H R - NABH Audit
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HRM 1a *
Human resource planning supports the organisation’s current and future ability to meet the care, treatment and service needs of the patient. *
HRM 1b *
The organisation maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.
HRM 1c *
The required job specification and job description are well defined for each category of staff. *
HRM 1d *
The organisation verifies the antecedents of the potential employee with regards to criminal/negligence background.
HRM 2a *
There is a documented procedure for recruitment. *
HRM 2b *
Recruitment is based on pre-defined criteria.
HRM 2c *
Every staff member entering the organisation is provided induction training.
HRM 2d *
The induction training includes orientation to the organisation’s vision, mission and values.
HRM 2e *
The induction training includes awareness on employee rights and responsibilities.
HRM 2f *
The induction training includes awareness on patient’s rights and responsibilities.
HRM 2g *
The induction training includes orientation to the service standards of the organisation.
HRM 2h *
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.
HRM 3a *
A documented training and development policy exists for the staff. *
HRM 3b *
The organisation maintains the training record.
HRM 3c *
Training also occurs when job responsibilities change/new equipment is introduced.
HRM 3d *
Evaluation of training effectiveness is done by the organisation
HRM 3e *
Feedback mechanisms are in place for improvement of training and development programme.
HRM 4a *
Staff are trained on the risks within the organisation’s environment.
HRM 4b *
Staff members can demonstrate and take actions to report, eliminate, or minimise risks.
HRM 4c *
Staff members are made aware of procedures to follow in the event of an incident.
HRM 4d *
Staff are trained on occupational safety aspects.
HRM 5a *
A documented performance appraisal system exists in the organisation. *
HRM 5b *
The employees are made aware of the system of appraisal at the time of induction.
HRM 5c *
Performance is evaluated based on the pre-determined criteria.
HRM 5d *
The appraisal system is used as a tool for further development.
HRM 5e *
Performance appraisal is carried out at pre-defined intervals and is documented.
HRM 6a *
Disciplinary and grievance handling - Documented policies and procedures exist. *
HRM 6b *
Disciplinary and grievance handling - The policies and procedures are known to all categories of staff of the organisation.
HRM 6c *
The disciplinary policy and procedure is based on the principles of natural justice.
HRM 6d *
The disciplinary and grievance procedure is in consonance with the prevailing laws.
HRM 6e *
There is a provision for appeals in all disciplinary cases.
HRM 6f *
The redress procedure addresses the grievance.
HRM 6g *
Actions are taken to redress the grievance.
HRM 7a *
A pre-employment medical examination is conducted on all the staff
HRM 7b *
Health problems of the employees are taken care of in accordance with the organisation’s policy.
HRM 7c *
Regular health checks of staff dealing with direct patient care are done at least once a year and the findings/results are documented.
HRM 7d *
Occupational health hazards are adequately addressed.
HRM 8a *
Personal files are maintained with respect to all staff.
HRM 8b *
The personal files contain personal information regarding the staff’s qualification,disciplinary background and health status.
HRM 8c *
All records of in-service training and education are contained in the personal files.
HRM 8d *
Personal files contain results of all evaluations.
HRM 9a *
Medical professionals permitted by law, regulation and the organisation to provide patient care without supervision are identified.
HRM 9b *
The education, registration, training and experience of the identified medical professionals is documented and updated periodically.
HRM 9c *
All such information pertaining to the medical professionals is appropriately verified when possible.
HRM 9d *
Medical professionals are granted privileges to admit and care for patients in consonance with their qualification, training, experience and registration.
HRM 9e *
The requisite services to be provided by the medical professionals are known to them as well as the various departments/units of the organisation.
HRM 9f *
Medical professionals admit and care for patients as per their privileging.
HRM 10a *
Nursing staff permitted by law, regulation and the organisation to provide patient care without supervision are identified.
HRM 10b *
The education, registration, training and experience of nursing staff is documented and updated periodically.
HRM 10c *
All such information pertaining to the nursing staff is appropriately verified when possible.
HRM 10d *
Nursing staff are granted privileges in consonance with their qualification,training, experience and registration.
HRM 10e *
The requisite services to be provided by the nursing staff are known to them as well as the various departments/units of the organisation.
HRM 10f *
Nursing professionals care for patients as per their privileging.
CQI 4b *
Monitoring includes risk management.
CQI 4e *
Monitoring includes employee satisfaction.
ROM 5h *
The organisation documents employee rights and responsibilities. *
COMMON *
Staff interview
AAC 2f *
 The organisation has a well-defined registration and admission process - The staff are aware of these processes.
AAC 8d *
Laboratory personnel are appropriately trained in safe practices.
AAC 11g *
Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures.
COP 5b *
Staff providing direct patient care are trained and periodically updated in cardiopulmonary resuscitation.
HRM 6d *
The disciplinary and grievance procedure is in consonance with the prevailing laws - Policy on prevention of sexual harassment (Committee).
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