B.
G Hospital, Tiruchendur
Document Name: HR procedure
Document No.: NABH/SHCO/ BG /
No. of Pages:
Date Created:
Date of Updated:
NABH CO ORDINATOR
Name
Prepared By: Signature
Designation: Medical Director
Name Dr. A. Ramamurthy, M.D
Signature:
Approved & Controlled By:
1
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
AMENDMENT SHEET
Sl. Section no Details of the Reasons Signature of the Signature
No. & Page no Amendment preparatory of the
authority approval
authority
CONTROL OF THE MANUAL
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
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.
NABH Co-ordinator 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.
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
Manager Medical Director NABH Co -ordinator
B.G Hospital
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 Manager
3 NABH Co-ordinator
4 Relevant Department
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
1. PURPOSE
To define Policy & Procedure for
2. SCOPE
This Policy & procedure is applicable to patient who undergoes.
Procedure
Policy and procedure Grievance handling
Definition: Grievance includes complaint pertainning to violation of-
1. The contract
2. A Statutory requirement.
3. A past Practice
4. The employee’s right.
Procedure:
1. The witness who has seen the violence or experienced it will inform the same to the administrator.
2. The witness gives a complaint in written to the administrator.
3. The incident is submitted to the multidisciplinary community.
4. On the basis of review of the incidence action is taken.
5. If the violation is organizations rules and a past practice a memo is issued and if the violation of law
the police complaint is laughed.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
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Policy and procedure Human Resource Planning
Aim:
1. To acquire ,provide retain and maintain competent people in right numbness to meet the needs of the
patients and community severed by the organization.
Procedure Human resource Planning:
1. Deciding goals objective for a short term goal (For Year) which will maximize the future return on
investment in human resources.
2. Estimating future organizational structure and manpower requirement - It is an Comparison of desired
organizational structure and the existing organizational structure -it includes new strategies profit
projections and
3. Human Resolve audit- Auditing each employee’s , skills abilities.
4. Job Analysis: After deciding the desired Manpower, a job analysis is improved . It includes job
description and job specifications.
5. Human resource Planning:
Specific roles
Competencies and Capabilities needed.
Manpower hiring
Internal / External Sourcing.
Training
In case of Surpluses planning for deployment.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Succession on planning and for key positions in the company.
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Policy and Procedure of Training:
Aim: To address the training and development of staff.
Procedure:
Identification of training needs.
Direct method and observation -Detail task analysis.
Use of questionarrie and
Interviews / Records / feedback of supervisions.]
Attitude Surveys
Address to SOP (Standard operating protocol)
Task Analysis:
Execution of Internal training programs.
1. The data of training needs is submitted to top management.
2. Top management approves it ( If require budget)
3. The personal department frames and plans and the training.
4. The incharge / Supervision evaluate the effectiveness of training at place.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
5. Feedback is taken from the employees.
Teaching Methods:
1. Presentations
2. Lectures / Group discussions
3. Supportive documents for demoes
External Programs:
1. Evaluate the need of training among the employees.
2. Select the employees who should attend it.
3. Get the approval of Top Management.
4. Calculate the cost of training.
5. Keep records / Certificates.
Training Records:
1. Various training records are kept in HR department.
2. Every employee has her own file which contains her /his training schedule , training records calender.
1st Monday and month- New staff orientation.
Infection Control: - Once in a month - Nurses / Technicians
CPR- Once in a month- Nurses.
General training for all staff for hospital rules - once in a month
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
Topics for training:
1. Induction Program
2. risk in hospital / risk management/ Occupational health hazards
3. Job responsibilities changes / New equipment introduced.
4. Hospital rules.
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Policy for addressing health problems:
Aim: To address the health problems of employee at the time of joining.
Rationale:
Procedure:
Pre-employment Check-up includes:
HB/ CBC
Chest X-Ray
Physical fitness.
Hospital Policy Manual Policy and Procedure on
Registration
NABH SHCO 3nd Edition Standard NABH/SHCO/ BG /
Reference:
Policy /Version No/ Issue Date NABH/ / Ver. No 2/
ECG
Vision test
Pregnancy test
OPD/ IPD Facilities provided by hospital
· The employee is permitted to see a doctor in the hospital on OPD basis in 50 % discount.
· If employee needs admission.
Employee has to pay pharmacy, lab and CT –MRI + 50 % of the bill remained.
Pre-employment for Hope Hospital:
1. I undersigned ___________ agree to undergo the following tests, as per the policy of the hospital to
join it.
HB/ CBC
Chest X-Ray
Physical fitness.
ECG
Vision test
Pregnancy test( for married staff)
I undersigned Dr. ________ states that the above mentioned employee is fit to join the
