Hospital Standards for Accreditation for Afghanistan
Section 5: Administration and Management
Human Resource Management in Hospitals
Hospital Standards for Accreditation for Afghanistan: Assessment of Progress in Achieving the Standards Hospital Department or Area:
Human Resource Management in Hospitals
Hospital Facility:
__________________________________________
Assessor:
__________________________________________
Standard Number
Standard
Date of assessment: ____________________
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
1
2
Staffing: The roles, functions and hierarchy of each employee is clearly defined Recruitment: Staff have been recruited utilizing a competitive recruitment process (e.g.. Civil Service Commission PRR)
Verify the existence of at least: • The staffing patterns for the hospital organizational structure and the levels of each post are clearly indicated and are displayed in each department Verify whether: • Posts are advertised widely • There is a short-listing process based upon the criteria outlined in the job description. This may include skills testing and /or written examination • An interviewing panel of a minimum of 3 persons interviews the short-listed candidates • Interview questions are relevant to the job
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Standard Number
Standard
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
3
4
Staffing: Each health worker is fully aware of his/her job description.
Performance: The performance of each member of staff is evaluated annually
being filled • Results of both testing and interview are combined and highest scoring candidate is offered the post. Verify whether: • Each health worker has received a copy of his/her job description • Support staff who have literacy problem have job description explained to them • The job description is compatible with the job the health worker is doing • The job description clearly shows the main functions and level of responsibility • Each health worker meets the requirements in terms of qualifications for the job based on the job description Verify whether: • A staff appraisal process is implemented annually • Management staff and supervisors are trained in implementation of appraisal system • Results are communicated to hospital Board , PHD and MOPH GD of Human Resources (if government hospital)
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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Standard Number
Standard
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
•
5
6
Salary increments and promotion are based on results of performance appraisal Verify whether: Ensuring 24 hour coverage: There is • Each department in the hospital has appropriate 24 hour developed weekly/ monthly staff rosters coverage by staff in the (staffing plans) to ensure appropriate hospital staffing levels for each shift • Staffing for each shift is appropriate to ensure adequate work coverage on each of the shifts based on work load • There is an appropriate plan for the hospital to mobilize staff who are not on duty in the event of having to deal with a major emergency Verify whether: Strengthening capacity of staff: here • All management and supervisory staff are appropriate plans have been appropriately trained and are for strengthening the receiving further capacity building capacity of hospital (appropriate training). managerial, clinical and • Head of each section has identified the support staff training needs of the different categories of staff in their section to ensure strengthening of staff performance within the section • All training attended by staff is relevant to
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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Standard Number
Standard
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
7
8
Personnel Procedures: All health workers are registered with the MOPH General directorate of Human Resources.
Personnel Procedures: There is a process for implementing staff
the work they undertake • Details of all formalized training, including details of staff trained, HR identification (ID) numbers and results of training are notified to Provincial HR Officer for inclusion in the HR Database Verify whether: • All health workers have completed the MOPH Human Resource Database form • Qualifications of employees are verified with General Directorate of HR for authenticity and to identify who requires testing and certification • Staff have been issued with their national HR ID Card which includes their national HR ID Number and photograph • Staff movements and all types of leave as well as retirement , death and disability are notified on a regular basis to the PH HR Officer for sharing with the PHD and General Directorate of HR Verify whether • There are clear disciplinary procedures • Staff are informed of health professional ethics
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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Standard Number
Standard
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
disciplinary measures
9
10
11
Personnel Procedures: There is an effective process for monitoring staff attendance Personnel Procedures: There is a system in place to manage leave
Personnel Procedures: Employees receive all their rights and privileges/benefits in accordance with the terms of their employment and/or CSC Law.
•
Staff are informed of how the disciplinary process is implemented • The procedures are implemented correctly Verify whether: • There is a process for monitoring staff attendance and hours worked • There is a process is applied accurately and staff are on duty as indicated by the staffing roster and the leave applications. Verify whether: • The staff are aware of the process and rules for applying for leave including short time leave • Leave applications correspond with leave reports which are officially submitted to PHD and GD HR Verify whether: • Employees are all aware of their rights in accordance with Afghan Labor Laws, CSC Laws and the terms of their contract • Employees are aware of the process for complaint or appeal if their rights are not observed • The official processes for complaint or appeal are observed
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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Standard Number
Standard
Human Resource Management in Hospitals Compliance in Criteria for Verification of Meeting Meeting Standard (Score) Standard
Basis for Evaluation Score/ Comments/Action Plan
Full Partial None 2 1 0 (Circle appropriate score)
12
13
Personnel Procedures: There is an adequate system of Personnel Management within the hospital Administration
Personnel Procedures: There is a system for dealing with complaints by the public about individual health workers
Verify whether: • Personnel records are well organized and maintained securely to ensure confidentiality • Personnel records are updated regularly • There is a regular reporting of information required for updating of MOPH General Directorate of Human Resource central database Verify whether: • There is a system in place to deal with staff complaints about staff members • The staff complaint system is in line with CSC regulations • The staff system for dealing with complaints about staff is utilized (review of process used)
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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Row A B
Scoring compliance with the standards
E
Total Score (sum total checks for full, partial and no compliance) Score for each category (Full compliance =2, Partial compliance =1 and Non-compliance =0) Score of Full, Partial and Non-compliance (Multiply Row A times Row B) TOTAL: Sum of scores for Full, Partial and Non-compliance—(Add all three columns in Row C) Score possible (Total criteria times 2—less any N/A)
F
Percentage Compliance with these standards (Divide Row D by Row E)
C D
Section 5: Administration and Management. Human Resource Management in Hospitals Hospital Standards Manual—Afghanistan
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86 %
0
Total criteria 43 x 2 pts = maximum 86 point s possible (less any N/A)
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