SCOPE of SERVICES

          CONTENTS

*          General Instructions

*          Abbreviations

1.0     Introduction

2.0      Purpose

3.0      Scope of the Department

4.0      Methods Used to Access

5.0      Definitions

6.0      Planning and Policies

7.0      Planning and Procedures

8.0      Records

9.0      Occupational Health Hazard

1.0 Introduction

HR as a strategic partner in business will focus on bottom line enhancement, and will be the key driving force in our business. HR will engage all stakeholders by synergizing their potential to deliver contextual and continual values to the organizational goals.

Human Resource Management requires good planning of human resources while at the same time use the human touch, expertise, and commitment towards ensuring productive use of human capital while at the same time motivating the employees to make them give their fullest potential towards patient care activities in the Hospital.

To facilitate the above, HR will focus on developing the right values, build competencies and also shared irrelevant competencies in the IT enabled environment, promote business culture and strive for improving functional effectiveness.

Goals of HR Department

Human resource department supports the organizational goals in providing the required human resources by recruiting right candidates for the right job at the right time, developing the right values, build competencies, promote organizational culture, harmonious relations and continuously strive for improving the Clinical, Non Clinical &functional service effectiveness.

Objectives

§    To reward and compensate performance.

§    To provide challenging and rewarding work.

§    To communicate effectively with all the employees.

§    To provide a clean, safe, healthy and enjoyable working environment.

§    To Foster a spirit of teamwork, a culture of excellence in the work place. 

§    To motivate employees through performance management and reward system.

§    To provide career opportunities which allow employees to develop to their potential.

§    To develop distributed leadership and to build the right potential and capabilities to face challenges.

§    To Link human capital to the achievement of business objectives by strategically positioning the resources.

§    To nourish an environment in which members voluntarily participate in the development of the organization.

§    To provide training and development for all the employees to enable them to achieve the highest level of skills possible.

§    To secure commitment to equal opportunity and diversity goals and to integrate them progressively into the culture, ethos.

§    To recruit people who have a positive attitude towards patients, themselves and other employees and who are able to give quality service.

§    To ensure that employees are selected, trained, promoted and treated based on their relevant skills, talents and performance without any discrimination.

§    To promote employment practices, consistent with operational effectiveness, which recognize and respect the needs and rights of individual employees in work?

§    To build a learning organization where the members voluntarily participate in the process of learning to nourish their skills and attune to the changing paradigms.

§    To enable integrated delivery of quality healthcare services through progressive human resource management and development practices supported by right organizational culture.

§    To communicate systematically with employees through a variety of channels, positively encouraging consultation and participation in support of objectives and decision taking within the context of institutional leadership and management.

2.0 Purpose

o    To provide a clean, safe, healthy, professional and enjoyable working environment.

o    To motivate employees through reward & recognitions system and build confidence among staffs.

o    To plan the right mix of work force for the Hospital in line with the volume of scope of the services being provided by the hospital.

o    To provide training and development for all the employees to enable them to achieve the highest level of skills possible and provide job satisfaction largely.

o    To recruit competent people with a positive attitude towards organization and customers, and have the capability to guide or work in a group to achieve the goal of the hospital.

o    To ensure that employees are selected, trained, promoted and treated based on their relevant skills, talents and performance without any discrimination as per the requirement of the organization.

3.0 Scope & Complexity of Services Provided by HR Department

This manual covers the following:

• Discipline

• Recruitment

• Employee Welfare

• Employee Relations

• Manpower planning

• Statutory Compliance

• Training & Development

• Promotion and Incentives

• Performance Management

• Human Resource Planning

•  Time Office Administration

• Compensation Management

• Joining - Reporting & Induction

• Employee personal file maintenance

• Recruitment and selection, and placement

• Employee Health care & Occupational Hazards

4.0 Methods Used to Access the Services Provided

 ·       Exit interview

 ·       Patient feedback

·       Organizational Climate Survey

·       HR Score card & Audit checklist

·       Audit by external agency on statutory compliance

·       Quality Indicators

5.0 Definitions

Human Resources Department: Shall mean the ‘Department having charge of the HR function of the hospital’

Scope of Service means any description of the type of activity, including but not limited to, number served, outcomes being sought, target group, and geographic area in which the activity takes place.

Scope of Service means the document explaining the services to be provided as set forth in Exhibit D, Scope of Services. This document is managed and may be altered with the written consent of the project managers for the Parties.

Scope of Service means the specified range of services that may be provided under Member supervision within UMHHC, as determined through UMHHC administrative and/or Medical Staff credentialing mechanisms.

Days and Hours of Operation

The HR department is operational 6 days a week from 9.00AM –6.00PM

Department Organogram

Designations - roles & seniority levels of HR department

• Chief Human Resources’ Officer – CHRO - Top Level

o  HR Manager - Mid Level

o  Training Manager

§  HR Executive - Basic Level

§  Payroll Executive

*  HR Assistant - Entry level

*   HR Trainee

*   Intern’s

6.0 Planning and Policies

Planning

Manpower Planning is done in the hospital taking in to account the services scope, the volume of out patients, Emergency patients and Inpatients, based on the past. This also takes in to account the periodical staff turnover. The Chairman analysis at the beginning of every year such manpower requirements of various categories of staff – Clinicians (full time), Clinicians (On Call), Nursing staff, other paramedics – technicians for Diagnostic Labs, Medical records department, Administrative staff, Front office staff, Maintenance staff, Housekeeping staff (both in-house & contractual), other hospital workers, etc.

Human Resource Planning

Human resource planning is critical to the success of organizational strategy and planning. Human Resource planning is concerned not only to ensure appropriate levels of staffing, but also to develop, implement and monitor effective personnel policies, to satisfy the business requirements and development needs of the future.

The main purpose of the staff planning process is to ascertain the needs with respect to the number of personnel with appropriate qualification, experience and skills required to fulfill the Organization’s mission and to work towards meeting the patient needs. This helps in reassigning staff from one department / section to another in response to changing patient needs or staff shortages and to consider staff request for reassignment based on exigency or special circumstance.

Workforce Planning (Non-Medical)

* Responsibility for manpower planning for the hospital rests with HR department and the management ensures availability of the right mix of manpower required to provide quality healthcare services taking in to consideration the patient walk-in and bed occupancy ratio, number of beds, number and type of procedures, type and level of care, specializations, infrastructure etc.

* The assessment of manpower requirement in each department/division is periodically reviewed depending on increase or decrease of workload, technological changes or any other relevant factor.

* In case any new staff is required to affect continuity of care either directly or indirectly, the same is communicated to the Decision Makers through Human Resources Manager, who is responsible for the approval and provision of the required manpower.

* On approval by the Unit Head or Chairman, these manpower plans will constitute sanction for creation of posts including posts of trainees and form the general basis of recruitment according to the need of staff in each department.

Manpower Planning (Recruitment, Selection & Induction)

* While merit would be the main criteria for filling up a vacant position, Skills, Hands on experience, seniority and past performance shall also be kept in mind.

* For filling up position at higher levels, employees of the Hospital shall be given preference and would be considered before outside sources are tapped. The mix of the employees shall be cosmopolitan.

* The best available talent would be absorbed without considering region, religion, sex or race.

* All recruitment along with the approval of unit head or chairman shall be done through the HR Department only.

Recruitment

Human Resource is one of the key resources, which contributes to the success of the hospital. It is imperative that human resource department will have to identify the right talent to achieve organizational objectives, values and culture and in turn contribute their best to the organization effectiveness. The success of identification of right talent depends upon finding the applicants with the most appropriate level of skills, qualifications and experience, who will identify themselves with the organizational objectives, values and culture and in turn contribute their best to the organization.

Training Policy

* Training helps in exchange of ideas from one person to another.

* Training is the process of imparting necessary knowledge, skills and attitudes to the employees to enrich their existing knowledge, skills and attitudes, and develop newer ones.

Induction Policy

* Induction helps in reducing the turnover of the employees.

* Induction enhances the image of the hospital as people friendly.

* It gives maximum relevant information to the new employees in shortest time.

* It eliminates the feeling of the uneasiness, apprehensions etc. in the new employee.

* Induction helps to attain maximum training requirements and learning compliance as per NABH requirements.

* To ensure that a new employee settles down smoothly into the hospital so that he/she reaches standard level of performance as soon as possible.

Induction

* This Induction program &training is provided to all the new recruits at the time of joining.

* This training generally introduces the employee to the hospital’s quality policy, Vision, Mission, hospital practices and procedures, employees Job Description and many more as per needs of hospital & NABH standards.

On Job Training

On-job training is imparted by the department heads/leads. OJT training includes management of various risks associated with the care environment. Nursing staff, OT/ICU staff, housekeeping staff, laboratory staff, imaging dept. staff etc., are trained on infection control practices that include needle stick injury, hand wash practices, use of appropriate personal protective equipment’s (PPEs), injection & infusion practices and bio-medical waste management practices.

Change of Department/Rotation /Transfer

Training is imparted to the employee at the time of Change of Department/Rotation /Transfer to other department in order to make him familiar of the new department, roles and responsibilities of the employee etc.

Advancement/introduction/change in Technology / equipment

All concerned employee will be provided training to upgrade him or her to such situation. In case of installation of new equipment, the Service/installation Engineer to all the concerned staff also provides training.

Mock Drills

Safety Training will be a continuous program – Mock drills will be conducted as per Annual - quality planner.

Mock drills will be conducted twice in a year for different category of employee to provide them practical experience of handling critical situations such as various Emergency Codes like fire, bomb threats, mass casualties, etc.

Training Methodology

Training shall be done by issuing training materials or manuals to the employees. Basic training materials or manual is issued to every class of employee. The training is documented in training formats for each employee, dated and duly signed by the employee and the HR Personnel.

Sexual Harassment Policy

* ICC –Internal Compliance Committee

* POSH Act – Prevention of Sexual Harassment

* Any incident of sexual harassment will be viewed extremely serious by ICC.

* This applies equally to relations between superior and subordinates as well as between peers.

* The Hospital policy is to totally prohibit any form of sexual harassment in the way employees behave with each other.

* Such action will depend on the nature and seriousness of the offense and will include strict disciplinary action including termination of service.

* A complaint or report of sexual harassment will be immediately investigated and ICC will take appropriate action against the offending employee or employees.

* A team of Experts 60% more than female and one External Female Social worker will be a part of ICC.

Attendance & Working Hours

Working Hours: Employee in all departments / sections of the Hospital shall work for 54 hours a week, which includes their tea & lunch, breaks.

Attendance: All employees working in the wards shall punch their Digital Attendance & report daily to their reporting manager.

Punctuality: All employees are expected to report for work as per the duty timings allotted. For those who report late for more than 30 minutes three occasions, every third occasion of late coming will count the loss of one leave. For those who report late for more than 35 minutes, will be considered as half a day leave.

Identification: All the employees are required to be displaying the Identity Cards on their person while on duty.

Absenteeism: Unauthorized absenteeism in the Hospital results in disruption of the work in the Hospital besides making an employee liable for disciplinary action. In case of habitual / unauthorized absenteeism, the management shall take suitable disciplinary action in accordance with the law.

7.0 Planning and Procedures

Annual Manpower Planning -Recruitment, Selection & Induction

Workforce Planning

Classification of Employee

Manpower requirements of each department/section of the Hospital shall be determined and done.

The manpower requirements so arrived, after approval of Chairman/Head HR

Manager-(HRD & Personnel) shall constitute the approved strength of the department/section and shall form the basis of manpower planning of the department/section. All recruitment shall be as per the approved strength of each department/section.

Care must be taken that all recruitment exercise is done at a minimum cost and time.

Interview Call

All interview call shall be done through the Mail or telecom communication by HRD Department.

Selection Process

The HR Department with active involvement of the Departmental Head shall do short listing of all ‘CV’. While recruiting manual employees their physical attributes shall be taken into consideration. Only those candidates, who fulfill the pre-defined minimum physical attributes, shall be recruited. The HR department with involvement of Chairman/HR Manager- (HRD & Personnel) shall carry out all arrangements for interviews.

Appointment Letter

The selected candidate will be issued a letter of intent immediately on his selection. A detailed appointment letter would be issued preferably after receiving the favorably medical reports. Acceptance of appointment would be obtained on the duplicate copy of the appointment letter before a person joins.

Joining Formalities

Every employee on joining would be required to fill up the following basic forms: Employee Application Form. P.F. Nomination Form. Six Passport size photograph. Selected candidates should submit complete CV with proper address. Selected candidate should submit all certificates, should be verified with all original certificates and other norms as per Hospital norms.

Probation

All employees would be appointed on probation of Six months. During this period, performance would be reviewed. The Reporting Head & HR Manager - HRD Department, shall initiate the performance review. Confirmation of the services of employees would be done only after successful completion of the probation period. In case the employee’s performance does not meet the desired level, his probation may be extended for a period of Six Months/Twelve Months or Termination of employee with a period of written notice can also be an option.

Reference Checking

BGV – Background Verification or Employment History Check is also a part of HR services

The HRD Department will verify the information submitted by him in the application, from previous employer of the new employee.

Employees’ Rights and Responsibilities

Employee Rights

To be aware of the hospital wide policies.

To be treated considerably and respectfully without any discrimination.

To be aware of the terms and conditions of his/her employment before joining the organization.

If any one believes that he/she has been the victim of any kind of harassment, or knows of another employee who has the right to, report it immediately to the HR Department or to ICC.

To seek clarity on the targets to be achieved and the roles/responsibilities associated with the task to be performed.

 Employee Responsibilities

Employees are expected to work on their duty hours to support the Hospital’s 24*7 operations and are required to work overtime when the workload necessitates.

Employees shall be responsible for the equipment allocated to them and maintain it in accordance with the standard operating procedures. Employees are expected to maintain proper discipline, professional ethics.

Employees are expected to plan leave and if unable to report to work on schedule he/she shall intimate to the department head.

Employees are responsible to maintain complete confidentiality of patient’s information’s.

Employees shall be encouraged not to converse in their local vernacular language while in patient contact areas. Employees are expected to maintain proper dress code.

Employees shall devote their time exclusively for the work assigned to them and do not engage in unwanted activities.

 Duty Hours & Shift Working

The rules regarding hours of work, shift, weekly holidays and rest intervals, etc. shall be in accordance with the law applicable to the establishment and as specified by the Management. The provisions regarding period of duty and hours of work of each category of employees and each shift will be fixed by the HRD Dept. and the same are liable to be altered from time to time either to suit the Administrative requirements of the Hospital or to ease the pressure of work, as the case may be. No employee shall change his shift without orders and permission from the Departmental Head. Such change may be made either temporarily or permanently.

Time Office

* Time Office operates round the clock to meet the requirements of employees.

* It also plays a vital role in enforcing discipline and culture building.

Attendance

An employee has to punch his attendance while coming on duty and while leaving from duty. No employee shall mark attendance for another employee. After marking the attendance every employee shall present himself in uniform where provided, and keep himself ready for work in his/her respective department at the appointed time. An employee who does not report for duty at the appointed time will be considered as late.

Compensation Management

* Salary has to be deposited or paid to employees on or before of seventh of every month, if employee strength exceeds the norms will be varied as per labour laws.

* Compensation Management focuses on providing monetary values to all employees based on the nature of job and its value. It helps to practice uniform formulae, eliminate gender discrimination, ensures equal remuneration for common jobs, comply statutory norms and reward performance. 

* It helps to ensure that the hospital is able to attract, motivate and retain highly qualified workforce in order to achieve organizational goals in the most cost effective manner.

Promotion

* Performance Management exercises and interviews have to be a part of Promotion and appraisal process.

* The Management will promote only qualified and eligible employees to higher positions when vacancies arise in such higher cadre. Promotions will be effected strictly based on merit, efficiency, and suitability for Para-medical staff and for other categories wherever applicable based on past record of service, performance, requisite skills, seniority and state of health and suitability of the employee. Solely the Management will decide the suitability of an employee for promotion. Upon promotion or regularization, the employee will be granted such benefit and the management may decide increase in wages as. The management’s decision on promotions shall be final and conclusive.

Performance Management

The purpose of performance management system is to assess the staff member’s performance and competencies involved in patient care delivery process. This helps to enhance the knowledge, skill and behavior of the employees to enable them to contribute their best to achieve Departmental / Organizational goals. 

This is accomplished by providing a means of measuring employees' effectiveness on the job; identifying areas of development where employees are in need of training, growth, improvement and/or additional resources; maintaining a high level of motivation through the feedback from the respective supervisors/managers.

Discipline

The promotion and maintenance of employee discipline is essential in an organization to be effective and productive. This function lays down acceptable norms of behavior, code of conduct, dos and don’ts as rules and regulations. It helps to achieve the organizational goals through a controlled coordination among the workforce.

Redressal of Grievance of Employees against Unfair Treatment

All complaints arising out of employment including those relating to unfair treatment and wrongful application of these service rules shall be submitted to the Unit Head or Chairman. The employees shall exhaust the above procedure before resorting to any legal remedy.

Welfare

The Organization believes that a satisfied individual contributes more. The Welfare function aims to improve the level of satisfaction, increase motivation and build morale to perform better. This is being achieved by way of implementation of various welfare programs, Counseling programs, Grievance Redressal mechanism and implementation of special program for the employees’& their family.

Employee Personal Record Policy

Employee’s Personal Records contains

* An employee’s personal file is maintained by the HR department.

* Remember – Employee Personal Record is a confidential info – To be maintained under lock & Key

* The employee can access to his / her Records by a written Request to the HR Manager-HRD & Personnel.

* Employee Detail Form with Photograph Appointment Order Photocopy Employee Bio data / CV.

* Employee documents supporting his/her Educational Qualification in the order-Matriculation, Inter, Degree, Post-Graduation, Professional courses, Employee Health Record.

* Once an employee leaves the organization or on cessation of his/her employment, the employee’s file will be labeled as Ex-employee file.

8.0 Records - Retention & Destruction

All the below mentioned records shall be maintained for one year in the HRD and destruction shall be done by the Medical Record department after getting approval from the management.

 S.No               Title                               Responsibility                             Code                              Retention Period           

1          Attendance Register                    HR Manager                Attendance/REG/HR/1              12 Months       

2          Time Attendance Register             HR Manager                Time/REG/HR/2                             12 Months       

3          Training Register                          HR Manager                Training/REG/HR/3                    12 Months       

4          Vaccination Register                   HR Manager                Vaccination/REG/HR/4             12 Months       

9.0 Occupational Health Hazard

Vaccination: Our hospital is providing vaccination against vaccine preventable diseases (HBV) to all employees those who are working in patient care areas and have direct contact with patients. E.g. Doctors, Nurses, Laboratory staff, Housekeeping staff, Maintenance staff and biomedical engineers. The register is maintained in the HR department.

 Regulatory agencies relevant to service

* Intradepartmental Regulations:

·   Report generation. E.g. HR MIS report

* Inter departmental regulations:

·   Interdepartmental meetings

·   Meeting with HODs on the various HR requirements

External Agencies & Reporting

Outside Regulatory Authorities:

·       Police Department

·       Labour Department (Central & State) Corporation

Statutory Compliance

Statutory Compliance function ensures compliance to the law of the land applicable to the personnel working in the organization. It protects the well-being of the workforce, provides social security and follows the service conditions. It also helps to settle the issues of the personnel in a reasonable manner and encourages the personnel to be part in the growth of the organization.  

Redressal of Grievance of Employees against Unfair Treatment

All complaints arising out of employment including those relating to unfair treatment and wrongful application of these service rules shall be submitted to the Unit Head or Chairman. The employees shall exhaust the above procedure before resorting to any legal remedy.

Welfare

The Organization believes that a satisfied individual contributes more. The Welfare function aims to improve the level of satisfaction, increase motivation and build morale to perform better. This is being achieved by way of implementation of various welfare programs, Counseling programs, Grievance Redressal mechanism and implementation of special program for the employees & their family.

Hospital Safety Rules

The only way to do a job in the Hospital is the safe way. Urgency is not a justifiable excuse for neglecting safety. Know your job thoroughly, when in doubt, do not indulge in guesswork, ask your supervisor.

Do not handle or operate machinery, tools and equipments without authorization. Be alert and observe keenly. Report immediately any faulty equipment, unsafe condition or act, and defective or broken equipment. Do not try amateur repair.

Stay physically and emotionally fit for work by maintaining good health and a proper diet. Abstain from alcoholic drinks. Take sufficient rest and practice cleanliness. Personal hygiene is important. Wash your hands often in many areas of the Hospital. This is necessary.

Wear proper uniform or clothing for your job: Neither to tight nor too loose. Tight clothing does not permit freedom of movement, while loose one runs the risk of being entangled. Jewelry and high-heeled footwear may be hazardous.

Prevent the spread of infection and contagious disease. Cooperate with the Hospital infection control committee by observing established procedures. When you are ill with an infectious disease, report to the doctor immediately and stay at home.

Walk, not run particularly when you are carrying delicate, breakable article or instrument. Be extra cautious at the corridor intersections, in front of swinging doors (especially when they do not have view panels), as blind corners and in congested areas. If you see some foreign material, loose wire, oil spill, etc., on the floor that may cause an accident, make sure it is removed as once. Never indulge in horseplay or practical jokes involving fire, acid, water, compressed air and other potentially dangerous things.

Pay attention to all warning boards. Their signs caution you about dangerous and hazards that may cause injury or harm. For example, smoking in an area where oxygen is being administered or oxygen cylinders are stored. Be familiar with your work procedure. All departments have within work procedures that include safety practices at work and handling equipments.

Always remember to use handrails on stairways. They are there to ensure your safety and are meant to be used by all, not just the sick and the old. When you want to reach overhead objects, always use a good ladder. Do not climb on chairs or boxes.

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