All Essential Documents to be Maintained by HR Department

PRE Employment

SOP

HR Policy

HR Manual

Recruitment and Selection Procedure

Human Resources Plan of the Organization

Training and Development Policy

PF Registration

ESI - Employer's Registration

PT - Professional Tax Register

LWF - Labour Welfare Fund Registration

Contract Labour Registration

Catering Act Registration

The required Job Specifications and Job Description are well defined for each category of staff.

The organization verifies the Antecedents of the Potential Employee with regards to criminal/negligence background. All Staffs

Employee Personal File - Documented Personal Record for Each Staff Member by Collecting, Verifying and Evaluating the Credentials

Management & HR

Registration Certificate of hospital under one of the following body / act to be Documented & Displayed

* State / Local Statutory Hospital Registering Body

* Clinical Establishment Act

* Shops and Establishment Act

Registration Certificate of Hospital for type of ownership/partnership like private-corporate, proprietary, cooperative society etc. to be Documented & Displayed

Certificate of the hospital under any government empanelment schemes (as applicable) such as ESI, ECHS, CGHS, etc. to be Documented & Displayed

Employment

HR Aspects

The organization addresses the Health Needs of the Employees

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

The staff joining the organization is socialized and Oriented to the Hospital Environment.

Addressing health needs of employee

Pre and Post exposure prophylaxis

Job specification and job description of each category of staff

Training Aspects

Training SOP

In-service” Training sessions

Training Calendar - Monthly, Quarterly, Half Yearly, Annually

Regular Pre-Induction Training , Training on JD & JS, Training on Safety

Professional Training and Development of the staff

Induction programme of new staff

POST Employment

Skill Matrix & Skill Management System

Credentialing and Privileging of Medical Professionals

Credentialing and Privileging of Nursing Professionals

Credentialing and Privileging of Para Medical Staff - Those who Handle Patients Directly and Provides Clinical Care 

Employee Appraisal System - Performance Appraisal & Evaluation System

Documented Disciplinary Procedure

Disciplinary and Grievance Handling System

Committees & Complaints Register 

Policy on Prevention of Sexual Harassment - (ICC - Internal Compliance Committee) - (POSH)

**. Many more - Other essential documents as and when required ..

All Essential Documents to be Maintained by Training Department

1          Manual

a          Standard Operating Procedure

b         Training Policy Manual

c          Safety Manual

d         Infection Control Manual 

e         Quality Systems Standards document (JCI/NABH Standards pertaining to T&D)

f Job Description & Job Specification of All Departments

2          Statements & Documents to be displayed at the department

a          Quality Objective- Statement Document

b         Quality Monitor-  Statement Document

c          Quality Policy of the company

d         Vision , Mission and Values of L & D

3          Templates forms for data capture

a          TNI- Excel Template

b         Annual Training Calendar-Template

c          Training Plan – Template

d         “Training Returns and Pre & Post-test Summary” sheet- Template

e         "T&D Record Books" to be present in the individual department

4          Training Feedback Forms-All templates

a          Hospital Induction & Orientation

b         Generic - Mandate trainings

c          Nursing Communication skills

d         Soft Skills for Nursing & Other staffs

e         Grooming Standards & Hygiene Look

5          Orientation Form

a          Medical (Doctors and Nurses)

b         Non-Medical

c          Orientation Schedule

d         HR program Hospital Induction Resource materials.

e         Department Orientation/induction

6          Template for compilation of data

a          TNI Compilation-Excel Template for compilation of data from “TNI”

b         TNA- Sample

c          “Master Monthly Schedule” – Excel sheet template used for compilation of data from “Training Plan” forms

d         Training Returns Consolidation- Excel used for compilation of data from “Training Returns Pre and Post-test Summary” Sheet

k          “Training Materialisation Report”-

(Maintain Excel template to draw conclusion by referring common data points from Master Monthly Schedule & Training Returns)

f          Continuous Quality Improvement Indicators for T&D

g          Quality Monitors-Charts with excel data sourced from reports of AAPIE feedback Analysis & Training Materialisation Report

h         RCA and CAPA Report (Logical Outcome of Feedback Analysis)

i           D E A R S F O C C-Data Entry And Retrieval System for Orientation and Certificate Compliance -

j           Training MIS report

k          Training Expenditure Report

7          “Training Feedback Analysis Report” – Excel sheet templates used for compilation of data points from Feedback forms

a          Hospital Induction & Orientation

b         Generic - Mandate trainings

c          Nursing Communication skills

d         Soft Skills for Nursing & Other staffs

e         Grooming Standards & Hygiene Look

8          Resource Materials viz., PPTs, Videos, Hand outs (kit for induction) and Q&A Sheets

a          Hospital Induction & Orientation

b         BLS

c          ACLS

d         PALS

e         NLS

f          Fire and Hazmat safety

g          Employee Rights and Responsibility

h Patients Rights & Responsibilities

9          Falcon Eye Functional Training Intervention Mechanism

a          Visual Audit

b         Physical & Oral Audit Checklist

c          Tracker

d         Q R F I - Quality Review & Functional Improvement -Documentation Audit.

e          Tracker

Employee Personal File Checklist

Kindly Ensure All the Relevant Documents are Collected from Employees before permitting to start their services

Employee Name………...………………………………………................................

Employee No ........................................Department………………………....

Designation…………………………………………     DOJ ……...............................

HR Formalities

1.             Recruitment Requisition Form        

2.             Interview Evaluation Form           

3.             Application Form

• Reference Check

• Residential Address Form

• Personal Information Form

• Pre Employment Medical Checkup               

4.             Antecedent Form                

5.             Good Standing Certificate               

6.             Joining Sheet          

7.             Job Description                   

8.             Updated CV            

9.             Job Offer - Appointment Letter

• Joining Report

• Salary Break Up

Educational Credentials

10.           10th / SSLC - Certification           

11.           12th / Intermediate - Certification           

12.           UG - Under Graduation Credentials            

13.           PG - Post Graduation Credentials             

14.           Diploma / Degree Certificate          

15.           Registration Certificate                   

16.           Others - Additional Educational Qualifications        

Id Proofs & Key Documents

17.           Pan Card                 

18.           Passport / Voter ID             

19.           Aadhar Card / Ration Card             

20.           Driving License / Proof for Date of Birth

21.           Experience Certificates

• No Dues Certificate from Previous Employer - (Cash Handling Employees only )

• Relieving Letter from previous Employer

• Salary Proof-Copy & Bank Statement or PF Statement for Cross Verification                  

22.           Hepatitis -B Vaccination                 

23.           Bank Pass Book Front Page            

24.           Statutory - 

• ESI / PF  Nomination Data Collection

• Gratuity Form &  Form VIII - Nomination for Gratuity          

25.           Pre-Employment Medical Check-up  - Self Declaration for Fitness          

26.           Passport Size Photos – 6 Nos          

27.           Form 16                  

Induction & Training

28.           Induction Documents                    

29.           Orientation Documents            

30.           Evaluation, Feedback & Analysis - Induction & Orientation                  

31.           Others - External Trainings & Certifications         

Clinical & Doctors Certification

32.   Medical Council ID            

33.   UG Degree Certificate        

34.   UG Registration Certificate             

35.   PG Degree Certificate         

36.   PG Registration Certificate              

37.   Diploma Certificate            

38.   Diploma Registration Certificate                 

39.   Research Publications         

40.   Others         

Periodical Information

1.     Training Records                                                                                                    

2.     Probation Evaluation                                                                                              

3.     Performance Appraisal Form                                                                                  

4.     Disciplinary Letters                                                                                             

5.     Employment Health Checkups                                                                                       

6.     Disciplinary Action / Memo                                                                                    

Exit Formalities

1.     Letter of Resignation  

2.     Exit Interview 

3.     Employee No Dues Checklist (e.g. ID card, CUG, Phone, Keys) others: ________________

4.     Last Working Date - Date of Exit    

HR sign _________________________ Date ____________      

Deployment of Training Accountabilities

Employee Induction / Orientation / Reorientation Form

Below Mentioned Are Mandatory Training Programs to be Covered under Induction for New Joiners

Training Topics

• Employment - Joining Norms - HR File 

• Human Resource Documentations / ID Card etc.

DEPARTMENT / ORGANISATIONAL INPUTS

.Org Orientation & Induction

Safety Education Programme

Dress Code / Grooming Standards

Time & Attendance, Duty Scheduling

Mission Statement & Goals of Institution

Review Organisation Structure & Resources

Bonding & Belonging - ISBAR Effective Communication

Communication Process: Public Addressing System/Phones/Email

JOB DESCRIPTION & RESPONSIBILITY

Employee Benefits

Annual Performance Reviews

Employee Rights & Responsibilities

Review Performance Improvement Plan

Review Job Description & Responsibilities

Disciplinary Procedures / Grievance Handling & Redressal / ICC

HOSPITAL CONTINIOUS QUALITY IMPROVEMENT

Patient Rights & Responsibilities

Hospital Wide Policies & Committees

Quality Indicators & Incident Reporting System

Review of Hospital Policy Manual & Scope of Services

Discuss NABH Accreditation Process & Employees Role

Various Types of Emergency Colour Codes & Code Drills

SAFETY & SECURITY

Safety Manual

No Smoking Policy

Emergency Paging Codes

Disaster Management Plan

Fire Safety Plan & Code Red - Fire Mock Drills

HOSPITAL CLINICAL POLICIES

Employee Incident Form

Needle Stick Injury – NSI

Patient Incident Reporting Form

Infection Control Policies & Practices

Medication Administration Procedure - Nurses/Doctors

LIFESAVER COURSES

Basic Life Support – BLS

Awareness of Incidents & Accidents

Training on Care of Emergency Patients

CLINICAL SAFETY & RISK MANAGEMENT

Medication Error

Basics of Housekeeping

Occupational Health Hazards

Safety Education Programme

Spill Management - HAZMAT

Code Pink - Child Abduction Prevention

Hazardous Materials & Waste Management Policy

Preparation & Administration of Chemotherapeutic Drugs

TECHNOLOGICAL SAFETY

Safe Practices in Imaging

Safe Practices in Laboratory

Basics of Biomedical Engineering

Safe Practices in Imaging, Film Badges & other Safety Devices

Clinical Alarm Systems Policy, Equipment Maintenance & Safety

Training Evaluation

Written Test, Quiz , Games, Training Evaluation,  Feedback  & Analysis

Photographs for the Above Training

Other Training Titles:

Declaration & Documentation

I Have Completed a Review of the Above-Noted Items with my Administrator / Supervisor / HOD

Employee Signature                                                                                              HODs Signature

Date:                                                                                                                     Date:

Training Manager