1. health and fitness

Quality Improvement Programme
CoH
Effective Human Resource Management
enhances organizational performance
Dr J L Meena
State Quality Assurance Officer
Commissionerate of Health, MS & ME
Department of Health & Family welfare
www.gujhealth.gov.in/quality-assurance-program.htm
Email:- [email protected]
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
1
Effective Human Resource
Management
www.gujhealth.gov.in
CoH
Health & Family Welfare, Govt of Gujarat
2
Quality Improvement Programme
CoH
Effective human resource management
enhances organisational performance
by improving employee's opportunities
to be effective and productive. It
involves the productive use of people in
achieving the organisation's objectives
as well as satisfying individual
employee needs.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
3
The purpose of good human
resources management
CoH
Create meaningful jobs linked to the organisation's mission.
Maintain the right mix of people with the knowledge, skills,
and abilities to accomplish the work required.
Provide a structure that helps staff be effective at their work.
Provide fair and consistent treatment of staff.
Provide staff with on-going feedback about their
performance.
Foster an organisational culture that supports and motivates
staff.
Create a positive work environment.
Help retain effective staff members.
Help staff and the organisation to manage change
effectively.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
4
Why is it important? CoH
One of the most important resources that an organisation has
is its people as it is through them that the organisation’s vision
is realized.
Supporting and taking care of staff will better equip them to
meet customer needs and in turn motivate staff to take care of
their organisation.
Competent staff who are happy with their work and their
workplace are more productive and are more likely to stay with
the organisation longer. Committed staff can provide loyalty, long
term sustainability and program success.
Organizations that are socially aware and not only support
employee rights but endorse them whole heartedly, will gain a
reputation as an employer of choice and have less difficulty
attracting good staff.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
5
Human resource
management responsibilities
CoH
Job analysis/Work design
Human resource planning
Recruitment
Selection
Performance appraisal
Training and development
Career planning and development
Employee motivation
Mentoring
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
6
Job analysis/Work design
CoH
This defines a job in terms of its specific tasks
and
responsibilities
including
the
qualifications and skills needed to perform
within the role successfully. A job analysis will
consider the time taken to complete tasks;
which tasks should be logically grouped
together to form a position. It will also
consider optimal design to enhance employee
performance. The end product of this analysis
is the position description/specification.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
7
Human resource planning
CoH
This process involves the analysis
of matching the number of
appropriately qualified staff to
allocated
positions
and
the
consideration of staffing levels to
meet projected demand. Decisions
to add, reduce or reallocate staff
are made accordingly.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
8
Recruitment
CoH
The
process
of
finding and attracting
qualified applicants
for vacancies within
an organisation.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
9
Selection
CoH
This involves choosing someone based
on merit, who is most likely to perform
successfully in the position. Written
applications, interviews and reference
checking are the traditional methods
used to select staff. However, other
creative
strategies
can
include
presentations and written exercises
relevant to the job.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
10
Performance appraisal
CoH
Performance management is the process of
defining employee performance expectations,
measuring, evaluating and recording performance
relative to those expectations and providing
feedback. This is a formal procedure between staff
and their manager to evaluate employee
performance.
Performance
appraisals
are
primarily focused on the achievement and
development of skills. The process is participatory
and also provides an opportunity for the
recognition of an employee's achievements and
identification of career goals.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
11
Training and development
CoH
Training and development facilitates employee
learning of job related skills and activities to
improve performance. The provision of training
and development are important tools in ensuring
staff are equipped to provide the quality and type
of service the organisation is aiming to achieve.
Examples of training and development activities
include running in house courses, providing
access to tertiary or private sector courses, setting
up job rotations, mentor schemes and providing
opportunities to shadow and observe other staff.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
12
Career planning and development
CoH
Career planning and development
provides opportunities for both the
employee and employer. By identifying
future job prospects, career goals and
areas
for
personal
and
skill
improvement, the employee creates a
future career path. At the same time the
organisation benefits as it retains
appropriately qualified and skilled staff.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
13
Employee motivation CoH
Employee motivation is concerned with
the internal will to achieve and work
towards organisational goals. Setting
up conditions to enhance employee
motivation is critical to the success of
any organisation. Highly motivated staff
tend to be more productive, have lower
rates of absenteeism, turnover and
lateness.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
14
Mentoring
CoH
Mentoring involves sharing your
knowledge and expertise with another
staff member. The mentor's role
includes supporting the employee in
their personal growth and career
development. The role of all mentors:
guide, coach, encourage, support and
counsel to support the learning
process.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
15
16
17
Quality Improvement Programme
CoH
Effective Human Resource Management
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
18
Section I:
Patient-Centered Standards
CoH
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE
(AAC)
Chapter 2: CARE OF PATIENTS (COP)
Chapter 3: MANAGEMENT OF MEDICATION (MOM)
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)
Chapter 5: HOSPITAL INFECTION CONTROL (HIC)
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
19
Section II:
Health Care Organization Management Standards
CoH
Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
20
Quality Improvement Programme
CoH
Chapter 9: HUMAN RESOURCE
MANAGEMENT (HRM)
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
21
HRM.1: The organization has a documented
system of human resource planning.
CoH
A- Human resource planning supports the
organisation's current and future ability to meet the
care, treatment and service needs of the patient.
This shall be done in a structured manner keeping in
mind the scope of services, mission and the
healthcare needs of the community that it serves. It
shall use recognised methods for determining levels of
staffing.
It shall match the strategic and operational plan of
the organisation.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
22
HRM.1: The organization has a documented
system of human resource planning.
CoH
B- The organisation maintains an adequate number and mix of
staff to meet the care, treatment and service needs of the patient.
The staff should be commensurate with the workload and the
clinical requirement of the patients.
A good reference could be the MCI and INC guidelines.
C- The required job specification and job description are well defined
for each category of staff.
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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
23
“Job description” CoH
 It entails an explanation pertaining to duties, responsibilities
and conditions required to perform a job.
 A summary of the most important features of a job, including
the general nature of the work performed (duties and
responsibilities) and level (i.e., skill, effort, responsibility and
working conditions) of the work performed. It typically
includes job specifications that include employee
characteristics required for competent performance of the job.
A job description should describe and focus on the job itself
and not on any specific individual who might fill the job.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
24
“Job specification"
CoH
The qualifications / physical requirements,
experience and skills required to perform a
particular job / task.
A statement of the minimum acceptable
qualifications that an incumbent must
possess to perform a given job
successfully.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
25
HRM.1: The organization has a documented
system of human resource planning.
CoH
D- The organisation verifies the antecedents of the
potential employee with regards to criminal /
negligence background.
Self-explanatory.
This report can be obtained from the district
magistrate's office of the district where the
employee has served earlier and / or from the
previous employer. In case of fresh graduates, the
same could be obtained from the last institute
attended. In case of a doctor or a nurse, a "good
standing certificate" may be obtained from the
regulatory body.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
26
HRM.2: The organization has a documented
procedure for recruiting staff and orienting
them to the organisation's environment.
CoH
A- There is a documented procedure for recruitment.
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.
B- Recruitment is based on pre-defined criteria.
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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
27
HRM.2: The organization has a documented
procedure for recruiting staff and orienting
them to the organisation's environment.
C- Every staff member entering the organisation is
provided induction training.
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 the organisational level and for the
respective departments.
CoH
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
28
HRM.2: The organization has a documented
procedure for recruiting staff and orienting
them to the organisation's environment.
CoH
D- The induction training includes orientation to the
organisation's vision, mission and values.
The organisation's staff including the outsourced staff should be aware
and should correctly interpret the vision, mission and values of the
organisation.
E- The induction training includes awareness on employee rights
and responsibilities.
Self-explanatory.
F- The induction training includes awareness on patient's rights
and responsibilities.
The employees should be able to identify and report violation of
patient rights as and when it occurs.
For patient rights refer to PRE 2.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
29
Vision & Mission CoH
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
30
Employee Rights and
Responsibilities
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Dr J L Meena
CoH
Health & Family Welfare, Govt of Gujarat
31
Employee Rights and
Responsibilities
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Dr J L Meena
CoH
Health & Family Welfare, Govt of Gujarat
32
PATIENTS & FAMILY RIGHT &
RESPONSIBILITY (Respect)
CoH
Rights:To be treated with respect and courtesy.
To receive safe, considerate, ethical and cost effective
medical care.
To have your individual cultural, spiritual and
psychosocial needs respected.
To have your privacy and personal dignity maintained.
To expect that information regarding your care will be
treated as confidential.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
33
PATIENTS & FAMILY RIGHT &
RESPONSIBILITY (Respect)
CoH
Responsibilities:To respect hospital personnel.
To respect care givers’ efforts to provide care
for other patients.
To respect hospital property.
To be considerate of other patients and to see
that your visitors do the same.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
34
PATIENTS & FAMILY RIGHT &
RESPONSIBILITY (Treatment)
CoH
Rights:To receive treatment regardless of race, religion or any
other discrimination prohibited by law.
To receive emergency treatment regardless of ability to
pay.
To expect reasonable continuity of care and to be informed
of available and realistic care options when hospital care is
no longer appropriate.
To have your needs for pain management addressed and
treated.
To be free from the use of restraints and/or seclusion
unless clinically necessary.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
35
PATIENTS & FAMILY RIGHT &
RESPONSIBILITY (Treatment)
CoH
Responsibilities:To follow your care givers’ instructions and help them in
their efforts to return you to health.
To inform your care givers if you think there may be
problems in following their instructions.
To participate in decision making about your medical care.
To recognize the impact of life style on your personal
health.
To ask your treating physician if he/she has any conflicts of
interests that directly affect your care.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
36
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Advance Directives)
Rights:To have an advance directive (living will and/or
durable power of attorney for health care decisions).
To obtain information regarding an advance
directive.
To have your advance directive (if you have one)
included in your medical record.
To have your advance directive followed to the
extent that is medically appropriate and lawful.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
37
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Advance Directives)
Responsibilities:To inform the hospital if you have
an advance directive.
To give the hospital a copy of your
written advance directive (if you
have one).
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
38
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Information)
Rights:To understand your diagnosis and treatment, as well as the
possible outcomes, risks and benefits of your care.
To have information regarding your medical treatment
explained to your family member or other appropriate
individual when you are unable to participate in decisions
about your care.
To access a foreign language or American Sign Language
interpreter and/or adaptive equipment (including TDDs) if
needed.
To be advised of hospital policies, procedures, rules and
regulations that may affect your care.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
39
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Information)
Rights:To be aware of any proposed hospital research in which you
may be involved.
To be aware that the hospital’s bioethics committee is available
to you to discuss ethical issues related to your care
To understand that your caregivers may be both teachers and
students
To know the names/titles of your caregivers
To see your medical records (in accordance with hospital policy
and/or the law)
To review your bill and to have any questions or concerns you
have adequately addressed
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
40
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Information)
Responsibilities:To provide the hospital with accurate and
complete information about your medical
history.
To ask your care givers for more information if
you do not understand your illness or treatment
To provide the hospital with necessary
payment and/or insurance information.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
41
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Involvement)
Rights
To be involved in decisions concerning your care
To have your family members and/or others involved in
decisions about your care
To exclude your family members and/or others from participating
in decisions about your care
To discuss any treatment planned for you
To give your informed consent or informed refusal for treatment
To leave the hospital or request a transfer (in accordance with
hospital policy and/or the law)
To refuse to be treated by a student
To consent or decline to participate in clinical research
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
42
PATIENTS & FAMILY RIGHT &
CoH
RESPONSIBILITY (Involvement)
Responsibilities
To stand by hospital rules and
regulations
To keep your appointments
To pay your bills on time
To inform the hospital if you believe
your rights have been violated
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
43
PATIENTS RIGHT &
RESPONSIBILITY
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Dr J L Meena
CoH
Health & Family Welfare, Govt of Gujarat
44
PATIENTS RIGHT &
RESPONSIBILITY
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Dr J L Meena
CoH
Health & Family Welfare, Govt of Gujarat
45
PATIENTS RIGHT &
RESPONSIBILITY
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Dr J L Meena
CoH
Health & Family Welfare, Govt of Gujarat
46
HRM.2: The organization has a documented
procedure for recruiting staff and orienting
them to the organisation's environment.
CoH
G- The induction training includes orientation to the service standards of
the organisation.
Self-explanatory.
The employees should be trained to implement 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 / programme's
policies and procedures.
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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
47
HRM.3: There is an ongoing programme for
professional training and development of
the staff.
CoH
A- A documented training and development policy exists for the
staff.
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).
B- The organisation maintains the training record.
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) and the post-training
feedback.
Where possible, the contents of the training may also be captured.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
48
HRM.3: There is an ongoing programme for
professional training and development of
the staff.
CoH
C- Training also occurs when job responsibilities change / new
equipment is introduced.
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.
D- Feedback mechanisms for assessment of training and
development programme exist and the feedback is used to
improve the training programme.
This shall include both internal and external training. For external
training, it could be done either by the organisation itself or by the
external agency, which imparted the training, Impact of training at
user level should also be documented.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
49
HRM.4: Staff is adequately trained on
various safety-related aspects.
CoH
A- Staff is trained on the risks within the organisation's
environment.
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.
B- Staff members can demonstrate and take actions to
report, eliminate / minimize risks.
Self-explanatory.
Staff should be able to practically demonstrate actions like
taking care of blood spills, medication errors and other
adverse event reporting systems.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
50
HRM.4: Staff is adequately trained on
various safety-related aspects.
CoH
C- Staff members are made aware of procedures to
follow in the event of an incident.
Self-explanatory.
The staff should be able to intimate the sequence of
events that they will undertake in the eventuality of
occurrence of any adverse event.
D- Staff is trained on occupational safety aspects.
This shall include making them aware of the possible risks
involved and preventive actions to avoid risks.
Some examples are : Needle stick injury and Blood /
Body fluid exposure.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
51
HRM.5: An appraisal system for evaluating the
performance of an employee exists as an integral part
of the human resource management process.
CoH
A- A documented performance appraisal system
exists in the organisation.
Self-explanatory. 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.
B- The employees are made aware of the system of
appraisal at the time of induction.
Self-explanatory.
This could be incorporated in the service booklet and
included in the induction training.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
52
Performance Appraisal
CoH
It is the process of evaluating the
performance of employees during
a defined period of time with the
aim
of
ascertaining
their
suitability for the job, potential
for
growth
as
well
as
determining training needs.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
53
HRM.5: An appraisal system for evaluating the
performance of an employee exists as an integral part
of the human resource management process.
C- Performance is evaluated based on the pre-determined
criteria.
Self-explanatory.
D- The appraisal system is used as a tool for further
development.
Self-explanatory. 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.
E- Performance appraisal is carried out at pre defined intervals
and is documented.
Self-explanatory.
This shall be done at least once a year.
CoH
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
54
HRM.6: The organization has documented
disciplinary and grievance-handling policies and
procedures.
A- Documented policies and procedures exist.
Self-explanatory.
For definition of "disciplinary procedure" and
"grievance handling" refer to glossary. The
documentation shall be done keeping in mind objective
elements "c, d and e".
B- The policies and procedures are known to all
categories of staff of the organisation.
Self-explanatory. All the staff should be aware of the
disciplinary procedure and the process to be
followed in case they fell aggrieved.
CoH
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
55
“Disciplinary Procedure" and
“Grievance Handling"
CoH
Sequence of activities of the healthcare
organization who are employed full time and
are paid suitable remuneration for their
services as per the laid-down policy.
Sequence of activities carried
out to address the grievances of
patients, visitors, relatives and
staff.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
56
HRM.6: The organization has documented
disciplinary and grievance-handling policies and
procedures.
CoH
C- The disciplinary policy and procedure is based
on the principles of natural justice.
This implies that both parties (employee and
employer) are given an opportunity to present their
case and decision is taken accordingly.
D- The disciplinary procedure is in consonance with the
prevailing laws.
Self-explanatory.
Refer to relevant labour laws and CCS (CCA) rules. Antisexual harassment committee should also be established
in the organisation.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
57
HRM.6: The organization has documented
disciplinary and grievance-handling policies and
procedures.
CoH
E- There is a provision for appeals in all-disciplinary
cases.
The organisation shall designate an appellate authority to
consider appeals in disciplinary cases.
Appellate authority should be higher than the disciplinary
authority.
F- The redress procedure addresses the grievance.
Self-explanatory.
G- Actions are taken to redress the grievance.
Self-explanatory. This shall be documented
communicated to the aggrieved staff.
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Dr J L Meena
and
Health & Family Welfare, Govt of Gujarat
58
HRM.7: The organisation addresses the
health needs of the employees.
CoH
A- A pre-employment medical examination is
conducted on all the employees.
Self-explanatory. This shall, however, be in
consonance with the law of the land.
For example, performing pre-employment HIV
testing without consent is illegal.
B- Health problems of the employees are taken care
of in accordance with the organization’s policy.
Self-explanatory. This shall be in consonance with the
law of the land and good clinical practices.
For example, employee health and safety policy.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
59
HRM.7: The organisation addresses the
health needs of the employees.
CoH
C- Regular health checks of staff dealing with direct patient care
are done at-least once a year and the findings/ results are
documented.
Self-explanatory. 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.
D- Occupational health hazards are adequately addressed.
Self-explanatory. 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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
60
“Occupational health hazard"
CoH
The hazards to which an
individual is exposed during
the course of performance of
his
job.
These
include
physical,
chemical,
biological, mechanical and
psychosocial hazards.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
61
HRM.8: There is documented personal
information for each staff member.
CoH
A- Personal files are maintained
in respect of all staff.
Self-explanatory.
B- The personal files contain personal
information regarding the employees
qualification, disciplinary background
and health status
Self-explanatory.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
62
HRM.8: There is documented personal
information for each staff member.
CoH
C- All records of in-service training and education
are contained in the personal files
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.
D- Personal files contain result of all evaluations.
Evaluations would include performance appraisals,
training assessment and outcome of health checks.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
63
HRM.9: There is a process for credentialing and
privileging of medical professionals, permitted
to provide patient care without supervision.
CoH
A- Medical professionals permitted by law, regulation and
the hospital to provide patient care without supervision is
identified.
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.
B- The education, registration, training and experience of the
identified medical professionals is documented and updated
periodically.
Self-explanatory. Updating is done after acquisition of new
skills and / or qualification.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
64
“Credentialing" CoH
The
process
of
obtaining,
verifying
and assessing the
qualification
of
a
healthcare provider.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
65
HRM.9: There is a process for credentialing and
privileging of medical professionals, permitted
to provide patient care without supervision.
CoH
C- All such information pertaining to the medical professionals
is appropriately verified when possible.
The organisation shall do the same by verifying the credentials
from
the
organization
which
has
awarded
the
qualification/training.
A good reference could be MCI's website.
D- Medical professionals are granted privileges to admit and
care for patients in consonance with their qualification,
training, experience and registration.
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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
66
Privileging
CoH
It
is
the
process
for
authorizing
all
medical
professionals to admit and
treat patients and provide
other
clinical
services
commensurate
with
their
qualifications and skills.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
67
HRM.9: There is a process for credentialing and
privileging of medical professionals, permitted
to provide patient care without supervision.
CoH
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.
Self-explanatory.
This could be done by internal communication.
F- Medical professionals admit and care for patients as per their
privileging.
Self-explanatory. A standardised format can be used for each
faculty and a norm for providing privilege should be practiced
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.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
68
HRM.10: There is a process for credentialing and
privileging of medical professionals, permitted to
provide patient care without supervision.
CoH
A- Nursing staff permitted by law, regulation and the
organisation to provide patient care without
supervision are identified.
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.
B- The education, registration, training and experience
of nursing staff is documented and updated
periodically.
Updating is done after acquisition of new skills and / or
qualification.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
69
HRM.10: There is a process for credentialing and
privileging of medical professionals, permitted to
provide patient care without supervision.
CoH
C- All such information pertaining to the nursing
staff is appropriately verified when possible.
The organisation shall do the same by verifying the
credentials from the organization which has
awarded the qualification/training.
D- Nursing staff are granted privileges in consonance with
their qualification, training, experience and registration.
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.
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Dr J L Meena
Health & Family Welfare, Govt of Gujarat
70
HRM.10: There is a process for credentialing and
privileging of medical professionals, permitted to
provide patient care without supervision.
CoH
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.
Self-explanatory.
This could be done by internal communication.
F- Nursing professionals care for patients as per their
privileging.
Self-explanatory. New staff members can be under the
proctorship till independent privilege is being provided for
each staff.
The organisation could evolve a mechanism to ensure that
medical professionals are providing only those services that
they have been privileged to offer.
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
71
Quality Improvement Programme
CoH
Thanks
www.gujhealth.gov.in
Dr J L Meena
Health & Family Welfare, Govt of Gujarat
72