

HRM 6e: Staff are trained in the organisation's disaster management plan. (CO)

• Objective Element Text: Staff are trained in the organisation's disaster management plan.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, highlighting the critical need for all staff to be trained on the disaster management plan with mandatory system documentation to prove it.

• Detailed Explanation: Hospitals must be prepared for various types of disasters – natural disasters, man-made disasters, internal emergencies. This Objective Element mandates that all staff are trained on the organization's disaster management plan. This ensures a coordinated and effective response in emergency situations, protecting patients, staff, and hospital assets. "Core OE" status emphasizes the vital importance of disaster preparedness.

• Key Training Areas (Blue Box - "Disaster management training"):

  • "Various elements of disaster management plan.": Training should cover the key components and elements of the hospital's disaster management plan as a whole. Staff need to understand the overall framework and strategy.

    • Practical Implication: Training on the structure of the disaster management plan, different phases of disaster response (preparedness, response, recovery), command and control structure during disasters, communication protocols, evacuation plans, emergency resources available, roles and responsibilities of different teams and departments in disaster response, and activation triggers for the disaster plan.

  • "Specific role in disasters.": Critically, training must clarify each staff member's individual role and responsibilities within the disaster management plan. Vague general training is not sufficient; staff need to understand what they are expected to do in specific disaster scenarios.

    • Practical Implication: Training should be role-based. Staff should be informed about their specific duties during different types of disasters. This may vary depending on their department, job role, and skills. Examples: nurses in patient care areas - evacuation of patients, providing first aid, maintaining patient records; security staff - controlling access, maintaining order; administrative staff - communication, resource mobilization. Training should use drills and simulations to practice these role-specific responsibilities.

HRM 6f: Staff are trained in handling fire and non-fire emergencies. (CO)

• Objective Element Text: Staff are trained in handling fire and non-fire emergencies.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, emphasizing the critical life safety training for handling emergencies with mandatory system documentation.

• Detailed Explanation: This Objective Element focuses on training staff to respond to specific types of emergencies: fire emergencies and non-fire emergencies. These are common and potentially catastrophic events that hospitals must be prepared for. Effective training is crucial to ensure staff can react quickly and appropriately in these critical situations, minimizing harm and protecting lives. "Core OE" status underscores the life-saving importance of emergency preparedness training.

• Training on handling fire emergencies (Left White Box): Training should cover the specifics of fire safety and fire response:

  • "Knowledge about various classes of fires.": Staff should understand different classes of fires (Class A, B, C, D, etc.) as different types of fires require different types of extinguishers.

    • Practical Implication: Training on the classification of fires, types of combustible materials associated with each class, and the appropriate type of fire extinguisher for each class.

  • "Information and demonstration on how to use fire extinguishers.": Training must include practical instruction and demonstrations on the proper use of fire extinguishers. Theoretical knowledge is insufficient; staff need to know how to operate extinguishers effectively.

    • Practical Implication: Hands-on training sessions with fire extinguishers (using safe, simulated fire scenarios). Training should cover: identification of different extinguisher types, parts of an extinguisher, P-A-S-S technique (Pull pin, Aim, Squeeze, Sweep), safe distance to use an extinguisher, and limitations of different extinguishers.

  • "Evacuation plans and other procedures to be followed.": Training must cover the hospital's fire evacuation plans and other relevant procedures during a fire emergency. Evacuation is often the priority in a fire.

    • Practical Implication: Training on: hospital evacuation routes, emergency exits, assembly points, procedures for evacuating patients (different procedures for mobile vs. immobile patients), vertical and horizontal evacuation strategies, fire alarm procedures, communication protocols during evacuation, and role of fire wardens or designated evacuation personnel.

  • "Specific role during an emergency.": As with disaster management (HRM 6e), staff should understand their individual roles and responsibilities during a fire emergency.

    • Practical Implication: Role-specific drills and simulations for fire emergencies. Clarify roles for: nurses in patient evacuation, security staff in controlling access and guiding evacuation, engineering staff in shutting down systems or assisting with evacuation, etc.

• Examples of non-fire emergencies (Right White Box): Provides examples of other types of emergencies beyond fire that staff need to be prepared for:

  • Earthquake: Procedures for earthquake preparedness and response (drop, cover, hold, evacuation aftershocks, etc.)

  • Floods: Procedures for flood preparedness and response (evacuation, moving equipment and supplies, dealing with water damage, infection control after floods).

  • Mob violence: Procedures for managing situations of mob violence or civil unrest affecting the hospital (security protocols, lockdown procedures, patient and staff protection).

  • Power failure: Procedures for managing power outages (backup power systems, emergency lighting, critical equipment backup, communication during power failure, patient care considerations during outages).

    • Practical Implication: Develop and conduct training sessions and drills for each of these non-fire emergency scenarios relevant to the hospital's geographical location and risk assessment. Training should cover specific response protocols, communication pathways, resource utilization, and individual staff roles for each scenario.

HRM 6g: Staff are trained on the organisation's quality improvement programme. (C)

• Objective Element Text: Staff are trained on the organisation's quality improvement programme.

• Compliance Level: Commitment (C) - Commitment level, emphasizing that quality improvement training is a core expectation for all hospital staff.

• Detailed Explanation: Quality improvement (QI) is a fundamental principle in modern healthcare. This Objective Element mandates that all staff are trained on the organization's quality improvement programme. This ensures that everyone understands the hospital's approach to QI, their role in QI efforts, and how to contribute to a culture of continuous quality improvement.

• Key Training Areas (Blue Circle - "Awareness of aspects of quality improvement programme"):

  • "Structure of the programme.": Training must cover the overall structure and framework of the hospital's QI program. Staff need to understand how QI is organized and managed within the hospital.

    • Practical Implication: Training on: the hospital's QI policy, QI committees or teams (structure, membership, functions), QI methodology used (e.g., PDSA cycle, Lean, Six Sigma), data collection and analysis processes for QI, QI project lifecycle, communication channels for QI initiatives.

  • "Roles of the staff in contributing to the programme.": Training must clearly define how individual staff members can contribute to the QI program. QI is not just a top-down initiative; it requires engagement from all levels of staff.

    • Practical Implication: Training on: individual staff responsibilities in QI (e.g., identifying areas for improvement in their own work, participating in QI projects, contributing data, providing feedback), methods for staff to raise suggestions for improvement, channels for participating in QI activities, examples of how staff contributions have led to QI successes in the hospital, and recognition mechanisms for QI contributions.

• Note:

  • "Staff working in lab, imaging services, emergency, ICUs and surgical services should be trained on their respective quality assurance programmes." Similar to safety programs, this emphasizes the need for department-specific quality assurance (QA) or QI programs and training, especially for high-impact clinical areas like labs, imaging, emergency, ICUs, and surgical services. These areas often have their own specialized QA/QI initiatives and metrics.

    • Practical Implication: Departments like Lab, Imaging, Emergency, ICUs, and Surgical Services should have department-specific QA/QI programs that are aligned with the overall hospital QI program but address the unique quality and safety challenges of their specific service areas. Staff working in these departments should receive both the general hospital QI program training and department-specific QA/QI training, ensuring they understand both the big picture and the specific quality initiatives within their own work environment.

In summary, HRM 6 focuses on ensuring staff are thoroughly trained in a wide spectrum of safety and quality-related aspects. It emphasizes not just general safety awareness, but proactive risk management, incident preparedness, occupational safety, disaster and emergency response, and importantly, active participation in the hospital's quality improvement efforts. The Objective Elements within HRM 6 are designed to create a comprehensive safety and quality culture where every staff member is well-informed, prepared, and contributes to a safer and higher-quality healthcare environment for patients, visitors, and themselves. The "Interpretation modified" note across many OEs suggests that the 6th Edition may offer more refined and updated guidance on implementing these training requirements.

HRM 7: An appraisal system for evaluating the performance of staff exists as an integral part of the human resource management process

Overall Standard HRM 7 Summary:

• Standard Text: HRM7: An appraisal system for evaluating the performance of staff exists as an integral part of the human resource management process.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard. The core requirement for a performance appraisal system remains the same. However, HRM 7d has had its objective element level changed from Achievement to Commitment.

• Objective Elements: There are 5 Objective Elements under HRM 7 in both the 5th and 6th editions, detailing the key features and requirements of a performance appraisal system within the hospital.

Detailed Breakdown of Objective Elements under HRM 7:

HRM 7a: Performance appraisal is done for staff within the organisation. (C)*

• Objective Element Text: Performance appraisal is done for staff within the organisation.* (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment (C) - As a Core OE at the Commitment level, this emphasizes that conducting performance appraisals for all staff is a fundamental and critical aspect of HRM, requiring system documentation for compliance.

• Detailed Explanation: This Objective Element establishes the fundamental requirement that the hospital must conduct performance appraisals for all staff members within the organization. It's not optional or limited to certain categories of staff; it's expected to be a universal process for evaluating employee performance. "Core OE" status underscores its essential role in managing and developing the workforce.

• Key Implementation Aspects (Blue Box - "Performance appraisal"):

  • "It should be done for all categories of staff (including HOD and doctors).": The scope of performance appraisal is inclusive. It must cover all categories of staff, from entry-level positions to senior leadership, including:

    • All employee levels: From junior staff to senior management.

    • All departments: Clinical and non-clinical departments.

    • Heads of Departments (HODs): Even leaders are subject to appraisal, demonstrating that performance evaluation is a system of accountability at all levels.

    • Doctors and Medical Professionals: Including physicians in the appraisal process is crucial in a hospital setting. Performance appraisal should be adapted to evaluate clinical performance and professional conduct of medical staff.

    • Practical Implication: Design an appraisal system that is flexible enough to be applied across diverse job roles and levels within the hospital. Develop appropriate appraisal tools and criteria that are relevant to each category of staff. Ensure all staff understand that they will be subject to performance appraisal as a standard organizational practice.

  • "It should include competency assessment.": Performance appraisal should not solely focus on subjective traits or general impressions. It should incorporate competency assessment. This means evaluating staff against specific, demonstrable competencies required for their roles.

    • Practical Implication: Integrate competency-based assessment into the appraisal process. Identify key competencies for different job roles (technical competencies, clinical competencies, soft skills competencies, leadership competencies). Appraisal tools should include criteria for evaluating these competencies using objective measures and observable behaviors where possible. Competency assessment should be linked to job descriptions and performance standards.

• Note:

  • "The contractor can conduct performance appraisal of outsourced staff." Acknowledges the practical aspect of managing outsourced staff. While outsourced staff are not direct employees, their performance still impacts hospital operations and quality. This note clarifies that the contracting agency providing outsourced staff can be responsible for conducting performance appraisals of their staff. The hospital may then review these appraisals or have input into the process, depending on the contract terms. This ensures accountability for the performance of outsourced staff as well.

HRM 7b: The staff are made aware of the system of appraisal at the time of induction. (C)

• Objective Element Text: The staff are made aware of the system of appraisal at the time of induction.

• Compliance Level: Commitment (C) - Commitment level, highlighting the importance of transparency and early communication about the appraisal system to new staff.

• Detailed Explanation: This Objective Element emphasizes the principle of transparency in the appraisal process. New staff members should be informed and educated about the hospital's performance appraisal system right from the start, during their induction or onboarding. This proactive communication sets clear expectations and ensures staff are not surprised by the appraisal process later.

• Methods of Awareness (Blue Box - "Appraisal system"):

  • "Incorporate information in service booklet.": Recommends including written information about the appraisal system in the employee handbook or service booklet provided to new staff. This ensures they receive formal, documented information that they can refer to later.

    • Practical Implication: Include a dedicated section on performance appraisal in the employee handbook or induction booklet. This section should explain: the purpose of appraisal, the appraisal cycle (frequency), the appraisal process (steps involved, timelines), the appraisal criteria or factors, how appraisal ratings are used, and who to contact for questions or clarifications about appraisal.

  • "Explain in induction training.": In addition to written information, the appraisal system should be explained verbally during the induction training program itself. This allows for interactive explanation, Q&A, and reinforcement of key points.

    • Practical Implication: Dedicate a segment within the induction training session to explain the performance appraisal system. Use presentations, slides, or videos to illustrate the process. Allow time for questions and answers to address any concerns or clarify any ambiguities new staff might have. Ensure the explanation is in simple, understandable language.

HRM 7c: Performance is evaluated based on the pre-determined criteria. (C)

• Objective Element Text: Performance is evaluated based on the pre-determined criteria.

• Compliance Level: Commitment (C) - Commitment level, highlighting the necessity of having objective and pre-defined criteria for fair and transparent performance evaluations.

• Detailed Explanation: This Objective Element stresses the principle of objectivity and fairness in performance appraisal. Evaluations should not be subjective or arbitrary. Performance must be assessed against pre-determined, clear, and objective criteria. This ensures that appraisals are based on actual job requirements and performance expectations, rather than personal biases.

• Levels of Criteria (Concentric Circles - "Pre-determined criteria"): Illustrates a hierarchy or layers of criteria that can be used for performance evaluation, moving from broad to more specific:

  • Job description (Outermost Circle): The job description itself is the foundational document that defines the scope and responsibilities of the role. Appraisal criteria should be directly linked to the key duties and responsibilities outlined in the job description. The job description provides the overall framework for performance expectations.

  • KPIs (Key Performance Indicators) (Middle Circle): Key Performance Indicators (KPIs) are specific, measurable, achievable, relevant, and time-bound metrics used to assess performance against specific goals or targets. KPIs provide quantifiable and objective criteria for evaluation, particularly for roles where output can be measured numerically.

    • Practical Implication: Identify relevant KPIs for different job roles. These could be quantitative metrics (e.g., patient satisfaction scores, number of procedures performed, turnaround time, error rates) or qualitative metrics (e.g., achievement of project milestones, successful implementation of initiatives, positive feedback from colleagues or patients). KPIs should be aligned with departmental and organizational goals and be clearly communicated to staff.

  • Key result areas (Inner Circle): Key Result Areas (KRAs) are broader areas of responsibility or critical functions within a job role where successful performance is essential. KRAs are less quantifiable than KPIs but provide a framework for evaluating performance in key areas of accountability.

    • Practical Implication: Define 3-5 KRAs for each job role. KRAs should represent the most important aspects of the job. For example, for a nurse, KRAs could be: patient safety, quality of care, effective communication, teamwork, and professional development. Within each KRA, define specific performance expectations or indicators.

  • Pre-determined criteria (Innermost Circle): This is the core concept. Performance evaluation must be based on criteria that are defined and communicated to staff in advance. This ensures that staff know what is expected of them and how their performance will be measured. These pre-determined criteria form the basis of the entire appraisal process.

HRM 7d: The appraisal system is used as a tool for further development. (C)

• Objective Element Text: The appraisal system is used as a tool for further development.

• Compliance Level: Commitment (C) - Changed from Achievement to Commitment in 6th Edition. At the Commitment level, it signifies that using appraisal for development is now considered a foundational principle, not just a best practice.

• Detailed Explanation: This Objective Element shifts the focus of performance appraisal from just evaluation and rating to employee development. Appraisal should not be seen as solely a judgmental exercise, but primarily as a tool to identify areas for staff growth and development, and to guide professional development planning. The change from Achievement to Commitment reinforces that a development-focused appraisal system is now considered a fundamental expectation for accreditation.

• Development-Focused Appraisal (Blue Area - "Appraisal"):

  • "Identify key result areas.": The appraisal process should identify staff member's strengths and areas where they are performing well in relation to their key result areas (KRAs). Recognition of strengths is an important part of development.

  • "Perform training need assessment.": A primary purpose of appraisal is to identify training and development needs. Appraisal should pinpoint specific areas where staff may require further training, skill enhancement, or knowledge updates to improve their performance in their current role or prepare them for future roles.

    • Practical Implication: Appraisal forms should include sections specifically for identifying development needs. Appraisal discussions should actively explore training and development opportunities that can address identified gaps. Appraisal outcomes should directly inform individual training plans and the overall organizational training calendar (HRM 4a).

  • "Provide training (wherever possible).": The appraisal process should lead to action. Where training needs are identified, the hospital should make efforts to provide relevant training opportunities "wherever possible." This demonstrates a commitment to employee development.

    • Practical Implication: Allocate resources for training and development based on identified needs from appraisals. Connect staff to appropriate training programs, internal or external. Develop individual development plans (IDPs) for staff based on appraisal feedback and agreed-upon development goals. Track training undertaken and its impact on performance (linking back to HRM 4e evaluation of training effectiveness).

• Note:

  • "The organisation should have written guidance for effective management of underperformance." While HRM 7d emphasizes development, it also acknowledges that performance appraisal can identify instances of underperformance. This note highlights the need for separate written guidance on how to manage underperformance effectively and fairly. Development-focused appraisal is not just about praising good performance; it also provides a structured basis for addressing performance issues constructively.

    • Practical Implication: Develop a separate policy and procedure for managing underperformance. This guidance should outline: steps for addressing underperformance (coaching, performance improvement plans, warnings), due process and fairness considerations, disciplinary procedures (if underperformance is persistent and unaddressed despite support), and timelines for performance improvement. This guidance should be distinct from the general appraisal policy but linked to the appraisal system as appraisal findings may trigger underperformance management procedures in some cases.

HRM 7e: Performance appraisal is carried out at defined intervals and is documented. (C)

• Objective Element Text: Performance appraisal is carried out at defined intervals and is documented.

• Compliance Level: Commitment (C) - Commitment level, emphasizing the need for regular and formally documented performance appraisals.

• Detailed Explanation: This Objective Element emphasizes regularity and documentation as key aspects of a credible performance appraisal system. Appraisals should not be infrequent or informal; they need to be conducted at defined, regular intervals and must be formally documented. This ensures appraisals are systematic, consistent, and auditable.

• Key Aspects (Blue Box - "Timeframe for performance appraisal"):

  • "It should be done at least once a year.": Sets a minimum frequency for performance appraisals: at least annually (once per year). This means every staff member should undergo a formal performance appraisal at least once a year. Annual appraisals are a common standard practice in many organizations. Hospitals may choose to conduct appraisals more frequently (e.g., bi-annually, or for new staff after probation), but annual is the minimum expectation.

    • Practical Implication: Establish an annual performance appraisal cycle. Define specific timelines for each stage of the appraisal process (self-appraisal, manager review, feedback discussion, documentation completion). Communicate the appraisal cycle and timelines to all staff well in advance.

  • "Performance appraisal is carried out at defined intervals and is documented.": Reiterates two core requirements:

    • Defined Intervals: Appraisals must be scheduled and conducted regularly according to a pre-set frequency (at least annually). This systematic approach ensures appraisals are not neglected or done inconsistently.

    • Documented: The entire appraisal process and its outcomes must be formally documented. This documentation is crucial for record-keeping, tracking performance trends, demonstrating fairness and consistency in appraisals, supporting development planning, and for audit purposes.

• Practical Implication for Documentation:

  • Use standardized appraisal forms to ensure consistency in data collection and documentation across all appraisals.

  • Ensure appraisal forms are properly completed and signed by both the appraiser (manager) and the appraisee (staff member).

  • Maintain appraisal documentation securely in personnel files or in an HR information system.

  • Documentation should include: appraisal ratings, comments on performance against criteria, identified strengths and areas for development, agreed-upon development goals, and signatures.

  • Have a system for archiving appraisal records appropriately and for retrieving them when needed (e.g., for performance reviews, promotion decisions, etc.).

In summary, HRM 7 focuses on establishing a systematic, fair, and development-focused performance appraisal system. It moves beyond just evaluating performance to using appraisal as a tool for staff growth and continuous improvement. The Objective Elements emphasize key principles: appraisals for all staff, competency-based assessment, transparency, objectivity through pre-determined criteria, developmental focus, regularity, and formal documentation. The change of HRM 7d to Commitment level underscores that a development-oriented appraisal system is now considered a core expectation for NABH accreditation, highlighting the importance of investing in staff growth and development.

HRM 8: Process for disciplinary and grievance handling is defined and implemented in the organisation

Overall Standard HRM 8 Summary:

• Standard Text: HRM8: Process for disciplinary and grievance handling is defined and implemented in the organisation.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard. The core requirement for having a defined and implemented disciplinary and grievance handling process remains consistent.

• Objective Elements: There are 6 Objective Elements under HRM 8 in both the 5th and 6th editions, outlining the key features and requirements of a fair and effective disciplinary and grievance handling system within the hospital.

Detailed Breakdown of Objective Elements under HRM 8:

HRM 8a: Written guidance governs disciplinary and grievance handling mechanisms. (C)*

• Objective Element Text: Written guidance governs disciplinary and grievance handling mechanisms.* (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment (C) - As a Core OE at the Commitment level, this highlights the critical need for written policies and procedures for disciplinary and grievance handling, mandating system documentation to demonstrate their existence.

• Detailed Explanation: This Objective Element is foundational. It mandates that the hospital must have formal, written policies and procedures that govern both disciplinary actions and grievance handling processes. This ensures that these critical HR processes are not arbitrary, inconsistent, or based on personal preferences, but rather are governed by pre-defined, transparent, and documented guidelines. "Written guidance" ensures fairness, consistency, and legal defensibility.

• Key Components of Written Guidance (Blue Box - "Written guidance"):

  • "Include workplace issues in grievances. For example: Bullying and harassment.": The written guidance must explicitly include that the grievance handling mechanism is available to address a wide range of workplace issues, going beyond just pay or leave issues. The example of "Bullying and harassment" is specifically mentioned to emphasize that grievances should cover interpersonal workplace issues and a safe and respectful working environment.

    • Practical Implication: The written grievance policy should clearly state the scope of issues that can be raised as grievances. It should not be limited to just contractual or compensation-related matters. It should explicitly include grievances related to: working conditions, unfair treatment, discrimination, harassment (including sexual harassment), bullying, interpersonal conflicts, safety concerns, and any other workplace issues that negatively impact an employee's well-being or job satisfaction.

    • Bullying and Harassment Specifically: Emphasize that the grievance procedure is a formal channel to report and address bullying and harassment. The policy might outline specific definitions of bullying and harassment (aligned with legal definitions) and the hospital's zero-tolerance stance towards such behaviors.

• Note:

  • "Documentation should be done in accordance with HRM8c, HRM8d and HRM 8e." This is a crucial cross-reference. The written guidance (HRM 8a) and its implementation (the mechanisms themselves) must be aligned with the principles outlined in subsequent Objective Elements:

    • HRM 8c (Principles of natural justice): The disciplinary and grievance processes must adhere to principles of fairness and natural justice.

    • HRM 8d (Consonance with prevailing laws): The processes must be legally compliant and in line with relevant labor laws and regulations.

    • HRM 8e (Provision for appeals): The disciplinary process must include a provision for appeals.

    • Practical Implication: When drafting or reviewing the written guidance for disciplinary and grievance handling, consciously ensure that these principles (natural justice, legal compliance, appeals provision) are embedded within the policies and procedures. The documentation itself should reflect adherence to these principles. For example, the policy might explicitly state that the disciplinary procedure will adhere to natural justice principles and that employees have a right to appeal disciplinary decisions.

HRM 8b: The disciplinary and grievance handling mechanism is known to all categories of staff of the organisation. (C)

• Objective Element Text: The disciplinary and grievance handling mechanism is known to all categories of staff of the organisation.

• Compliance Level: Commitment (C) - Commitment level, highlighting the essential step of ensuring staff awareness of these mechanisms for fair and accessible processes.

• Detailed Explanation: It's not enough to just have written policies and procedures. They need to be actively communicated and made "known" to all staff categories within the hospital. Staff need to be aware of both the disciplinary and grievance procedures, understand how they work, and know how to access them when needed. If staff are unaware of these mechanisms, they cannot be utilized effectively, undermining their purpose of ensuring fairness and conflict resolution.

• Key Aspects of Staff Awareness (Blue Box - "Staff awareness"):

  • "Disciplinary procedure.": Staff should be made aware of the hospital's disciplinary procedure. This means understanding:

    • Types of misconduct or policy violations that may lead to disciplinary action.

    • The different levels of disciplinary action (verbal warning, written warning, suspension, termination) and the process for each level.

    • Who is responsible for initiating and conducting disciplinary investigations and actions.

    • Their rights during a disciplinary process (e.g., right to be informed of allegations, right to present their side, right to representation if applicable).

  • "Process to raise grievance.": Staff should be equally aware of the grievance handling process. This involves knowing:

    • What types of issues can be raised as grievances.

    • The steps involved in filing a grievance (who to submit it to, what format, timelines).

    • The process for investigation and resolution of grievances.

    • Confidentiality aspects of the grievance process.

    • Protection against retaliation for raising a genuine grievance.

• Practical Implementation for Staff Awareness:

  • Induction Training: Introduce both the disciplinary and grievance procedures during induction training for all new staff. This ensures awareness from day one of employment (as linked to HRM 7b awareness of appraisal system at induction).

  • Employee Handbook/Service Booklet: Include detailed explanations of the disciplinary and grievance procedures in the employee handbook or service booklet (as linked to HRM 7b). This provides written reference material.

  • Posters and Notices: Display posters or notices in common staff areas (notice boards, break rooms) summarizing key aspects of both procedures (e.g., steps to file a grievance, contact information for HR).

  • Intranet and Digital Accessibility: Make the full written policies and procedures readily accessible on the hospital intranet or through other digital platforms used by staff.

  • Training Sessions and Refresher Courses: Conduct periodic training sessions or refresher courses specifically on disciplinary and grievance handling for all staff. This reinforces awareness and addresses any changes to policies or procedures.

  • Regular Reminders: Include brief reminders about the existence and importance of these mechanisms in internal communications (staff newsletters, emails, meetings).

HRM 8c: The disciplinary policy and procedure are based on the principles of natural justice. (C)

• Objective Element Text: The disciplinary policy and procedure are based on the principles of natural justice.

• Compliance Level: Commitment (C) - Commitment level, highlighting the ethical and legal imperative of adhering to natural justice principles in disciplinary processes.

• Detailed Explanation: This Objective Element emphasizes that the disciplinary policy and procedure must be grounded in "principles of natural justice." These principles are fundamental legal and ethical standards for fairness in decision-making, particularly in situations where individuals' rights or interests may be affected (like disciplinary actions). Adherence to natural justice is essential for ensuring fair process, ethical conduct, and legal defensibility of disciplinary actions.

• Principles of Natural Justice (Image of Scales): The presentation illustrates "Principles of natural justice" using a scales image, symbolizing balance and fairness between "Employee" and "Employer." The key implied principles are:

  • Principles of natural justice may imply that both parties are allowed to:

    • "Present their case.": This is a core principle - the employee who is facing disciplinary action must be given a fair opportunity to present their side of the story, to explain their perspective, and to offer any evidence or information they believe is relevant. It's about the right to be heard.

      • Practical Implication: The disciplinary procedure should include a step where the employee is formally informed of the allegations against them in writing, is given reasonable time to prepare a response, and is provided a platform (e.g., a hearing or meeting) to present their case, provide evidence, and answer questions. They should not just be informed of the decision; they must have a chance to participate in the process.

    • "Take decision accordingly.": The decision regarding disciplinary action must be made based on a fair and impartial consideration of all the evidence and information presented by both sides (employer and employee). It should not be a pre-determined outcome or based on biases. "Accordingly" means based on the presented case and in line with due process.

      • Practical Implication: The decision-maker (manager, disciplinary committee) must be impartial and unbiased. They should carefully consider all the information presented by the employee and the employer's case. The decision should be reasonable and proportionate to the alleged misconduct. The decision and the reasons for it should be communicated to the employee in writing.

• Further Elaboration on Principles of Natural Justice (Not explicitly in presentation, but implied): Beyond the two points mentioned, "natural justice" typically includes other aspects, such as:

  • Right to Notice: Employee must be clearly informed in advance about the nature of the allegations against them.

  • Right to a Fair Hearing: Employee should have an opportunity to present their case in a hearing or meeting, if appropriate for the level of disciplinary action.

  • Right to Representation: Depending on hospital policy and legal frameworks, employee may have the right to be represented by a union representative or colleague during a disciplinary hearing.

  • Decision by an Unbiased Decision-Maker: The person making the disciplinary decision should be impartial and free from conflicts of interest.

  • Decision Based on Evidence: Disciplinary action should be based on credible evidence and facts, not just assumptions or hearsay.

  • Right to Appeal: As mentioned in HRM 8e, there should be a right to appeal against a disciplinary decision.

HRM 8d: The disciplinary and grievance procedure is in consonance with the prevailing laws. (CO)

• Objective Element Text: The disciplinary and grievance procedure is in consonance with the prevailing laws.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, highlighting the legal imperative of ensuring HR processes are compliant with labour laws, with mandatory system documentation to demonstrate legal adherence.

• Detailed Explanation: This Objective Element is crucial for legal compliance. The hospital's disciplinary and grievance procedures must be "in consonance with the prevailing laws." This means they must be consistent with and adhere to all applicable labor laws, employment regulations, and other relevant legislation in the jurisdiction where the hospital operates. Legal compliance is not just about avoiding lawsuits; it's about ethical and responsible employer practices and protecting employee rights as mandated by law. "Core OE" underscores the paramount importance of legal compliance in HR processes.

• Key Aspect of Legal Consonance (Blue Box - "Disciplinary and grievance procedure"):

  • "It should be based on prevailing laws. For example: Relevant labour laws and CCS (CCA) rules.": The procedures must be designed and implemented taking into account all applicable laws. The example provided highlights:

    • Relevant labour laws: This is a broad category encompassing laws related to employment terms and conditions, termination, disciplinary actions, working hours, wages, employee rights, trade unions, etc. The specific labor laws will vary depending on the country and region of operation. Hospitals must be familiar with and comply with all relevant labor legislation.

    • CCS (CCA) rules: "CCS (CCA)" likely refers to the Central Civil Services (Classification, Control and Appeal) Rules, which are specific to government employees in certain countries (e.g., India). If applicable to the hospital's context (e.g., if it is a government-run hospital or certain employee categories are governed by these rules), the disciplinary and grievance procedures must also comply with these specific rules. This highlights that legal consonance is not just about general labor laws, but also potentially sector-specific or government employee-specific rules if applicable.

• Note:

  • "The organisation should establish internal complaints committee to handle sexual harassment complaints." This note specifically highlights the legal requirement to have an Internal Complaints Committee (ICC) to address sexual harassment complaints. In many jurisdictions, laws mandate the establishment of such a committee in workplaces to handle complaints of sexual harassment in a structured and sensitive manner. This is a prime example of legal compliance within the HRM 8 framework.

    • Practical Implication: The hospital must establish an ICC as per the prevailing laws on sexual harassment. The grievance handling procedure must specifically include a dedicated process for addressing sexual harassment complaints through the ICC. This includes: procedures for lodging complaints with the ICC, investigation process by the ICC, composition of the ICC (as legally mandated), timelines for investigation and resolution, confidentiality protocols, and action taken based on ICC findings. The ICC mechanism should be clearly communicated to all staff as part of the overall grievance handling framework.

HRM 8e: There is a provision for appeals in all disciplinary cases. (C)

• Objective Element Text: There is a provision for appeals in all disciplinary cases.

• Compliance Level: Commitment (C) - Commitment level, highlighting the fairness principle of providing an appeal mechanism against disciplinary decisions.

• Detailed Explanation: This Objective Element ensures fairness and due process by mandating that the disciplinary system must include a provision for appeals in all disciplinary cases. An appeal mechanism provides a safeguard against potential errors or biases in the initial disciplinary decision. It allows employees who believe they have been unfairly disciplined to seek a review of the decision by a higher authority. This reinforces the principles of natural justice and promotes employee trust in the fairness of the disciplinary system.

• Key Aspects of Appeal Provision (Blue Diamond - "Appellate authority"):

  • "Considers appeals in disciplinary cases.": The disciplinary system must have a clearly defined appellate authority or mechanism that is responsible for reviewing appeals against disciplinary decisions. There must be a process for employees to formally lodge an appeal.

    • Practical Implication: Define in the disciplinary policy:

      • Who is the appellate authority? (e.g., a higher level manager, a disciplinary appeal committee, a board of directors sub-committee, depending on the organizational structure and level of disciplinary action).

      • Procedure for lodging an appeal: How to file an appeal (in writing, to whom, within what timeframe).

      • Scope of appeal: What aspects can be appealed (e.g., fairness of process, severity of penalty, factual accuracy of allegations).

      • Process for reviewing appeals: How the appellate authority will consider the appeal (review of documentation, potential hearing, timelines for decision).

  • "Is higher than disciplinary authority.": The appellate authority must be at a higher level of authority than the person or body that made the initial disciplinary decision. This ensures impartiality in the review process. An appeal to the same decision-maker would be ineffective and defeat the purpose of an appeal.

    • Practical Implication: Clearly define the appellate authority to be a person or committee that is senior to and independent of the initial disciplinary decision-maker. This ensures a genuine review and reduces the risk of bias. For example, if a department head makes a disciplinary decision, the appeal authority might be a functional head at a higher organizational level or a designated HR committee.

HRM 8f: Actions are taken to redress the grievance(C)

• Objective Element Text: Actions are taken to redress the grievance(C)

• Compliance Level: Commitment (C) - Commitment level, highlighting the crucial step of taking action to resolve grievances effectively, not just processing them.

• Detailed Explanation: This Objective Element emphasizes that the grievance handling process must be action-oriented and lead to redressal of genuine grievances. It's not enough to just have a process for filing and investigating grievances; the process must result in concrete actions to resolve the grievance and address the legitimate concerns raised by the employee. "Redress" means providing a remedy or solution to the grievance. This demonstrates that the grievance process is meaningful and not just a procedural exercise.

• Key Aspects of Grievance Redressal (White Box - "Actions are taken to redress the grievance(C)"):

  • "The redressal procedure addresses the grievance.": The grievance handling procedure must be designed to actually address and resolve the substance of the grievance, if it is found to be valid after investigation. Redressal is the intended outcome of the process.

    • Practical Implication: The grievance procedure should outline the types of actions that can be taken to redress a grievance. These actions will depend on the nature of the grievance and the findings of the investigation. Examples of redressal actions:

      • Apology to the aggrieved employee.

      • Correction of a procedural error or policy violation.

      • Change in working conditions.

      • Reversal or modification of an unfair decision.

      • Counseling or mediation between parties involved in a conflict.

      • Disciplinary action against another employee if their actions caused the grievance.

      • Policy changes or process improvements to prevent similar grievances in the future.

  • "Actions taken shall be documented and communicated to the aggrieved staff.": It is crucial that the actions taken to redress the grievance are both documented and communicated to the employee who raised the grievance. Documentation ensures a record of the resolution and accountability. Communication to the employee shows transparency, closure, and respect for their participation in the process.

    • Practical Implication: Maintain a record of all grievances received, including the investigation process, findings, and actions taken to redress the grievance. Communicate the outcome of the grievance investigation and the redressal actions to the aggrieved employee in writing. This communication should be clear, concise, and timely. Even if a grievance is not upheld, communicate the findings and reasons to the employee in a respectful and transparent manner.

In summary, HRM 8 focuses on establishing a fair, transparent, legally compliant, and action-oriented disciplinary and grievance handling system. The Objective Elements emphasize the need for written guidance, staff awareness, adherence to natural justice principles, legal consonance, appeals provision, and concrete actions to redress grievances. These elements combine to create a robust framework for managing employee conduct and resolving workplace disputes in a just and effective manner, fostering a more positive and equitable working environment within the hospital. The designation of HRM 8a and HRM 8d as Core OEs underscores the fundamental importance of documented policies and legal compliance in these critical HR processes.

HRM 8: Process for disciplinary and grievance handling is defined and implemented in the organisation.

Overall Standard HRM 8 Summary:

• Standard Text: HRM8: Process for disciplinary and grievance handling is defined and implemented in the organisation.

• Summary of Changes (6th Edition vs. 5th Edition): No change in the overall standard. The core requirement for having a defined and implemented disciplinary and grievance handling process remains consistent.

• Objective Elements: There are 6 Objective Elements under HRM 8 in both the 5th and 6th editions, outlining the key features and requirements of a fair and effective disciplinary and grievance handling system within the hospital.

Detailed Breakdown of Objective Elements under HRM 8

HRM 8a: Written guidance governs disciplinary and grievance handling mechanisms. (C)*

• Objective Element Text: Written guidance governs disciplinary and grievance handling mechanisms.* (Asterisk denotes Core OE requiring mandatory system documentation)

• Compliance Level: Commitment (C) - As a Core OE at the Commitment level, this highlights the critical need for written policies and procedures for disciplinary and grievance handling, mandating system documentation to demonstrate their existence.

• Detailed Explanation: This Objective Element is foundational. It mandates that the hospital must have formal, written policies and procedures that govern both disciplinary actions and grievance handling processes. This ensures that these critical HR processes are not arbitrary, inconsistent, or based on personal preferences, but rather are governed by pre-defined, transparent, and documented guidelines. "Written guidance" ensures fairness, consistency, and legal defensibility.

• Key Components of Written Guidance (Blue Box - "Written guidance"):

  • "Include workplace issues in grievances. For example: Bullying and harassment.": The written guidance must explicitly include that the grievance handling mechanism is available to address a wide range of workplace issues, going beyond just pay or leave issues. The example of "Bullying and harassment" is specifically mentioned to emphasize that grievances should cover interpersonal workplace issues and a safe and respectful working environment.

    • Practical Implication: The written grievance policy should clearly state the scope of issues that can be raised as grievances. It should not be limited to just contractual or compensation-related matters. It should explicitly include grievances related to: working conditions, unfair treatment, discrimination, harassment (including sexual harassment), bullying, interpersonal conflicts, safety concerns, and any other workplace issues that negatively impact an employee's well-being or job satisfaction.

    • Bullying and Harassment Specifically: Emphasize that the grievance procedure is a formal channel to report and address bullying and harassment. The policy might outline specific definitions of bullying and harassment (aligned with legal definitions) and the hospital's zero-tolerance stance towards such behaviors.

• Note:

  • "Documentation should be done in accordance with HRM8c, HRM8d and HRM 8e." This is a crucial cross-reference. The written guidance (HRM 8a) and its implementation (the mechanisms themselves) must be aligned with the principles outlined in subsequent Objective Elements:

    • HRM 8c (Principles of natural justice): The disciplinary and grievance processes must adhere to principles of fairness and natural justice.

    • HRM 8d (Consonance with prevailing laws): The processes must be legally compliant and in line with relevant labor laws and regulations.

    • HRM 8e (Provision for appeals): The disciplinary process must include a provision for appeals.

    • Practical Implication: When drafting or reviewing the written guidance for disciplinary and grievance handling, consciously ensure that these principles (natural justice, legal compliance, appeals provision) are embedded within the policies and procedures. The documentation itself should reflect adherence to these principles. For example, the policy might explicitly state that the disciplinary procedure will adhere to natural justice principles and that employees have a right to appeal disciplinary decisions.

HRM 8b: The disciplinary and grievance handling mechanism is known to all categories of staff of the organisation. (C)

• Objective Element Text: The disciplinary and grievance handling mechanism is known to all categories of staff of the organisation.

• Compliance Level: Commitment (C) - Commitment level, highlighting the essential step of ensuring staff awareness of these mechanisms for fair and accessible processes.

• Detailed Explanation: It's not enough to just have written policies and procedures. They need to be actively communicated and made "known" to all staff categories within the hospital. Staff need to be aware of both the disciplinary and grievance procedures, understand how they work, and know how to access them when needed. If staff are unaware of these mechanisms, they cannot be utilized effectively, undermining their purpose of ensuring fairness and conflict resolution.

• Key Aspects of Staff Awareness (Blue Box - "Staff awareness"):

  • "Disciplinary procedure.": Staff should be made aware of the hospital's disciplinary procedure. This means understanding:

    • Types of misconduct or policy violations that may lead to disciplinary action.

    • The different levels of disciplinary action (verbal warning, written warning, suspension, termination) and the process for each level.

    • Who is responsible for initiating and conducting disciplinary investigations and actions.

    • Their rights during a disciplinary process (e.g., right to be informed of allegations, right to present their side, right to representation if applicable).

  • "Process to raise grievance.": Staff should be equally aware of the grievance handling process. This involves knowing:

    • What types of issues can be raised as grievances.

    • The steps involved in filing a grievance (who to submit it to, what format, timelines).

    • The process for investigation and resolution of grievances.

    • Confidentiality aspects of the grievance process.

    • Protection against retaliation for raising a genuine grievance.

• Practical Implementation for Staff Awareness:

  • Induction Training: Introduce both the disciplinary and grievance procedures during induction training for all new staff. This ensures awareness from day one of employment (as linked to HRM 7b awareness of appraisal system at induction).

  • Employee Handbook/Service Booklet: Include detailed explanations of the disciplinary and grievance procedures in the employee handbook or service booklet (as linked to HRM 7b). This provides written reference material.

  • Posters and Notices: Display posters or notices in common staff areas (notice boards, break rooms) summarizing key aspects of both procedures (e.g., steps to file a grievance, contact information for HR).

  • Intranet and Digital Accessibility: Make the full written policies and procedures readily accessible on the hospital intranet or through other digital platforms used by staff.

  • Training Sessions and Refresher Courses: Conduct periodic training sessions or refresher courses specifically on disciplinary and grievance handling for all staff. This reinforces awareness and addresses any changes to policies or procedures.

  • Regular Reminders: Include brief reminders about the existence and importance of these mechanisms in internal communications (staff newsletters, emails, meetings).

HRM 8c: The disciplinary policy and procedure are based on the principles of natural justice. (C)

• Objective Element Text: The disciplinary policy and procedure are based on the principles of natural justice.

• Compliance Level: Commitment (C) - Commitment level, highlighting the ethical and legal imperative of adhering to natural justice principles in disciplinary processes.

• Detailed Explanation: This Objective Element emphasizes that the disciplinary policy and procedure must be grounded in "principles of natural justice." These principles are fundamental legal and ethical standards for fairness in decision-making, particularly in situations where individuals' rights or interests may be affected (like disciplinary actions). Adherence to natural justice is essential for ensuring fair process, ethical conduct, and legal defensibility of disciplinary actions.

• Principles of Natural Justice (Image of Scales): The presentation illustrates "Principles of natural justice" using a scales image, symbolizing balance and fairness between "Employee" and "Employer." The key implied principles are:

  • Principles of natural justice may imply that both parties are allowed to:

    • "Present their case.": This is a core principle - the employee who is facing disciplinary action must be given a fair opportunity to present their side of the story, to explain their perspective, and to offer any evidence or information they believe is relevant. It's about the right to be heard.

      • Practical Implication: The disciplinary procedure should include a step where the employee is formally informed of the allegations against them in writing, is given reasonable time to prepare a response, and is provided a platform (e.g., a hearing or meeting) to present their case, provide evidence, and answer questions. They should not just be informed of the decision; they must have a chance to participate in the process.

    • "Take decision accordingly.": The decision regarding disciplinary action must be made based on a fair and impartial consideration of all the evidence and information presented by both sides (employer and employee). It should not be a pre-determined outcome or based on biases. "Accordingly" means based on the presented case and in line with due process.

      • Practical Implication: The decision-maker (manager, disciplinary committee) must be impartial and unbiased. They should carefully consider all the information presented by the employee and the employer's case. The decision should be reasonable and proportionate to the alleged misconduct. The decision and the reasons for it should be communicated to the employee in writing.

• Further Elaboration on Principles of Natural Justice (Not explicitly in presentation, but implied): Beyond the two points mentioned, "natural justice" typically includes other aspects, such as:

  • Right to Notice: Employee must be clearly informed in advance about the nature of the allegations against them.

  • Right to a Fair Hearing: Employee should have an opportunity to present their case in a hearing or meeting, if appropriate for the level of disciplinary action.

  • Right to Representation: Depending on hospital policy and legal frameworks, employee may have the right to be represented by a union representative or colleague during a disciplinary hearing.

  • Decision by an Unbiased Decision-Maker: The person making the disciplinary decision should be impartial and free from conflicts of interest.

  • Decision Based on Evidence: Disciplinary action should be based on credible evidence and facts, not just assumptions or hearsay.

  • Right to Appeal: As mentioned in HRM 8e, there should be a right to appeal against a disciplinary decision.

HRM 8d: The disciplinary and grievance procedure is in consonance with the prevailing laws. (CO)

• Objective Element Text: The disciplinary and grievance procedure is in consonance with the prevailing laws.

• Compliance Level: Commitment Core OE (CO) - Core OE at the Commitment level, highlighting the legal imperative of ensuring HR processes are compliant with labour laws, with mandatory system documentation to demonstrate legal adherence.

• Detailed Explanation: This Objective Element is crucial for legal compliance. The hospital's disciplinary and grievance procedures must be "in consonance with the prevailing laws." This means they must be consistent with and adhere to all applicable labor laws, employment regulations, and other relevant legislation in the jurisdiction where the hospital operates. Legal compliance is not just about avoiding lawsuits; it's about ethical and responsible employer practices and protecting employee rights as mandated by law. "Core OE" underscores the paramount importance of legal compliance in HR processes.

• Key Aspect of Legal Consonance (Blue Box - "Disciplinary and grievance procedure"):

  • "It should be based on prevailing laws. For example: Relevant labour laws and CCS (CCA) rules.": The procedures must be designed and implemented taking into account all applicable laws. The example provided highlights:

    • Relevant labour laws: This is a broad category encompassing laws related to employment terms and conditions, termination, disciplinary actions, working hours, wages, employee rights, trade unions, etc. The specific labor laws will vary depending on the country and region of operation. Hospitals must be familiar with and comply with all relevant labor legislation.

    • CCS (CCA) rules: "CCS (CCA)" likely refers to the Central Civil Services (Classification, Control and Appeal) Rules, which are specific to government employees in certain countries (e.g., India). If applicable to the hospital's context (e.g., if it is a government-run hospital or certain employee categories are governed by these rules), the disciplinary and grievance procedures must also comply with these specific rules. This highlights that legal consonance is not just about general labor laws, but also potentially sector-specific or government employee-specific rules if applicable.

• Note:

  • "The organisation should establish internal complaints committee to handle sexual harassment complaints." This note specifically highlights the legal requirement to have an Internal Complaints Committee (ICC) to address sexual harassment complaints. In many jurisdictions, laws mandate the establishment of such a committee in workplaces to handle complaints of sexual harassment in a structured and sensitive manner. This is a prime example of legal compliance within the HRM 8 framework.

    • Practical Implication: The hospital must establish an ICC as per the prevailing laws on sexual harassment. The grievance handling procedure must specifically include a dedicated process for addressing sexual harassment complaints through the ICC. This includes: procedures for lodging complaints with the ICC, investigation process by the ICC, composition of the ICC (as legally mandated), timelines for investigation and resolution, confidentiality protocols, and action taken based on ICC findings. The ICC mechanism should be clearly communicated to all staff as part of the overall grievance handling framework.

HRM 8e: There is a provision for appeals in all disciplinary cases. (C)

• Objective Element Text: There is a provision for appeals in all disciplinary cases.

• Compliance Level: Commitment (C) - Commitment level, highlighting the fairness principle of providing an appeal mechanism against disciplinary decisions.

• Detailed Explanation: This Objective Element ensures fairness and due process by mandating that the disciplinary system must include a provision for appeals in all disciplinary cases. An appeal mechanism provides a safeguard against potential errors or biases in the initial disciplinary decision. It allows employees who believe they have been unfairly disciplined to seek a review of the decision by a higher authority. This reinforces the principles of natural justice and promotes employee trust in the fairness of the disciplinary system.

• Key Aspects of Appeal Provision (Blue Diamond - "Appellate authority"):

  • "Considers appeals in disciplinary cases.": The disciplinary system must have a clearly defined appellate authority or mechanism that is responsible for reviewing appeals against disciplinary decisions. There must be a process for employees to formally lodge an appeal.

    • Practical Implication: Define in the disciplinary policy:

      • Who is the appellate authority? (e.g., a higher level manager, a disciplinary appeal committee, a board of directors sub-committee, depending on the organizational structure and level of disciplinary action).

      • Procedure for lodging an appeal: How to file an appeal (in writing, to whom, within what timeframe).

      • Scope of appeal: What aspects can be appealed (e.g., fairness of process, severity of penalty, factual accuracy of allegations).

      • Process for reviewing appeals: How the appellate authority will consider the appeal (review of documentation, potential hearing, timelines for decision).

  • "Is higher than disciplinary authority.": The appellate authority must be at a higher level of authority than the person or body that made the initial disciplinary decision. This ensures impartiality in the review process. An appeal to the same decision-maker would be ineffective and defeat the purpose of an appeal.

    • Practical Implication: Clearly define the appellate authority to be a person or committee that is senior to and independent of the initial disciplinary decision-maker. This ensures a genuine review and reduces the risk of bias. For example, if a department head makes a disciplinary decision, the appeal authority might be a functional head at a higher organizational level or a designated HR committee.

HRM 8f: Actions are taken to redress the grievance(C)

• Objective Element Text: Actions are taken to redress the grievance(C)

• Compliance Level: Commitment (C) - Commitment level, highlighting the crucial step of taking action to resolve grievances effectively, not just processing them.

• Detailed Explanation: This Objective Element emphasizes that the grievance handling process must be action-oriented and lead to redressal of genuine grievances. It's not enough to just have a process for filing and investigating grievances; the process must result in concrete actions to resolve the grievance and address the legitimate concerns raised by the employee. "Redress" means providing a remedy or solution to the grievance. This demonstrates that the grievance process is meaningful and not just a procedural exercise.

• Key Aspects of Grievance Redressal (White Box - "Actions are taken to redress the grievance(C)"):

  • "The redressal procedure addresses the grievance.": The grievance handling procedure must be designed to actually address and resolve the substance of the grievance, if it is found to be valid after investigation. Redressal is the intended outcome of the process.

    • Practical Implication: The grievance procedure should outline the types of actions that can be taken to redress a grievance. These actions will depend on the nature of the grievance and the findings of the investigation. Examples of redressal actions:

      • Apology to the aggrieved employee.

      • Correction of a procedural error or policy violation.

      • Change in working conditions.

      • Reversal or modification of an unfair decision.

      • Counseling or mediation between parties involved in a conflict.

      • Disciplinary action against another employee if their actions caused the grievance.

      • Policy changes or process improvements to prevent similar grievances in the future.

  • "Actions taken shall be documented and communicated to the aggrieved staff.": It is crucial that the actions taken to redress the grievance are both documented and communicated to the employee who raised the grievance. Documentation ensures a record of the resolution and accountability. Communication to the employee shows transparency, closure, and respect for their participation in the process.

    • Practical Implication: Maintain a record of all grievances received, including the investigation process, findings, and actions taken to redress the grievance. Communicate the outcome of the grievance investigation and the redressal actions to the aggrieved employee in writing. This communication should be clear, concise, and timely. Even if a grievance is not upheld, communicate the findings and reasons to the employee in a respectful and transparent manner.

In summary, HRM 8 focuses on establishing a fair, transparent, legally compliant, and action-oriented disciplinary and grievance handling system. The Objective Elements emphasize the need for written guidance, staff awareness, adherence to natural justice principles, legal consonance, appeals provision, and concrete actions to redress grievances. These elements combine to create a robust framework for managing employee conduct and resolving workplace disputes in a just and effective manner, fostering a more positive and equitable working environment within the hospital. The designation of HRM 8a and HRM 8d as Core OEs underscores the fundamental importance of documented policies and legal compliance in these critical HR processes.

 HRM 9: The organisation promotes staff well-being and addresses their health and safety needs