|| Document Manager ||
Chapter - IX
NABH Audit - Document Manager
Digital Publishers
https://sites.google.com/view/hospitalhr/home
“Hospital HR is a virtual HR platform designed to serve all basic HR needs of Health Care Organisations”
All Essential Documents - As per NABH Requirements - Supporting Documents to be Displayed while Quality Audit
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
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
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
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 ..
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 -
(JCI/NABH Mandatory training program compliance report)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
Kindly Ensure All the Relevant Documents are Collected from Employees before permitting to start their services
Employee Name………...………………………………………................................
Employee No ........................................Department………………………....
Designation………………………………………… DOJ ……...............................
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
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
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
28. Induction Documents
29. Orientation Documents
30. Evaluation, Feedback & Analysis - Induction & Orientation
31. Others - External Trainings & Certifications
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
1. Training Records
2. Probation Evaluation
3. Performance Appraisal Form
4. Disciplinary Letters
5. Employment Health Checkups
6. Disciplinary Action / Memo
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
Authorized SignatoryHR sign _________________________ Date ____________
Below Mentioned Are Mandatory Training Programs to be Covered under Induction for New Joiners
Employment - Joining Norms - HR File
Human Resource Documentations / ID Card etc.
.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
Employee Benefits
Annual Performance Reviews
Employee Rights & Responsibilities
Review Performance Improvement Plan
Review Job Description & Responsibilities
Disciplinary Procedures / Grievance Handling & Redressal / ICC
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 Manual
No Smoking Policy
Emergency Paging Codes
Disaster Management Plan
Fire Safety Plan & Code Red - Fire Mock Drills
Employee Incident Form
Needle Stick Injury – NSI
Patient Incident Reporting Form
Infection Control Policies & Practices
Medication Administration Procedure - Nurses/Doctors
Basic Life Support – BLS
Awareness of Incidents & Accidents
Training on Care of Emergency Patients
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
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
Written Test, Quiz , Games, Training Evaluation, Feedback & Analysis
Photographs for the Above Training
Other Training Titles:
I Have Completed a Review of the Above-Noted Items with my Administrator / Supervisor / HOD
Employee Signature HODs Signature
Date: Date:
Training Manager