HR-NABH 4TH EDITION

Standards Objective/Elements

1.The organisation has a a.Human resource planning

documented system of supports the organisation‘s
human resource planning. current and future ability to
meet the care, treatment and
service needs of the patient. *

b.The organisation maintains an

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

c.The required job specification

and job description are well
defined for each category of staff
*

d.The organisation verifies the

antecedents of the potential
employee with regards to
criminal/negligence background.
 2.The organisation has a a.There is a documented
documented procedure for procedure for recruitment. *
recruiting staff and
orienting them to the
organisation‘s environment.

b.Recruitment is based on pre-

defined criteria.

c.Every staff member entering

the organisation is provided
induction training.

d.The induction training includes

orientation to the organisation‘s
vision, mission
and values.

e.The induction training includes

awareness on employee rights
and
responsibilities.

f.The induction training includes

awareness on patient‘s rights
and responsibilities

g.The induction training includes

orientation to the service
standards of the
organisation
 h.Every staff member is made
aware of organisation‘s wide
policies and
procedures as well as relevant
department/unit/service/progra
mme‘s policies and
procedures.

3.There is an ongoing a. A documented training and

programme for professional development policy exists for the
training and staff. *
development of the staff.

b.The organisation maintains the

training record.

c.Training also occurs when job

responsibilities change/new
equipment is
introduced.

d.Evaluation of training
effectiveness is done by the
organisation

e.Feedback mechanisms are in

place for improvement of
training and
development programme.
 4.Staff are adequately a.Staff are trained on the risks
trained on various safety- within the organisation‘s
related aspects. environment.

b.Staff members can

demonstrate and take actions to
report, eliminate, or
minimise risks

c.Staff members are made aware

of procedures to follow in the
event of an
incident.

d.Staff are trained on

occupational safety aspects.

5.An appraisal system for a.A documented performance

evaluating the performance appraisal system exists in the
of an employee organisation. *
exists as an integral part of
the human resource
management process.

b.The employees are made

aware of the system of appraisal
at the time of
induction.

c.Performance is evaluated
based on the pre-determined
criteria.

d.The appraisal system is used as

a tool for further development.
 e.Performance appraisal is
carried out at pre-defined
intervals and is documented.

6.The organisation has a.Documented policies and

documented disciplinary and procedures exist. *
grievance handling policies
and procedures.

b.The policies and procedures

are known to all categories of
staff of the
organisation.

c. The disciplinary policy and

procedure is based on the
principles of natural justice.

d.The disciplinary and grievance

procedure is in consonance with
the prevailing
laws.

e.There is a provision for appeals

in all disciplinary cases

f.The redress procedure

addresses the grievance.
g.Actions are taken to redress
the grievance
7.The organisation addresses a. A pre-employment medical
the health needs of the examination is conducted on all
employees. the staff

b. Health problems of the

employees are taken care of in
accordance with the
organisation‘s policy.
 c. Regular health checks of staff
dealing with direct patient care
are done at least
once a year and the
findings/results are documented.

d. Occupational health hazards

are adequately addressed.

8.There is documented a. Personal files are maintained

personal information for with respect to all staff.
each staff member.

b. The personal files contain

personal information regarding
the staff‘s qualification,
disciplinary background and
health status.

c.All records of in-service training

and education are contained in
the personal
files.

d.Personal files contain results of

all evaluations.

9.There is a process for a. Medical professionals

credentialing and privileging permitted by law, regulation and
of medical the organisation to
professionals, permitted to provide patient care without
provide patient care without supervision are identified.
supervision.
 professionals, permitted to
provide patient care without
supervision.

b. The education, registration,

training and experience of the
identified medical
professionals is documented and
updated periodically.

c. All such information pertaining

to the medical professionals is
appropriately
verified when possible.

d. Medical professionals are

granted privileges to admit and
care for patients in
consonance with their
qualification, training,
experience and registration.

e. The requisite services to be

provided by the medical
professionals are known to
them as well as the various
departments/units of the
organisation.

f. Medical professionals admit

and care for patients as per their
privileging.
 10.There is a process for a. Nursing staff permitted by law,
credentialing and privileging regulation and the organisation
of nursing to provide patient
professionals, permitted to care without supervision are
provide patient care without identified.
supervision.

b. The education, registration,

training and experience of
nursing staff is
documented and updated
periodically.

c. All such information pertaining

to the nursing staff is
appropriately verified when
possible.

d. Nursing staff are granted

privileges in consonance with
their qualification,
training, experience and
registration.

e. The requisite services to be

provided by the nursing staff are
known to them as
well as the various
departments/units of the
organisation.

f. Nursing professionals care for

patients as per their privileging.
 HR-NABH 4TH EDITION 6/4/2018

Organisation Policy &

Interpretation Procedure AVAILABLE Evidence
YES/NO

This shall be done in a structured manner keeping in

mind the
hospital’s mission, volume and mix of patients,
services, and medical technology.
This is done with involvement of various stake holders
It shall use recognised
methods for determining levels of staffing.
It shall match the strategic and operational plan of
the organisation.

Yes

The staff should be commensurate with the workload

and the clinical requirement of the patients.
Whenever there is a shortfall of staff, contingency Man power
plans to meet workforce shortage exists. Nursing planning report
numbers shall be as per published guidelines. and budget
The content of each job should be well defined and
the qualifications, skills and experience required for
performing the job should be clearly laid down. The
job description should be commensurate with the
qualification.
Refer to glossary for definition of "job description‖
and ―job specification". For a job which requires the
skills of a doctor or a nurse the minimum qualification
shall be an MBBS and GNM degree respectively.

JDs have been

developed and
rolled out for
Yes all categories
The organisation can have a suitable methodology to
implement the same

Register for
antecendant
verification to
No be created
The recruitment process ensures an adequate
number and skill mix of staff to provide the
organisation‘s services. The procedure shall ensure
that the staff has the necessary registration,
qualifications, skills and experience to perform its
work.Recruitment is undertaken in accordance with
statutory requirements, where applicable.
Recruitment
Yes Policy
The laid-down recruitment procedure shall be
adhered to. The entire process shall be documented.
This shall ensure that the recruitment is done in a
transparent manner.

The organisation shall determine as to when

induction training shall be conducted. However, it
shall be within 15 days of the staff joining. Objective
elements ―d to ―g shall be covered in this training.
Similarly, all other requirements of this standard
could be covered. The contents of this training could
be provided to every staff in the form of a
booklet.There can be separate induction training at Induction
the organisational level and for the respective Training
departments. Yes Records
The organisation's staff including the outsourced staff
should be aware and should correctly interpret the
vision, mission and values of the organisation
Induction
Training
Records/Refres
her Training
Yes Records
Self-explanatory

Part of
Induction
Yes training

Part of
The employees should be able to identify and report Induction
violation of patient rights as and when it occurs. Yes training
The employees should be trained to implement the
service standards of the organisation

Part of
Induction
Yes training
The organisation's staff including the outsourced staff
should be aware and should correctly interpret the
policies and operating procedures of the organisation
as well as that of the department/ unit/ service in
which he is performing the requisite duties. It also
requires continuous on the job training to reinforce
the correct interpretation of policies and procedures.

A training manual incorporating the procedure for

identification of training needs, the training
methodology, documentation of training, training
assessment, impact of training and the training
calendar should be prepared. The training shall be for
all categories of staff including doctors and
outsourced staff (wherever applicable).

Yes T&D Policy

The HR department shall maintain a record of all

trainings provided. At a minimum, it shall include the
title of the training, the trainer(s), list of trainees
(with signatures). Where possible, the contents of the Individual
training may also be captured. Yes Training Record
The training should focus on the revised job
responsibilities as well as on the newly introduced
equipment and technology. In case of new
equipment, the operating staff should receive training
on operational as well as daily-maintenance aspects.
Departmental
Orientation
Yes Form

Training
feedback
mailed to all
stakeholders
after each
This shall include pre and post training documented Induction
evaluation. Yes training
This shall include both internal and external training.
Feedback includes collecting information on
appropriateness of course material, facilities for the
training program and capability of the trainer.

Feedback
Yes Forms
The organisation shall define such risks that shall
include patient, visitors and employee-related risks.
For example, fire and non-fire emergency,needle stick
injury, etc. In progress Safety training
Staff should be able to practically demonstrate
actions like taking care of blood spills, medication
errors and other adverse event reporting systems.

The staff should be able to intimate the sequence of

events that they will undertake in the eventuality of
occurrence of any adverse event.

The organisation shall identify the areas with

potential occupational hazards. Staff are made aware
of the possible risks involved and the preventive
actions to avoid risks. For example: Needle Stick
Injury and Blood/Body Fluid Exposure, radiation
exposure, chemotherapy exposure, noise in utility
areas.

This shall be done for all categories of employees

starting from the person heading the organisation
and including doctors who are employees. For
definition of "performance appraisal" refer to
glossary.

Performance
Appraisal
Yes Policy
This could be incorporated in the service booklet and
included in the induction training.

Part of
Induction
Yes training
Self-explanatory.

Yes

This can be done by identifying training requirements

and
accordingly providing for the same (wherever
possible). Key result areas are
identified for each staff and training need assessment
is also done.
Yes TNA
Self-explanatory. This shall be done at least once a
year. Yes
The documentation shall be done keeping in mind
objective elements ―c, d and e. For definition of
"disciplinary procedure" and "grievance handling"
refer to glossary.

Disciplinary &
Grievance
Yes handling policy
All the staff should be aware of the disciplinary
procedure and the process to be followed in case
they feel aggrieved
Part of
Induction
Yes training

This implies that both parties (employee and

employer) are given an opportunity to present their
case and decision is taken accordingly. Yes
Refer to relevant labour laws and CCS (CCA)
rules.Internal Complaints committee should also be
established in the organisation.

Yes

The organisation shall designate an appellate

authority to
consider appeals in disciplinary cases. Appellate
authority should be higher than
the disciplinary authority
Yes
Self-explanatory.
Yes
Actions that are taken shall be documented and
communicated to the aggrieved staff. Yes
This shall be in consonance with the law of the land.
For example, performing pre-employment HIV testing
without consent is illegal.
Health Check
Yes Reports
This shall be in consonance with the law of the land
and good clinical practices. For example: employee
health and safety policy.

Annual Health
Yes Checks
The results should be documented in the personal
file. The organisation could define the parameters
and it could be different for different categories of
personnel. The organisation could also identify
competent individuals to perform the same. The staff
member shall not be charged for this health check.

Appropriate personal protective equipment are

provided to the
staff concerned and they are educated on how to use
them. For definition of
"occupational health hazard" refer to glossary.

Each file must be current and updated. The

organisation maintains confidentiality and its access
are controlled. Documented policies and procedures
are needed for maintaining confidentiality and who
can have access to the personnel file.

Yes
Self-explanatory.

Yes

Self-explanatory. In case of internal trainings the

organisation could file a summary of all trainings
attended by the employee on an annual basis.
However, there shall be a supporting document to
verify that the employee has actually attended the
training. In case if the organisation maintains training
records elsewhere, traceability shall be provided in
the personal file to ensure that the intent of the
objective element is addressed. Yes Training Report
Evaluations would include performance appraisals,
training assessment and outcome of health checks.

Yes CR Reports
The organisation identifies the individuals who have
the required qualification(s), training and experience
to provide patient care in consonance with the law.
For definition of "credentialing" refer to glossary.
Update is done after acquisition of new skills and/or
qualification.

The organisation shall do the same by verifying the

credentials
from the organisation which has awarded the
qualification/training. A good
reference could be MCI's website.

The organisation shall identify services which each

medical
professional is authorised to do.
This shall be done based on qualification, experience
and any additional training
received.
For example, radiotherapy can only be given by a
radiation oncologist.

This could be done by internal communication.

A standardised format can be used for each faculty

and a norm
for providing privilege should be practised uniformly.
New faculty members can
be under proctorship till independent privileges are
provided. The organisation
could evolve a mechanism to ensure that medical
professionals are providing
only those services that they have been privileged to
offer.
The organisation identifies the individuals who have
the required
qualification(s), training and experience to provide
patient care in consonance
with the law. Refer to Indian Nursing Council Act,
1947.

Updation is done after acquisition of new skills and/or

qualification.

The organisation shall do the same by verifying the

credentials
from the organisation which has awarded the
qualification/training.

The organisation shall identify as to what each nurse

is
authorised to do. For example, an Infection Control
Nurse should have had
requisite in-house/external training and experience
and the aptitude and
knowledge to perform the tasks required of her.

This could be done by internal communication.

New staff members can be under the supervision till

independent
privilege is being provided for each staff. The
organisation could evolve a
mechanism to ensure that nursing professionals are
providing only those
services that they have been privileged to offer.
Organisation
Policy & SCORE 0-5-
Procedure EVIDENCE 10/10
IMPLIMENTED
YES/NO

Yes

manpower

No Deadline- 16th April

Yes
Yes Old Desktop HR Data\Sahana\Policies & Formats\Final Policies\Training and Development of Staff-Edited.d

Yes Training Formats\Training Card JSSH.doc

Yes Old Desktop HR Data\Sahana\Policies & Formats\Departmental Orientation Form.doc

Training Formats\Training Analysis\Feedback analysis- Mar 18.pdf

Yes
 Deadline- 16th April

Yes Old Desktop HR Data\Sahana\Policies & Formats\Final Policies\Performance Appraisal-Policy.doc

Yes Training Formats\TNA JSSH.xls

Yes Old Desktop HR Data\Sahana\Policies & Formats\Final Policies\New folder\Grievance Handling Mechanism

Yes
Yes

Yes

Yes