Document Name: HR POLICY

Document No: AMRUTA/HRM/01

No. of Pages: 20
Issue Date : 5/10/2019
Prepared By: Designation: Accreditation Coordinator
Name:
Signature:
Approved By: Designation: Medical Director
Name:
Signature:
Responsibility of Updating: Designation: Accreditation coordinator
Name:
Signature:
 AMENDMENT SHEET
[Link]. Section no & Details of the Reasons Signature of Signature
page no amendment the of the
preparatory approval
authority authority

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 CONTROL OF THE MANUAL
The holder of the copy of this manual is responsible for maintaining it in good and safe
condition and in a readily identifiable and retrievable. The holder of the copy of this Manual
shall maintain it in current status by inserting latest amendments as and when the amended
versions are received.

NABH Coordinator is responsible for issuing the amended copies to the copyholders, the
copyholder should acknowledge the same and he/she should return the obsolete copies to the
NABH Coordinator. The amendment sheet, to be updated (as and when amendments
received) and referred for details of amendments issued. The manual is reviewed once a year
and is updated as relevant to the hospital policies and procedures. Review and amendment
can happen also as corrective actions to the non-conformities raised during the self-
assessment or assessment audits by NABH.

The authority over control of this manual is as follows:

Approval Issue
Preparation

The procedure manual with original signatures of the above on the title page is considered as
Master Copy’ and the photocopies of the master copy for the distribution are considered as
‘Controlled Copy’.

Distribution List of the Manual:

Sr. No. Designation

1 Chairman

2 NABH Coordinator

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 INDEX

AMENDMENT SHEET 2
CONTROL OF THE MANUAL 3
INDEX 4
INTRODUCTION 5
HUMAN RESOURCE PLANNING 5
INDUCTIONS / ORIENTATION 5
TRAINING AND DEVELOPMENT 6
DISCIPLINARY ACTION 7
GRIEVIENCE HANDLING MECHANISM 9
EMPLOYEE MEDICAL NEED 11
PERSONAL RECORD OF EACH EMPLOYEE 13
TIMING POLICY 13
LUNCH AND TEATIME 14
SALARY AND LOAN POLICY 14
DRESS CODE POLICY 14
POINTERS 15
SECURITY POLICY 15
LEAVE POLICY 16
STAFF MEETING POLICY 16
TERMINATION POLICY 17
CERTIFICATE OF SERVICE 18
NO DUE FORM 18

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 AMRUTA HOSPITAL

HUMAN RESOURCE MANAGEMENT

AMRUTA/
HR POLICY
HRM/01

INTRODUCTION
AMRUTA HOSPITAL is a 30 bedded multispecialty hospital. The hospital considers its
human resource as an asset. Thus the hospital has formulated various policies and procedures
related to HR such as human resource planning, induction, training, disciplinary and
grievance handling, addressing the health needs etc. so as to cover all aspects of human
resource management in effective and efficient manner. All these policies and procedures
have been compiled under Human Resources policies.

HUMAN RESOURCE PLANNING

POLICY

● Administrator in conjunction with Managing Director shall be responsible for Manpower

Planning.
● Manpower planning will cover all categories of manpower and shall include:

⮚ Employees on regular rolls of the Hospital

⮚ Empaneled consultants

● Manpower will be controlled on both numbers and cost.

INDUCTIONS / ORIENTATION
POLICY

● All employees will undergo formal induction immediately upon joining the organization.

● Induction of new employees will be the responsibility of Administrator.

● Induction must be completed within one month of the date of joining of the employee.

PROCEDURE

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● Information about the date of joining of any new employee shall be provided by the
Administrator to the concerned people prior to joining of employee.
● The Administrator will ensure arrangements for work place and will prepare an induction
program for the employees.
● Employee will report to the Administrator on day of joining for completion of joining
formalities, which will include:
⮚ Collection of required documents/ certificate

⮚ Filling out of relevant forms

⮚ Issuing of detailed letter of appointment within one week of joining

⮚ Informing regarding applicable HR policies

⮚ Informing regarding scheduled induction

● After completion of joining formalities, the employee will be handed over to the
respective department, as well as making familiar with initial workplace & job.
● All the process is documented in induction checklist and its available in each employee
file.

TRAINING AND DEVELOPMENT

POLICY

● Hospital is committed to train all employees to:

⮚ Provide excellence in patient care

⮚ Understand and internalize the organizational vision, mission and policies

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⮚ Facilitate and improve job performance

⮚ Encourage employee self-development.

PROCEDURE

● Once an employee is inducted and oriented to the organization, it shall be the

responsibility of the respective Head of Department& supporting staff to impart function
specific training before allowing an employee to function independently. The span of
training may vary from the nature of the task and the experience and learning potential of
the individual.
● Under no circumstances, will an employee be allowed to impart independent patient care
without relevant functional training and being certified by the Superior to do so.
● Internal Appraisal and Patient feedback forms the basis for identifying the job specific
training needs of the employees at Hospital.
● Besides the job specific training, all the staff employed at Hospital are required to
undergo in house training on following aspects:
⮚ Employee and Patient Safety

⮚ BLS training

⮚ Infection Control Practices

⮚ Hygiene and Cleanliness

⮚ New Equipment Installation and equipment maintenance training

● The medical and paramedical staff at Hospital also undergoes training from time to time.
The records of all such training sessions and conferences attended by the staff are
maintained by Administrator.

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DISCIPLINARY ACTION

● Disciplinary action is taken on an employee in case of any misbehavior / misconduct/ any

error in practice/ poor performance which adversely affects or compromise hospital’s
core values or rules or integrity.
● Disciplinary action and corrective measures are taken at the discretion of the Hospital
management.
● The ground of disciplinary action depends on the seriousness of the behavior/act/offence
of employee or group.
● The possible disciplinary actions are:

⮚ Verbal warning, one or more

⮚ Formal written warnings, three

⮚ Deductions from salary

⮚ Suspension

⮚ Dismissal/Termination from Hospital services

Procedure:

● Administrator or respective Supervisor receives written complaint against employee.

● Administrator informs the respective management designee regarding the complaint.

● Note: If any staff receives complain, they should inform Administrator about complaint.

● Administrator evaluates severity of complaint and discussions between the employee and
his/her supervisor. This should be done to correct the situation for minor misconduct /
misbehavior.

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● Employee is asked to explain in writing the reason for his/her conduct/act.

● Verbal/Written warning may be issued, as deemed necessary in consultation with

management.
● Copy of written warning letter will be filed with employee’s personal records with
Administrator.
● An employee can appeal further to Director if he/she is not satisfied with the decision

Note:

● Three written warning notices within twelve (12) months’ time can be a ground of
suspension or termination.
● In case of serious offence or misbehavior or act, punishment in the form of suspension or
termination may be pursued with immediate effect.

Few examples (but not limited) for disciplinary action proceedings are:

● Unauthorized or excessive absence or frequent early quitting during working hours.

● Failure to meet/comply with hospital core values or established standards.

● Obscene, abusive, harassing, or disruptive language or behavior in hospital premises.

● Failure to perform assigned job responsibilities.

● Failure to follow predefined work procedures/SOPs.

● Failure to notify supervisor of absences.

● Neglect/damage/misuse of organization property/resources.

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● Excessive personal use of the telephone and IT resources. No personal computers are
allowed without prior approval.
● Any abnormal behavior/conduct/error compromising patient safety within hospital
premises.
● Absences without approved leave.

● Refusal to comply with instructions of a supervisor.

● Any Conduct endangering the safety of the patient, patients’ relatives, employee(s) or
workers
● Violating major safety rules.

● Fighting or threatening any individual in the workplace.

● Unauthorized possession of weapons on organization premises.

● Sexual harassment to any individual.

● Insubordination or the refusal to comply with the specific instructions of a Supervisor in

the context of an assigned job/task.
● Falsification of personnel records or history, time records, any other organization
documents and records.
● Fighting during work time or on work premises.

● Use of or possession of, alcohol or illegal drugs during work time or on work Property.

● Theft, misappropriation, embezzlement, unauthorized possession or removal of

organization property or the property of employees or customers.

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● Unauthorized or illegal possession of explosives, firearms, or other dangerous weapons

on work premises, including parking areas.
● Failure to report an absence for a three-day period without a satisfactory Explanation.

● Unauthorized release of confidential information or spreading bad image of organization

to patients, relatives, other employees.
● Continued unsatisfactory job performance.

● Violation of the organization's conflict of interest/ethical standards.

● Other behaviors that, in the opinion of the Managing Directors, seriously threaten the
well-being of the organization or any employee or patient.
● Bringing and keeping child / children during working hours without prior permission.

GRIEVIENCE HANDLING MECHANISM

Policy:

The objectives of the grievances procedure will be:

o To settle grievances of the employees in shortest possible time;

o At lowest possible level of authority.

Guidelines:

● The employee shall bring up his grievance immediately and in any case within a period of
one week of its occurrence.

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● If the grievance arises out of an order given by the management, the said order shall be
complied with before the employee concerned invokes the procedure laid down herein for
redressal of his/her grievance.
● Grievance pertaining to or arising out of the following shall not come under the purview
of the grievance procedure:
● Terms of appointment settled

● Annual performance appraisal, increment and promotion.

● Where the grievance does not relate to an individual employee.

● In the case of any grievance arising out of discharge or dismissal of an

employee.
● Matters relating to disciplinary actions, enquiry and court cases, if any

● Any other management decision taken.

● All grievances referred to the Grievance Redressal Committee, shall be entered in a

Grievance redressal Form to be maintained for the purpose by the designated employee.

COMPOSITION OF THE REDRESSAL COMMITTEE

The following staffs are part of Grievance Redressal Committee in Hospital at present:
Name Designation Role

Medical Director Chairman

Consultant Convener

Non Clinical Manager Member

Nurse Member

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The committee should consider and take a decision on the grievances within a period of one
month. If employee is dissatisfied with decision they can appeal to the director within a week
time

Procedure:

● The first step consists of the employee and their immediate supervisor talking together to
try to resolve the grievance.
● If the grievance is still not mutually and satisfactorily resolved, then the grievance is
appealed in writing to the Director who through this procedure will influence the conduct
of the parties, influence outcomes, assure fairness in the hearing, and assist in resolving
the problem.
● Director to meet up with the aggrieved employee on the same day of the complaint.

● Director to discuss the issue with reporting senior and close it within 24 hours of the
grievance being raised.
● It needs to refer it to the Grievance Redressal Committee in case the grievance is not
resolved or settled amicably.
● An employee can directly approach to grievance redressal committee for any sought of
grievance. The committee should consider and take a decision on the grievances within 7
working days
o Effective time of closing the issue in writing is 7 working days.

Grievance Record

Director must maintain written records for every valid grievance.

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EMPLOYEE MEDICAL NEED

POLICY

1. Policy For Annual Medical Health Checkup

2. Policy for Occupational Health and Safety

PROCEDURES

● Annual Medical Checkup

⮚ Hospital has introduced a system to undertake an annual health checkup of all its
employees so as to assess their level of fitness.
⮚ This check is done on every year.

⮚ Result of the check-up is documented in the same format for all.

⮚ Record of the same is maintained in the personal file of the employee.

⮚ Annual health check consists of: General Medical Check-up & Physical examination
by Physician
⮚ All the employees are to undergo annual-employment medical checkup. It is
responsibility of Non clinical manager and document is maintained and copy of health
record should be given to the Director of hospital.
● Occupational Health and Safety

⮚ Hospital provides quality environment by taking adequate preventive measures to

reduce occupational health hazards.
⮚ In so far as safety of the employees in the work place is concerned the hospital has
laid down policy with regard to protection against fire, infection control, handling of
dangerous equipment etc. (Refer-FMS)

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⮚ Every employee undergoes fire safety training and thereafter attends fire drills
periodically.
⮚ Employees who are exposed to patients and those required to handle waste are given
proper training in handling the waste as well as universal precautions.
⮚ In case of accidents or injury sustained (needle stick injury) by employees while at
work immediate medical attention would be directed.
⮚ As regards evacuation of employees in case of emergency due to fire, natural calamity
or any disaster, these matters are covered in detail in the safety manual and Disaster
Management Manual.

PERSONAL RECORD OF EACH EMPLOYEE

POLICY
Record of each employee with necessary documents is maintained in separate file
PROCEDURE
Permanent / Probation Employee

● The Non Clinical Manager maintains a personal file of each employee.

● Personal file of an employee is developed when the employee joins the organization

● There is a checklist in each file which gives information about the documents contained
in a file.
● File contains record relating to his employment, educational qualification, health status,
registration with professional bodies, training record, designation etc Explanation letters
from the employee for any misconduct or misappropriation, any appreciation letter from
organization to the employee etc.
Trainees:

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● List of Trainees

TIMING POLICY

● Normal working days are Monday to Saturday (Sunday on Rotation) with 8 hours of duty.

Timing:

● All the staff member may need to work in case of emergency, Over loaded work, or peak
time. In that case timing will be intimated to the staff by Director.
● It is expected that all the staff of AMRUTA HOSPITAL should come on time. If anyone
found not following the same, strict action will be taken. Deduction of any fix amount
may be possible depending on the severity and occurrence.
● Every staff shall punch in and punch out his attendance through the register at admin
department at time of entering and leaving AMRUTA HOSPITAL premises.

LUNCH AND TEA TIME

● There is no fix time.

● Every individual can complete the lunch in a span of 30min. however it should not
happen that all the department staff will go for lunch at the same time. This will be
considered as punishable offence.
● Employees are requested to take the lunch in the designated area.

● It should be observed that lunch hours should be in between 2PM to 4PM only

SALARY AND LOAN POLICY

● Salary will be paid preferably by cheque.

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● Salary will be issued as agreed mutually to each individual before 10th of every month.

● No advance will be paid to any individual if they have less than 1 year of service at
AMRUTA HOSPITAL .
● If person has done service of more than 1 year in AMRUTA HOSPITAL , 50% of the
monthly salary can be given as loan or advance, which should be paid back within 5
months.
● Whenever required in emergency cases on humanity ground management may alter the
policy, in that case payment will be made from their personal Account and hospital will
not be responsible for the same and same matter should not be considered as reference.

DRESS CODE POLICY

● Every staff should be well groomed and well dressed.

● The Hair must be groomed well & tied for female staff

● No Employee is allowed to come without Hospital uniform

● Two dresses will be provided on yearly basis to each team member of AMRUTA
HOSPITAL every year.
● Staff will be solely responsible for the care of the dress, if it is found that it has not been
maintained properly and found untidy, Person will be punished for the same/will have to
pay for the new dress
● Each member will be paying the fees of the Dress on actual and will be paid back on
completion of 1 year. If they resign before one year no payment will be made.
● Each member will be always carrying ID Cards.

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POINTERS

● Each employee should take care of their drawer keys and drawers have to be locked every
day.
● The workstations are to be kept neat and clean. No official documents should be kept
open on your tables unattended.
● Do not leave any official document on work-table while leaving for home.

● Eating food is only allowed in the designated area. No food is allowed on work-table.

● Chewing tobacco and smoking cigarette and alcoholic drinks are not allowed in premises.

SECURITY POLICY

● Any breach of security should be reported immediately to your superior and also to the
Director.
● All employees are provided with an identity card (ID) which, contain employee
particulars. This ID card is given for:

o Identification of the employee

o Emergency contact
o The employee shall carry his ID Card on him / herself, at all times when inside
the Organization

● The ID cards shall be the property of the Organization and should be surrendered to the
Director on termination of employment.
● AMRUTA HOSPITAL Premises have 24 hours CCTV Camera. No unauthorized person
will be allowed to enter the AMRUTA HOSPITAL premises.

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● Visitors will not be permitted after normal working hours without the prior approval of
the Director.

LEAVE POLICY
There will be 2 types of leave

Paid leave:

● Any two days of every month ,

● Sick leave (only in case of Hospitalization)

● 3 Diwali Holidays

● Rakshabandhan

● Uttarayan

● Dhuleti

● Republic Day

● Independence Day

● Gandhi Jayanti

● (All leaves are on Rotation Basis)

Unpaid Leave: Any other leave

● Unpaid leave will not be granted without approval on leave form

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● More than 2 Unplanned leaves will be considered as misbehavior & will affect the
Performance evaluation.
● Sick leave will be approved only in case of Hospitalization against medical certificate

● The employee not taking any paid leave will get benefit in Performance appraisal

● In case of any emergency the leave will be approved by Top Management Only.

● Nobody can leave the organization premise without permission of Top Management.

STAFF MEETING POLICY

● All the Departmental staff have to arrange a meeting with C.O.O. with a clear-cut
agenda communicated before one day of the meeting.

TERMINATION POLICY

● At least one working day notice of termination of service has to be given during the first
Uninterrupted Period of four weeks of employment by either party.
● At least two-calendar weeks’ notice of termination of service will be given after the
expiration of the first four weeks of uninterrupted employment and before the expiration
of 12 months of employment.
● During the period of the employee’s probation, either the employee or AMRUTA
HOSPITAL may give the other party two calendar weeks’ written notice (should the
employee be a monthly paid employee) to terminate the contract of employment. After
completion of Probation Period, such notice periods shall be extended to one month.
Probation period, if not otherwise specified will be 12 months
● At least one month notice of termination of service has to be given after any uninterrupted
period of employment of 12 months or longer.

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● During the first uninterrupted period of four weeks of employment notice can be given on
any working day.
● The employee’s service with AMRUTA HOSPITAL shall terminate on the day on which
the notice of termination of service expires.
● After the expiration of the first four weeks of uninterrupted employment and before the
expiration of 12 months of employment notice has to be given on or before the usual
payday and shall run from the day after such payday.
● After any uninterrupted period of employment of 12 months or longer –notice has to be
given on or before the first day of a month and shall run from such first day.
● A period of notice given by either party in terms of the above may not run concurrently
with annual leave,
● An employee who has given notice to resign will be required to liquidate all loans with
AMRUTA HOSPITAL (where applicable) before their last month’s dues is paid to them.
● The aforementioned stipulations may be deviated from only when there are compelling
reasons for the same.

CERTIFICATE OF SERVICE

● Certificate of Service shall be issued to each staff member every five years of successful
service or upon resignation on request. This certificate is neither a reference nor a
statement of the staff performance.
● In addition to the Certificate of Service the MD may therefore authorize the issuance of
any other testimonials

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NO DUE FORM

● All employees leaving AMRUTA HOSPITAL employment will be required to submit

duly filled No Dues form to the Director before their dues is paid to them.

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