NABH Standards - HRM

Hindu Mission Health Services
Chennai
D HUMAN RESOURCES MANAGEMENT
ocument Name :
Document No : E/NABH/ HMHS / HRM / 1
No. of Pages: 16
Date of Created : 31.10.2016
Date of Implementation 01.11.2016
Designation: Director
Prepared By : Name: MRS.USHA KRISHNAMOORTHY
Signature :
Designation: Medical Director
Approved By : Name DR.Y.V.S SHIVKUMAR
Signature :
Designation: Accreditation Coordinator
Issued By : Name; MR.MEENAKSHI SUNDARAM
Signature :
HMHS HOSPITAL HMHS/NABH-E/HRM
Issue No. 01
POLICIES & PROCEDURES ON HUMAN 00
RESOURCES ANAGEMENT 01.11.2017
Page 1 of 18
AMENDMENT SHEET
S.no Section no Details of the amendment Reasons Signature of Signature of

& page no the the approval
preparatory authority
authority
CONTROL OF THE MANUAL
The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a
readily identifiable and retrievable mode.
The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as
and when the amended versions are received.
DIRECTOR is responsible for issuing the amended copies to the copy holders; the copyholder should
`acknowledge the same and he /she should return the obsolete copies to the Medical Director.
The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.
Issue No. 01
Page 2 of 18
The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures.
Review and amendment can happen also as corrective actions to the non-conformities raised during the
self-assessment or assessment audits by NABH. The authority over control of this manual is as follows:
Preparation Approval Issue
DIRECTOR Medical Director NABH coordinator
The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’, and the
photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.
Distribution List of the Manual:
Sr. No. Designation

1 Medical Director
2 DIRECTOR
3 NABH Co-ordinator
1.0 INTRODUCTION:
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.
2.0 PURPOSE:
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2.1 To plan the right mix of manpower for the Hospital in line with the volume of scope of the
services being provided by the hospital
2.2 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 organization.
2.3 To ensure that employees are selected, trained, promoted and treated on the basis of their
relevant skills, talents and performance without any discrimination as per the requirement of
the organization.
2.4 To provide a clean, safe, healthy, professional and enjoyable working environment.
2.5 To motivate employees through performance appraisal and reward system and build
confidence among staffs.
2.6 To provide training and development for all the employees to enable them to achieve the
highest level of skills possible and provide job satisfaction to a large extent.
3.0 SCOPE:
3.1 The manual covers the following:
3.1.1 Manpower planning
3.1.2 Recruitment and selection, and placement
3.1.3 Joining induction
3.1.4 Training & Development
3.1.5 Performance appraisal, promotion and incentives, transfers
3.1.6 Employee discipline and grievance redressal
3.1.7 Employee Health care & Occupational Hazards
3.1.8 Employee personal file maintenance
4.0 ABBREVIATIONS:
4.1 HR : Human Resource
4.2 IT : Information Technology
5.0 DEFINITIONS
5.1 Human Resources Department: Shall mean the ‘Department having charge of the HR function
of the hospital’.
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6.0 PROCEDURES:
6.1 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 HR in-charge provides 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, Patient Counsellors, Maintenance
staff, Housekeeping staff (both in-house & contractual), ward boys / ayahs, other hospital
workers, etc.
6.2 Workforce Planning (Non-Medical):

6.2.1 Responsibility for manpower planning for the hospital rests with HR department and
ensures availability of the right mix of manpower required to provide quality
healthcare services taking in to consideration the patient load, number of beds,
number and type of procedures, type and level of care, specializations, infrastructure
etc.
6.2.2 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.
6.2.3 In case any new staff is required to affect continuity of care either directly or indirectly,
the same is communicated to the Head Human Resources who is responsible for the
approval and provision of the required manpower.
6.2.4 Based on the requirements of additional manpower of the individual departments, the
detailed manpower plan for the financial year will be prepared by HR in-charge for the
institution as a whole giving specific details of each new post other than casual posts.
6.2.5 And this manpower plan containing details of expenditure involved and will form a
part of the overall Manpower Budget for hospital.
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6.2.6 Annual manpower plans including the additional manpower requirements along with
all relevant details and estimated cost involved for all the department will be
consolidated into an integrated Institution Manpower Plan which will form a part of
the annual budget to be submitted for approval to the MS.
6.2.7 On approval by the MS, these manpower plans will constitute sanction for creation of
posts including posts of trainees and form the general basis of recruitment during
following financial year.
6.3 Manpower Planning (Recruitment, Selection & Induction):
6.3.1 While merit would be the main criteria for filling up a vacant position, seniority and
past performance shall be kept in mind.
6.3.2 For filling up position at higher levels, employees of the Hospital shall be given
preference and would be considered before outside sources are tapped.
6.3.3 The mix of the employees shall be cosmopolitan.
6.3.4 The best available talent would be absorbed without giving any consideration to
region, religion or race.
6.3.5 All recruitment excepting Doctors and Nurses shall be done through HR Department.
6.4 Induction Policy:
6.4.1 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.
6.4.2 It gives maximum relevant information to the new employees in shortest time.
6.4.3 It eliminates the feeling of the uneasiness, apprehensions etc. in the new employee.
6.4.4 It enhances the image of the hospital as people friendly.
6.4.5 It helps reducing the turnover of the employees.
6.5 Training Policy:

6.5.1 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.
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6.5.2 A complete Training Programme is developed for each category of employee. The
hospital conducts induction training, regular on job training and mock drills. The HR
manager, Respective departmental Head decides the contents of the Training
programmes. This is reviewed once in a year.
6.5.3 Induction: This training is provided to all the new recruits at the time of joining. This
training generally introduces the employee to the hospital’s philosophy, Vision,
Mission, hospital policies and procedures, employees Job Description etc.
6.5.4 On Job Training: On-job training is imparted as per training schedule. Training
schedule is prepared in the beginning of the year for every category of employee.
The training includes management of various risks associated with the care
environment. Nursing staff, OT/ICU staff, housekeeping staff, laboratory staff, imaging
dept. staff, laundry & linen staff, etc., are trained on infection control practices that
include needle stick injury, hand wash practices, use of appropriate personal
protective equipments (PPEs), injection & infusion practices, bio-medical waste
management practices.
6.5.5 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 and equipment etc.
6.5.6 Advancement/introduction/change in Technology / equipment: All concerned
employee will be provided training to upgrade them to such situation. In case of
installation of new equipment training is also provided by the Service/installation
Engineer to all the concerned staff
6.5.7 Mock Drills: Mock drills are 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.
6.5.8 Training Methodology: Training shall be done by issuing manuals to the employees.
Basic training manual is issued to every class of employee. Training is also imparted
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by PowerPoint presentations, lectures and drills. The training imparted is

documented in training register maintained by HR department. The training is also
documented in training formats for each employee, dated and duly signed by the
employee and the HR Personnel.
6.6 Sexual Harassment Policy:
6.6.1 The Hospital policy is to totally prohibit any form of sexual harassment in the way
employees behave with each other.
6.6.2 This applies equally to relations between superior and subordinates as well as
between peers.
6.6.3 Any incident of sexual harassment will be viewed extremely serious.
6.6.4 A complaint or report of sexual harassment will be immediately investigated and
appropriate action will be taken against the offending employee or employees.
6.6.5 Such action will depend on the nature and seriousness of the offense and will include
strict disciplinary action including termination of service.
6.7 Attendance & Working Hours:
6.7.1 Working Hours: Employee in all departments / sections of the Hospital shall work for
72 hours a week which includes their Lunch Break
6.7.2 Attendance: All employee working in the wards shall punch their Attendance cards to
the manager.
6.7.3 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 casual leave. For those who
report late for more than 35 minutes, will be considered as half a day casual leave.
6.7.4 Identification: All the employees are required to display the Identity Cards on their
person while on duty.
6.7.5 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/
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unauthorized absenteeism the management shall take suitable disciplinary action in

accordance with the law
6.8 Employee Personal Record Policy:
6.8.1 An employee’s personal file is maintained by the HR department.
6.8.2 The employee can access to his / her Records by a written Request to the Jt. Director-
HRD & Personnel.
6.8.3 Once an employee leaves the organization or on cessation of his/her employment,
the employee’s file will be labeled as Ex-employee file.
6.9 Performance Appraisal:

6.9.1 Annual appraisals are done every year on basis of performance of every employee.
6.9.2 The appraisals are done for the employees who have completed at least one year of
continuous service from the date of Joining.
7.0 PROCEDURES:
7.1 Workforce Planning:
7.2 Classification Of Employee:
7.3 Manpower Planning (Recruitment, Selection & Induction):
7.3.1 Manpower requirements of each department/section of the Hospital shall be
determined by proper work study done. The manpower requirements so arrived,
after approval of Medical Director shall constitute the approved strength of the
department/section and shall form the basis of annual manpower planning of the
department/section. All recruitment shall be as per the approved strength of each
department/section.Medical DirectorAny department desirous of filling an approved
vacancy, shall send a requisition to the HRD department in the prescribed Requisition
Form in duplicate. In case any approved position is required to be filled, the final
approving authority shall be the Manager- (HRD & Personnel). It shall be the
responsibility` of HRD Department to ensure that the request is within the approved
strength of the department/section.
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7.3.2 After the receipt of the approved requisition, HRD Department would attempt to
locate a person from the HRD database. In case of non-availability of a suitable
person from the Internal sources, outside agencies like advertisements, recruitment
agencies, educational institutions, personal contacts would be used.
7.3.3 Care must be taken that all recruitment exercise is done at a minimum cost and time.
7.3.4 Interview Call: All interview call letters shall be sent by the HRD Department.
7.3.5 Selection Process: Shortlisting of all ‘CV’ shall be done by the HR Department with
active involvement of the Departmental Head. 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. All
arrangements for interviews shall be carried out by the HR department with
involvement of Director/General Manager- (HRD & Personnel)-
7.3.6 Recruitment Interview Panels: Medical Director / Managers-(HRD & Personnel) .
7.3.7 Checkup of Antecedents and References: All appointments/confirmation shall be
given within 7 days of conducting interview. Reference check-ups shall be made for
employees recruited at senior levels except Manual Workers and also for those
employees who are recruited at sensitive jobs.
7.3.8 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 favourably medical reports. Acceptance of appointment
would be obtained on the duplicate copy of the appointment letter before a person
joins.
7.3.9 Joining Formalities: Every employee on joining would be required to fill up the
following forms: Joining Report. Employment Application Form. P.F. Nomination
Form. Four Passport size photograph. Selected candidates should submit complete
CV with proper address. Signature of the Interview Panel shall be taken on the CV of
the selected candidate immediately. Selected candidate should submit all certificates,
should be verified with all original certificates. To issue Offer Letter.
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7.3.10 Before joining candidate should submit the following documents:- For address
proof:(any one) Telephone Bills/Electricity Bills or any similar document. If married,
Marriage Certificate / Gazetted copy of change of name. Date of Birth proof. Copy of
PAN card / Election Card/Driving License for Identity Proof. Relieving letter from the
previous organization. Experience Certificate from two previous organization.
7.3.11 Induction Training: Notice regarding joining, designation and previous experience
etc., for every non-medical Supervisory/Managerial employee, would be put up at all
locations of the Hospital by the Medical Director / Managers-(HRD & Personnel). A
copy of the notice shall be marked to all Directors. All new employees will be
compulsorily require to undergo induction training. Communication of the Hospital’s
mission/values shall be carried out to all new employees during their induction
period.
7.3.12 Probation: All employees would be appointed on a probation of Six months. During
this period performance would be reviewed. The performance review shall be
initiated by the Manager (HRD Department). Confirmation of the services of
employees would be done in writing 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.
7.3.13 Reference Checking: The HRD Department will verify the information submitted by
him in the application, from previous employer of the new employee.
7.3.14 Exit Interviews: All employees planning to leave the services of the organisation
would be called for an Exit Interview. Exit interviews shall be carried out in case of
Managers / Officers by the Panel members as listed. The main point of the discussion
would be noted and forwarded to the Medical Director / Managers-(HRD &
Personnel). In case any pattern is noticed it shall be brought to the notice of the
Management.
7.3.15 Appointment Of Temporary Employees: All temporary appointments shall be made
with the approval of Medical Director/ Managers-(HRD & Personnel).
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7.3.16 EMPLOYEES’ RIGHTS AND RESPONSIBLITIES: EMPLOYEE RIGHTS: Right to receive an

appointment letter from the organization. Right to receive salary number and
I.D.Card. Right to get Remuneration and other benefits, which the employee is
entitled to receive. Right to receive sufficient and reasonable recourses / facilities
from the Hospital for performing his / her duties. Right to receive Training and
Education on Hazards in the Hospital and in the concerned department. Right to
express grievance and have the appropriate authority considers the grievance.
7.3.17 Duty Hours & Shift Working: The rules regarding hours of work, shift, weekly
holidays, rest intervals, spread-over 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. If an employee changes shift on his own
appropriate disciplinary action will be taken.
7.3.18 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. Each employee will be allowed 20 minutes grace time
thrice a month; thereafter, 1 leave (CL and, or PL) will be deducted.
7.3.19 Performance Appraisal: The Management will appraise and maintain performance
record of the employees periodically or as and when required. Normally the
performance of employees will be appraised before confirmation and thereafter
before granting annual increments. The Management will appraise the performance
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of employees in such format and manner as may be decided by the Management

from time to time and the conclusion of such appraisal shall be final and binding
upon all concerned. Any grievance arising out of the appraisal process can be taken
up with the HRD Manager for further action. All promotions, demotions, up
gradations, transfers, annual increments, will also be effected on the basis of
performance appraisal ratings and other factors of suitability relevant for any
position or post or work. Subject to terms and conditions of the settlement with
Union.
7.3.20 Training: In order to improve an employee’s performance, the management may
require him to undergo any training program for a minimum period of 25 hours every
year. At times and at the discretion of Management, an employee may be sponsored
for full or part – time training program outside the organization. If the Management
is of the opinion that both the employee and the Hospital will derive benefit from
such a programme, the Hospital may offer to bear a part of or the whole expenses
that may be incurred by the employee for the training program. An Employee
deputed for such training may be required to execute an agreement on such terms
and conditions, as the Management may deem necessary.
7.3.21 Promotion: The Management will promote only qualified and eligible employees to
higher positions when vacancies arise in such higher cadre. Promotions will be
effected strictly on the basis of merit, efficiency, oral test / written test and suitability
for para-medical staff and for other categories wherever applicable on the basis of
past record of service, performance, requisite skills, seniority, state of health and
suitability of the employee. The suitability of an employee for promotion will be
decided solely by the Management. If the employee’s performance is not found
satisfactory during or at the end of the training period, the employee will be reverted
to his earlier position, which he has held immediately prior to his promotion, with
pre-promotional salary and benefits. Upon promotion or regularization, the
employee will be granted such benefit and increase in wages as may be decided by
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the management. The management’s decision on promotions shall be final and

conclusive.
7.3.22 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 Head - HRD or any other
person duly authorized in this behalf. The employees shall exhaust the above
procedure before resorting to any legal remedy.
7.3.23 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 absolutely
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 getting 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
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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 equipment’s. Always remember to use handrails on
stairways or ramps. 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.
7.4 Employee Personal Record:
7.4.1 Employee’s Personal Records contains:
7.4.1.1 Job Description,
7.4.1.2 Employee Personal Profile/ Complete CV,
7.4.1.3 Interview assessment sheet (signed by all panel members),
7.4.1.4 Employee’s Documents supporting his/her Educational Qualification in
the order-Matriculation, Inter, Degree, Post Graduation, Professional
courses,
7.4.1.5 Special training,
7.4.1.6 Age proof (photocopy),
7.4.1.7 Employee’s Photograph (Three copies);
7.4.1.8 Photo Identity Proof (photocopy),
7.4.1.9 Address Proof (photocopy),
7.4.1.10 PAN Card (photocopy),
7.4.1.11 Pre-employment health check-up Reports,
7.4.1.12 Duly filled and signed Offer Letter with CTC detail,
7.4.1.13 Duly filled and signed Joining Letter and Appointment Letter,
7.4.1.14 Experiences Certificates of previous organisation (photocopies),
7.4.1.15 Relieving letter from previous organization of the employee,
7.4.1.16 Employee Identity/Employment No.;
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7.4.1.17 Employee Service Record Form,

7.4.1.18 Criminal antecedent form filled by the selected candidate,
7.4.1.19 Service bond (if any),
7.4.1.20 Disciplinary action taken,
7.4.1.21 Duly signed Training schedule for the employee;
7.4.1.22 Performance evaluation reports.
7.5 Performance Appraisal:
7.5.1 The appraisal forms is generated by HR Department and sent to the respective
Managers/ HOD concerned.
7.5.2 The filled in forms are expected to reach HR Department within 30 days, to enable us
to decide about any increment / promotion.
7.5.3 Increments / Promotions may be given to employees based on the overall ratings /
recommendations.
7.5.4 However this is not mandatory and is purely based on Management’s discretion and
also subject to terms and conditions mentioned in the settlement.
7.5.5 Different kinds of performance indicators are used for different categories of Person.
7.5.6 Responsibility of Applicant: Documents to be submitted: It is the responsibility of
the applicant to return a signed, dated, and fully completed application and request
for clinical privileges with the following:
7.5.6.1 Copies of certificates showing evidence of completion of education and
training, if available.
7.5.6.2 Copy of Degrees.
7.5.6.3 Current and dated curriculum vitae (month/year format) outlining
education
8.0 RECORDS:
8.1 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.
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S.no Title Responsibility Code Retention

Period
1 Attendance register Manager HMHS /REG/HR/1. 6 Months
2 Time attendance register Manager HMHS /REG/HR/2. 6 Months
3 Training register Manager HMHS /REG/HR/3. 6 Months
4 Vaccination Register Manager HMHS /REG/HR/4. 6 Months
9.0 TRAINING:
9.1 All new joining staff shall be oriented to the department by the Head of the department.
9.2 Training needs of the staff is assessed by the head of the department based on the
performance of staff.
10.0 Occupational Health Hazard
10.1.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. Eg: Doctors,
Nurses, Laboratory staff, HK staff, Maintenance staff and biomedical engineers. The register is maintained in
the HR department
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NABH Standards - HRM

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Hindu Mission Health Services

D HUMAN RESOURCES MANAGEMENT

Document No : E/NABH/ HMHS / HRM / 1

Date of Created : 31.10.2016

Date of Implementation 01.11.2016

Prepared By : Name: MRS.USHA KRISHNAMOORTHY

Designation: Medical Director

Approved By : Name DR.Y.V.S SHIVKUMAR

Designation: Accreditation Coordinator

Issued By : Name; MR.MEENAKSHI SUNDARAM

S.no Section no Details of the amendment Reasons Signature of Signature of

CONTROL OF THE MANUAL

Preparation Approval Issue

DIRECTOR Medical Director NABH coordinator

Distribution List of the Manual:

Sr. No. Designation

6.2 Workforce Planning (Non-Medical):

6.5 Training Policy:

by PowerPoint presentations, lectures and drills. The training imparted is

unauthorized absenteeism the management shall take suitable disciplinary action in

6.9 Performance Appraisal:

7.3.16 EMPLOYEES’ RIGHTS AND RESPONSIBLITIES: EMPLOYEE RIGHTS: Right to receive an

of employees in such format and manner as may be decided by the Management

the management. The management’s decision on promotions shall be final and

7.4.1.17 Employee Service Record Form,

S.no Title Responsibility Code Retention

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