Human Resource Management in Hospitals

1 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: _____ Date of assessment: _____ Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) 1 Staffing: The roles, functions and hierarchy of each employee is clearly defined 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 2 1 0 2 Verify whether: Posts are advertised widely 2 1 0 There is a short-listing process based upon the criteria outlined in the job description.

2 This may include skills testing and /or written examination 2 1 0 Recruitment: Staff have been recruited utilizing a competitive recruitment process ( Civil Service Commission PRR) An interviewing panel of a minimum of 3 persons interviews the short-listed candidates 2 1 0 Interview questions are relevant to the job 2 1 0 Section 5: Administration and Management . Human Resource Management in Hospitals hospital Standards Manual Afghanistan 2 of 8 Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) being filled Results of both testing and interview are combined and highest scoring candidate is offered the post.

3 2 1 0 3 Verify whether: Each health worker has received a copy of his/her job description 2 1 0 Staffing: Each health worker is fully aware of his/her job description. Support staff who have literacy problem have job description explained to them 2 1 0 The job description is compatible with the job the health worker is doing 2 1 0 The job description clearly shows the main functions and level of responsibility 2 1 0 Each health worker meets the requirements in terms of qualifications for the job based on the job description 2 1 0 4 Verify whether: A staff appraisal process is implemented annually 2 1 0 Performance: The performance of each member of staff is evaluated annually Management staff and supervisors are trained in implementation of appraisal system 2 1 0 Results are communicated to hospital Board , PHD and MOPH GD of Human Resources (if government hospital ) 2 1 0 Section 5: Administration and Management .

4 Human Resource Management in Hospitals hospital Standards Manual Afghanistan 3 of 8 Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) Salary increments and promotion are based on results of performance appraisal 2 1 0 5 Ensuring 24 hour coverage: There is appropriate 24 hour coverage by staff in the hospital Verify whether: Each department in the hospital has developed weekly/ monthly staff rosters (staffing plans) to ensure appropriate staffing levels for each shift 2 1 0 Staffing for each shift is appropriate to ensure adequate work coverage on each of the shifts based on work load 2 1 0 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 2 1 0 6 Verify whether: All Management and supervisory staff have been appropriately trained and are receiving further capacity building (appropriate training).

5 2 1 0 Strengthening capacity of staff: here are appropriate plans for strengthening the capacity of hospital managerial, clinical and support staff Head of each section has identified the training needs of the different categories of staff in their section to ensure strengthening of staff performance within the section 2 1 0 All training attended by staff is relevant to 2 1 0 Section 5: Administration and Management . Human Resource Management in Hospitals hospital Standards Manual Afghanistan 4 of 8 Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) 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 2 1 0 7 Verify whether: All health workers have completed the MOPH Human Resource Database form 2 1 0 Personnel Procedures.

6 All health workers are registered with the MOPH General directorate of Human Resources. Qualifications of employees are verified with General Directorate of HR for authenticity and to identify who requires testing and certification 2 1 0 Staff have been issued with their national HR ID Card which includes their national HR ID Number and photograph 2 1 0 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 2 1 0 8 Verify whether There are clear disciplinary procedures 2 1 0 Personnel Procedures: There is a process for implementing staff Staff are informed of health professional ethics 2 1 0 Section 5: Administration and Management .

7 Human Resource Management in Hospitals hospital Standards Manual Afghanistan 5 of 8 Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) disciplinary measures Staff are informed of how the disciplinary process is implemented 2 1 0 The procedures are implemented correctly 2 1 0 9 Verify whether: There is a process for monitoring staff attendance and hours worked 2 1 0 Personnel Procedures: There is an effective process for monitoring staff attendance There is a process is applied accurately and staff are on duty as indicated by the staffing roster and the leave applications.

8 2 1 0 10 Personnel Procedures: There is a system in place to manage leave Verify whether: The staff are aware of the process and rules for applying for leave including short time leave 2 1 0 Leave applications correspond with leave reports which are officially submitted to PHD and GD HR 2 1 0 11 Verify whether: Employees are all aware of their rights in accordance with Afghan Labor Laws, CSC Laws and the terms of their contract 2 1 0 Employees are aware of the process for complaint or appeal if their rights are not observed 2 1 0 Personnel Procedures: Employees receive all their rights and privileges/benefits in accordance with the terms of their employment and/or CSC Law.

9 The official processes for complaint or appeal are observed 2 1 0 Section 5: Administration and Management . Human Resource Management in Hospitals hospital Standards Manual Afghanistan 6 of 8 Human Resource Management in Hospitals Standard Number Standard Criteria for Verification of Meeting Standard Compliance in Meeting Standard (Score) Basis for Evaluation Score/ Comments/Action Plan Full 2 Partial 1 None 0 (Circle appropriate score) 12 Verify whether: Personnel records are well organized and maintained securely to ensure confidentiality 2 1 0 Personnel records are updated regularly 2 1 0 Personnel Procedures: There is an adequate system of Personnel Management within the hospital Administration There is a regular reporting of information required for updating of MOPH General Directorate of Human Resource central database 2 1 0 13 Verify whether: There is a system in place to deal with staff complaints about staff members 2 1 0 The staff complaint system is in line with CSC regulations 2 1 0 Personnel Procedures: There is a system for dealing with complaints by the public about individual health workers The staff system for dealing with complaints about staff is utilized (review of process used) 2 1 0 Section 5: Administration and Management .

10 Human Resource Management in Hospitals hospital Standards Manual Afghanistan 7 of 8 Row Scoring compliance with the standards A Total Score (sum total checks for full, partial and no compliance) B Score for each category (Full compliance =2, Partial compliance =1 and Non-compliance =0) 2 1 0 C Score of Full, Partial and Non-compliance (Multiply Row A times Row B) D TOTAL: Sum of scores for Full, Partial and Non-compliance (Add all three columns in Row C) E Score possible (Total criteria times 2 less any N/A) 86 F Percentage Compliance with these standards (Divide Row D by Row E) % Total criteria 43 x 2 pts = maximum 86 point s possible (less any N/A) Section 5: Administration and Management . Human Resource Management in Hospitals hospital Standards Manual Afghanistan 8 of 8