NABH MASTER CLASS
ON
UPGRADATION & MIGRATION TO
NABH 6TH EDITION
CHAPTER-9: HRM
ACME CONSULTING
Training Sessions for NABH 6th Edition
NABH STANDARDS – DISTRIBUTION OF “OEs”
Chapters STDs. OBJECTIVE ELEMENTS (OEs)
Core Commitment Achieve- Excellence Total OE
ment
AAC 13 6 68 9 4 87
COP 20 13 107 12 4 136
MOM 11 13 48 6 1 68
PRE 8 13 32 6 1 52
IPC 8 13 34 2 0 49
PSQ 7 8 27 7 4 46
ROM 5 4 21 9 3 37
FMS 7 11 29 2 1 43
HRM 13 16 55 5 0 76
IMS 7 9 33 2 1 45
TOTAL 100 105 457 60 17 639
Core & Commitment OEs are mandatory min. requirements For Surveillance For Re-Accreditation
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 2
Training Sessions for NABH 6th Edition
CHAPTER-9: HUMAN RESOURCES MANAGEMENT (HRM)…
STANDARD OBJECTIVE ELEMENT (OE)
HRM.1. The organisation has a documented system of human
resource planning.
HRM.2. The organisation implements a defined process for staff
recruitment.
HRM.3. Staff are provided induction training at the time of joining
the organisation.
HRM.4. There is an on-going programme for professional training
and development of the staff.
HRM. 5. Staff are appropriately trained based on their specific job
description.
HRM.6. Staff are trained in safety and quality-related aspects.
HRM.7. An appraisal system for evaluating the performance of
staff exists as an integral part of the human resource
management process.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 3
Training Sessions for NABH 6th Edition
CHAPTER-9: HUMAN RESOURCES MANAGEMENT (HRM)..
STANDARD OBJECTIVE ELEMENT (OE)
HRM.8. Process for disciplinary and grievance handling is
defined and implemented in the organisation.
HRM. 9. The organisation addresses their health and safety needs
of the staff.
HRM.10. There is documented personal information for each staff
member.
HRM.11. There is a process for credentialing and privileging of
medical professionals, permitted to provide patient care
without supervision.
HRM.12. There is a process for credentialing and privileging of
nursing professionals, permitted to provide patient care
without supervision
HRM.13. There is a process for credentialing and privileging of
para-clinical professionals, permitted to provide patient
care without supervision.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 4
Training Sessions for NABH 6th Edition
HRM.1. The organisation has a documented system of
human resource planning.
C a Human resource planning supports the organisation’s
current and future ability to meet the care, treatment
and service needs of the patient. (Slide:6)
Core b The organisation maintains an adequate number and mix
of staff to meet the care, treatment and service needs
of the patient. (Slides: 7, 8)
A c The organisation has contingency plans to manage long-
and short-term workforce shortages, including
unplanned shortages.
C d The job specification and job description are defined
for each category of staff. * (Slide:9)
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 5
Training Sessions for NABH 6th Edition
HRM.1. The organisation has a documented system of
human resource planning.
C e The organisation performs a background check of the
new staff.
C f Reporting relationships are defined for each category
of staff. *
A g Exit interviews are conducted and used as a tool to
improve human resource practices.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 6
Training Sessions for NABH 6th Edition
HRM.2. The organisation implements a defined process
for staff recruitment.
Core a Written guidance governs the process of recruitment. *
(Slide: 12)
C b A pre-employment medical examination is conducted on
the staff.
Core c The organisation defines and implements a code of
conduct for its staff. (Slide: 13)
C d Administrative procedures for human resource
management are documented. *
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 7
Training Sessions for NABH 6th Edition
HRM.3. Staff are provided induction training at the time
of joining the organisation.
Core a Staff are provided with induction training.
C b The induction training includes orientation to the
organisation’s vision, mission and values. (Slides: 15,16)
C c The induction training includes awareness on staff
rights and responsibilities and patient rights and
responsibilities.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 8
Training Sessions for NABH 6th Edition
HRM.3. Staff are provided induction training at the time
of joining the organisation.
C d The induction training includes training on safety.
C e The induction training includes training on cardio-
pulmonary resuscitation for staff (providing direct
patient care – BLS; For all Doctors and Nursing: ACLS;
PALS / Neonatal Resuscitation Program (NRP).
C f The induction training includes training in hospital
infection prevention and control.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 9
Training Sessions for NABH 6th Edition
HRM.3. Staff are provided induction training at the time
of joining the organisation.
C g The induction training includes orientation to the
service standards of the organisation. (Slides: 19, 20)
C h The induction training includes orientation on
administrative procedures.
C i The induction program includes an orientation on
relevant department / unit / service / programme’s
policies and procedures.
C j Staff is trained on information systems, information
security, information use and management. (New)
(Slide: 21)
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 10
Training Sessions for NABH 6th Edition
HRM.4. There is an on-going programme for professional
training and development of the staff.
Core a Written guidance governs training and development
policy for the staff. * (Slides: 23, 24)
C b The organisation maintains the training record. (Trg.
Contents, training attendance)
C c Training also occurs when job responsibilities change/
new equipment is introduced.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 11
Training Sessions for NABH 6th Edition
HRM.4. There is an on-going programme for professional
training and development of the staff.
C d Feedback mechanisms are in place for improvement
of training and development programme.
A e Evaluation of training effectiveness is done by the
organisation. (Slide: 26)
A f The organisation supports continuing professional
development and learning. (Slide: 27)
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 12
Training Sessions for NABH 6th Edition
HRM.5. Staff are appropriately trained based on their
specific job description.
C a Staff involved in blood transfusion services are
trained in the handling of blood and blood products.
C b Staff are trained in handling vulnerable patients.
C c Staff are trained in control and restraint
techniques.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 13
Training Sessions for NABH 6th Edition
HRM.5. Staff are appropriately trained based on their
specific job description.
C d Staff are trained in healthcare communication
techniques. (Slides: 30 To 34)
Core e Staff involved in direct patient care are provided
training on cardiopulmonary resuscitation
periodically.
C f Staff are provided training on infection prevention
and control.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 14
Training Sessions for NABH 6th Edition
HRM.6. Staff are trained in safety and quality-related
aspects.
C a Staff are trained on the organisation’s safety
programme. (Slides: 36,37)
C b Staff are provided training on the detection,
handling, minimisation and elimination of identified
risks within the organisation's environment.
C c Staff members are made aware of procedures to
follow in the event of an incident. (Slides: 38,39)
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 15
Training Sessions for NABH 6th Edition
HRM.6.c. Staff are made aware of procedures to
follow in the event of an incident..
Procedures in case of an incident:
Incident Reporting. Medication Error Reporting. Adverse Drug
Reactions. Nosocomial Infection Reports. Facility Safety
Surveillance
Any incident in the hospital should be investigated by the
Hospital Safety Committee and the report would be forwarded
to the higher authority for further action.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 16
Training Sessions for NABH 6th Edition
HRM.6. Staff are trained in safety and quality-related
aspects.
C d Staff are trained on occupational safety aspects.
Core e Staff are trained in the organisation's disaster
management plan.
Core f Staff are trained in handling fire and non-fire
emergencies.
C g Staff are trained on the organisation's quality
improvement programme.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 17
Training Sessions for NABH 6th Edition
HRM.7. An appraisal system for evaluating the
performance of staff exists as an integral part of the
human resource management process.
C a Performance appraisal is done for staff within the
organisation.*
C b The staff are made aware of the system of
appraisal at the time of induction.
C c Performance is evaluated based on the pre-
determined criteria.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 18
Training Sessions for NABH 6th Edition
HRM.7. An appraisal system for evaluating the
performance of staff exists as an integral part of the
human resource management process. (Old HRM.5).
C d The appraisal system is used as a tool for further
development. (Slides: 43 To 46)
C e Performance appraisal is carried out at defined
intervals and is documented.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 19
Training Sessions for NABH 6th Edition
HRM.8. Process for disciplinary and grievance handling is
defined and implemented in the organisation.
C a Written guidance governs disciplinary and grievance
handling mechanisms. *
C b The disciplinary and grievance handling mechanism
is known to all categories of staff of the
organisation.
C c The disciplinary policy and procedure are based on
the principles of natural justice.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 20
Training Sessions for NABH 6th Edition
HRM.8. Process for disciplinary and grievance handling is
defined and implemented in the organisation.
Core d The disciplinary and grievance procedure is in
consonance with the prevailing laws. (Slides: 49 To
51)
C e There is a provision for appeals in all disciplinary
cases.
C f Actions are taken to redress the grievance.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 21
Training Sessions for NABH 6th Edition
HRM.9. The organisation addresses their health and
safety needs of the staff..
C a Health problems of the staff, including occupational
health hazards are taken care of in accordance
with the organisation’s policy.
C b Health checks of staff dealing with direct patient
care are done at least once a year and the
findings/results are documented.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 22
Training Sessions for NABH 6th Edition
HRM.9. The organisation addresses their health and
safety needs of the staff.
C c Organisation provides treatment to staff who
sustain workplace-related injuries.
Core d Organisation has measures in place for prevention
and handling workplace violence.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 23
Training Sessions for NABH 6th Edition
HRM.10. There is documented personal information for
each staff member.
C a Personal files are maintained with respect to all
staff, and their confidentiality is ensured. (Slides:
55, 56)
C b The personal files contain personal information
regarding the staff’s qualification, job description,
verification of credentials and health status.
C c Records of in-service training and education are
maintained.
C d Personal files contain results of all evaluations and
remarks.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 24
Training Sessions for NABH 6th Edition
HRM.11. There is a process for credentialing and
privileging of medical professionals, permitted to provide
patient care without supervision.
Core a Medical professionals permitted by law, regulation and
the organisation to provide patient care without
supervision are identified. (Slide: 58)
C b The education, registration, training and experience
of the identified medical professionals are
documented and updated periodically.
C c The information about medical professionals is
appropriately verified when possible.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 25
Training Sessions for NABH 6th Edition
HRM.11. There is a process for credentialing and
privileging of medical professionals, permitted to provide
patient care without supervision.
Core d Medical professionals are granted privileges to admit
and care for patients in consonance with their
qualification, training, experience and registration.
(Slides: 60 To 65)
C 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.
C f Medical professionals admit and care for patients as
per their privileging.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 26
Training Sessions for NABH 6th Edition
HRM.12. There is a process for credentialing and
privileging of nursing professionals, permitted to provide
patient care without supervision.
Core d Nursing staff are granted privileges in consonance
with their qualification, training, experience and
registration. (Slides: 68 To 70)
C 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.
C f Nursing professionals care for patients as per their
privileging.
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 27
Training Sessions for NABH 6th Edition
HRM.13. There is a process for credentialing and
privileging of para-clinical professionals, permitted to
provide patient care without supervision.
Core a Para-clinical professionals permitted by law, regulation
and the organisation to provide patient care without
supervision are identified.
C b The education, registration, training and experience
of Para-clinical professionals is appropriately
verified, documented and updated periodically.
Core c Para-clinical staff are granted privileges in consonance
with their qualification, training, experience and
registration. (Slides: 72 To 75)
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 28
Training Sessions for NABH 6th Edition
HRM.13. There is a process for credentialing and
privileging of para clinical professionals, permitted to
provide patient care without supervision.
C d The requisite services to be provided by the para-
clinical staff are known to them as well as the
concerned departments / units of the organisation.
C e Para-clinical staff care for patients as per their
privileging. (Slide: 77)
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-9: Human Resources Management 29
THANK YOU
