In NABH standards there is a complete chapter devoted for HR management in hospitals. It is expected that the hospital follows all good HR practices which ultimately makes the hospital a better organization for delivering healthcare services. From NABH standards and various assessment observation, following are the important points with which an HR department of a hospital must be prepared.
Checklist for HR department
1. Having a documented HR plan for the hospital. The plan must mention the categories of employees, quantity required under each category, quantity available and future quantity requirements.
2. A well-developed organizational structure that incorporates all categories of employee and clearly identify their line of hierarchy
3. Job specification and job description for each category of employee
4. Conduction of background verification of all potential employee. A documentary evidence of the same should be available. Verification of qualification and experience should be done for all, but most importantly for doctors, nurses and technicians
5. Availability of a policy and SOP of recruitment of employee, which outlines criteria for selection/rejection of an employee
6. An induction training plan and record of provision of induction training to all new recruits. The induction training should necessarily cover following topics
a. Vision, mission and values of the organization
b. Employee rights and responsibilities
c. Service standards of the organization
d. Organization wide policies
e. Relevant department specific policies
7. Availability of a documented training and development plan, along-with records of all training provided (like attendance sheet)
8. Conduction of training need assessment
9. Evaluation of training conducted and its record; such as trainees test result, feedback from HOD etc.
10. Availability of feedback from participants of the training and provision of these feedback to trainers
11. Training topics must cover all safety related topics such as risks within hospital, what to do in case of disaster, procedure to follow in case of an incident, occupational safety etc. (Suggested read - Disaster handling checklist for hospitals)
12. Having a documented policy and process of conducting performance appraisal of employee. Performance appraisal system should be based on identified and defined criteria
13. Having a documented policy and process of receiving employee grievance and redressing them
14. Having a grievance redressal committee as a final authority to take decisions on grievance related matters (Refer grievance redressal and disciplinary action committee under 'List of hospital committees and teams')
15. All employee must have their annual health check-up done, at-least
16. There should be a policy to take care of healthcare needs of the employee
17. There should be personnel file of each employee which must be updated and is kept confidential. It should contain information on
a. Staff’s qualification and experience
b. Background verification
c. Health status
d. Record of all in-service training and education availed by the staff
e. Results of all evaluations of the training
18. Availability of a credentialing and privileging policy for doctors
19. A document listing credentials (qualifications, experiences, certificates etc.) of each doctor associated with the hospital
20. For each doctor there should be a document that lists all the treatments and patient care activities that he/she has been permitted to undertake
21. Availability of a credentialing and privileging policy for nurses
22. A document listing credentials (qualifications, experiences, certificates etc.) of each nurse associated with the hospital
23. For each nurse there should be a document that lists all the nursing care activities that he/she has been permitted to undertake
Other checklists available for NABH accreditation preparation:
Checklist for HR department
1. Having a documented HR plan for the hospital. The plan must mention the categories of employees, quantity required under each category, quantity available and future quantity requirements.
2. A well-developed organizational structure that incorporates all categories of employee and clearly identify their line of hierarchy
3. Job specification and job description for each category of employee
4. Conduction of background verification of all potential employee. A documentary evidence of the same should be available. Verification of qualification and experience should be done for all, but most importantly for doctors, nurses and technicians
5. Availability of a policy and SOP of recruitment of employee, which outlines criteria for selection/rejection of an employee
6. An induction training plan and record of provision of induction training to all new recruits. The induction training should necessarily cover following topics
a. Vision, mission and values of the organization
b. Employee rights and responsibilities
c. Service standards of the organization
d. Organization wide policies
e. Relevant department specific policies
7. Availability of a documented training and development plan, along-with records of all training provided (like attendance sheet)
8. Conduction of training need assessment
9. Evaluation of training conducted and its record; such as trainees test result, feedback from HOD etc.
10. Availability of feedback from participants of the training and provision of these feedback to trainers
11. Training topics must cover all safety related topics such as risks within hospital, what to do in case of disaster, procedure to follow in case of an incident, occupational safety etc. (Suggested read - Disaster handling checklist for hospitals)
12. Having a documented policy and process of conducting performance appraisal of employee. Performance appraisal system should be based on identified and defined criteria
13. Having a documented policy and process of receiving employee grievance and redressing them
14. Having a grievance redressal committee as a final authority to take decisions on grievance related matters (Refer grievance redressal and disciplinary action committee under 'List of hospital committees and teams')
15. All employee must have their annual health check-up done, at-least
16. There should be a policy to take care of healthcare needs of the employee
17. There should be personnel file of each employee which must be updated and is kept confidential. It should contain information on
a. Staff’s qualification and experience
b. Background verification
c. Health status
d. Record of all in-service training and education availed by the staff
e. Results of all evaluations of the training
18. Availability of a credentialing and privileging policy for doctors
19. A document listing credentials (qualifications, experiences, certificates etc.) of each doctor associated with the hospital
20. For each doctor there should be a document that lists all the treatments and patient care activities that he/she has been permitted to undertake
21. Availability of a credentialing and privileging policy for nurses
22. A document listing credentials (qualifications, experiences, certificates etc.) of each nurse associated with the hospital
23. For each nurse there should be a document that lists all the nursing care activities that he/she has been permitted to undertake
Additional useful posts: How to prepare for accreditation
