Chapter 9

Human Resource Management (HRM)

Intent of the Chapter:

The most important resource of the organisation is the human resource. Human resources are an asset for effective and efficient functioning of the organisation. The management plans on identifying the right number and skill mix of staff required to render safe care to the patients.

Recruitment of staff is accomplished by having a uniform and standardised system. The organisation must orient the new recruits to its environment and orient them to specific duties and responsibilities related to their position. Organisation should plan to have an ongoing professional training/in service education to continually enhance the competencies and skills of the staff.

A systematic and structured appraisal system must be used for staff development. The organisations use this as an opportunity to discuss, motivate, and identify the gaps in the performance of the employee.

Organisation promotes physical and mental well being of staff. A grievance handling mechanism and disciplinary procedure should be in place.

Credentialing and privileging health care professionals (medical, nursing and other para-medical staff) is done to ensure patient safety.

A document containing all such information has to be maintained for all staff.

Note:

The term “employee” refers to all salaried personnel working in the organisation. The term “staff” refers to including employees “fee for service” medical professionals, part time workers, contractual personnel and volunteers.

  Summary of Standards

HRM.1.      The organisation has a document system of human resource planning.

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

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

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

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

HRM.6.      Staff are trained on safety and quality related aspects.

HRM.7.          An appraisal system for evaluating the performance of an employee exists an integral part of the human resources management process.

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

HRM.9. The organisation staff promotes well-being and addressed their health and safety needs.

HRM.10.     There is documented personnel information for each staff member.

HRM.11.        There is a process for credentialing and privileging of medical professionals permitted to provide patient care without supervision.

HRM.12.        There is a process for credentialing and privileging of nursing professionals permitted to   provide patient care without supervision.

HRM.13.        There is a process for credentialing and privileging of para clinical professionals permitted to   provide patient care without supervision.

*This implies that this objective element require documentation.

Standards and Objective Elements

Standard - 1

HRM.1. The organisation has a document system of human resource planning.

Objective Elements

Excellence 

a.       Human resource planning supports the organisation’s current and future ability to meet the care, treatment and service needs of the patient.

Core Commitment   

b.      The organisation maintains an adequate number and mix of staff to meet the care treatment and service needs of the patient.

Achievement

c.       The organisation has contingency plans to manage long- and short-term manpower shortages including unplanned shortages.

Commitment

d.      The job specification and job description are defined for each category to staff.*

Commitment

e.       The organisations perform a background check of the potential employee.

Commitment

f.   Reporting relationships are defined for each category of staff. *

Achievement

g.   Exit interviews are conducted and used as a tool to improve human resource practices. (2024)

Standard - 2

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

Objective Elements

Core Commitment

a.   Written guidance governs the process of recruitment.*

Commitment

b.  A pre –employment medical examination conducted on the staff.

Core Commitment

c.   The organisation defines and implements code of conduct for it staff.

Commitment

d.  Administrative procedures for human resource management are documented.*

Standard - 3 

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

Objective Elements

Core Commitment

a.   Staff are provided induction training.

Commitment

b.  The induction training includes orientation to the organistion’s vision, mission and values.

Commitment

c.   The induction training includes awareness on staff rights and responsibilities and patient rights and responsibilities.

Commitment

d.  The induction training includes training on safety.

Commitment

e.   The induction training includes training on cardio-pulmonary resuscitation for staff.

Commitment

f.   The induction training includes training on hospital infection and prevention and control.

Commitment

g.  The induction training includes training on to the service standards of the organisation.

Commitment

h.  The induction training includes orientation on administrative procedures.

Commitment

i.        The induction training includes orientation on relevant department/unit/service/programme’s policies and procedures.

Commitment

j.        Staff is trained on information systems, information security, information use and management. (2024)

Standard - 4

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

Objective Elements

Core Commitment

a.   Written guidance governs training and development policy for the staff.*

Commitment

b.  The organisation maintains the training record.

Commitment

c.   Training also occurs when job responsibilities change/new equipment is introduced.

Commitment

d.  Feedback mechanisms are in place for improvement of training and development programme.

Excellence

e.   Evaluation of training effectiveness is done by the organisation.

Achievement

f.   The organisation supports continuing professional development and learning.

Standard - 5

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

Objective Elements

Commitment

a.   Staff involved in blood transfusion services are trained on handling on blood and blood products.

Commitment

b.  Staff are trained on handling vulnerable patients.

Commitment

c.   Staff are trained on control and restraint techniques.

Commitment

d.  Staff are trained in healthcare communication and techniques.

Commitment

e.   Staff involved in direct patient care are provided on training on Cardio Pulmonary Resuscitation periodically.

Commitment

f.   Staff are provided training on infection prevention and control.

Standard - 6

HRM.6. Staff are trained on safety and quality related aspects.

Objective Elements

Commitment

a.   Staff are trained on the organisation’s safety programme.

Commitment

b.  Staff are provided training on the dedection, handling, minimisation and elimination of

identified risk with in the organisation’s environment.

Commitment

c.   Staff members are made aware of procedures to follow in the event of an incident.

Commitment

d.  Staff are trained on occupational safety aspects.

Core Commitment

e.   Staff are trained in the organisation ‘s disaster management plan.

Core Commitment

f.   Staff are trained in handling fire and non fire emergencies.

Commitment

g.  Staff are trained on the organisation’s quality improvement programme.

Standard - 7

HRM.7. An appraisal system for evaluating the performance of an employee exists an integral part of the human resources management process.

Objective Elements

Commitment

a.   Performance appraisal is done for with in the organisation.*

Commitment

b.  The employees are made aware of the system of appraisal at the time of induction.

Commitment

c.   Performance is evaluated is based on the pre determined criteria.

 Achievement

d.  The appraisal system is used as a tool for further development.

Commitment

e.   Performance appraisal carried out at defined intervals and is documented.

Standard - 8

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

Objective Elements

Commitment

a.   Written guidance governs disciplinary and grievance handling mechanisms.*

Commitment

b.  The disciplinary and grievance handling mechanism is known to all categories of the organisation.

Commitment

c.   The disciplinary policy and procedures are based on the principles of natural justice.

Core Commitment

d.  The disciplinary and grievance procedure is in consonance with prevailing laws.

Commitment

e.   There is a provisional for appeals in all disciplinary cases.

Commitment

f.   Actions are taken to redress the grievance.

Standard - 9

HRM.9. The organisation staff promotes well-being and addressed their health and safety needs.

Objective Elements

Achievement

*.   Staff well-being promoted.

Commitment

a.  Health problem of the staff including occupational health hazards are taken care of in accordance with the organisation’s policy.

Commitment

b.   Health checks of staff dealing with direct patient care are done at least once a year and the findings/results are documented.

Commitment

c.  Organisation provides treatment to staff who sustain workplace related injuries.

Core Commitment

d.   Organisation has measures in place for prevention and handling work place violence.

Standard - 10

HRM.10. There is documented personnel information for each staff member.

Objective Elements

Commitment

a.   Personal files are maintained with respect to all staff, and their confidentiality is ensured. (2024)

Commitment

b.  The personal files contain personal information regarding the staff’s qualification, job description,  verification of credentials and health status.

Commitment

c.   Records of in-service training and education are maintained. (2024)  

> ( In old 2023 Standards - Records of in-service training and education are maintained in Personal File)

Commitment

d.  Personal files contain results of all evaluation and remarks.

Standard - 11

HRM.11. There is a process for credentialing and privileging of medical professionals permitted to provide patient care without supervision.

Objective Elements

Core Commitment

a.   Medical professions permitted by law, regulation and the organisation to provide patient care without supervision are identified.

Commitment

b.  The education, registration, training and experienced of the identified medical professionals is documented and updated periodically.

Commitment

c.   The information pertaining to the medical professionals is appropriately verified when possible.

Core Commitment

d.  Medical professionals are granted privileges to admit and care for patient in consonance with their qualification, training, experience and registration.

Commitment

e.   The requisite services provided by the medical professionals are known to them as well as various department/units of the organisation.

Commitment

f.   Medical professionals admit and care for patients as per their privileging.

Standard - 12

HRM.12. There is a process for credentialing and privileging of nursing professionals permitted to   provide patient care without supervision.

Objective Elements

Core Commitment

a.   Nursing staff permitted by law, regulation and the organisation to provide patient care without supervision are identified.

Commitment

b.  The education, registration, training and experienced of the nursing staff is appropriately verified, documented and updated periodically.

Commitment

c.   The information pertaining to the nursing staff is appropriately verified when possible.

Core Commitment

d.  Nursing staff are granted privileges in consonance with their qualification, training, experience and registration.

Commitment

e.   The requisite services provided by the nursing staff are known to them as well as various department/units of the organisation.

Commitment

f.   Nursing professional care for patients as per their privileging.

Standard - 13

HRM.13. There is a process for credentialing and privileging of para clinical professionals permitted to   provide patient care without supervision.

Objective Elements

Core Commitment

a.   Para clinical permitted by law, regulation and the organisation to provide patient care without supervision are identified.

Commitment

b.  The education, registration, training and experienced of para clinical professionals is appropriately verified, documented and updated periodically.

Core Commitment

c.   Para clinical (staffs) Professionals are granted privileges in consonance with their qualification, training, experience and registration. (2024)

Commitment

d.  The requisite services provided by the para clinical (staffs) Professionals are known to them as well as various department/units of the organisation. (2024)

Commitment

e.   Para clinical (staffs) Professionals care for patients as per their privileging. (2024)