Hospital s for Accreditation for Afghanistan Section 5: Administration and Management
Hospital s for Accreditation for Afghanistan: Assessment of Progress in Achieving the s Hospital Department or Area: Hospital Facility: Assessor: Date of assessment: 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) Meeting 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 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 Section 5: Administration and Management. Hospital s Manual Afghanistan of 8
Meeting being filled Results of both testing and interview are combined and highest scoring candidate is offered the post. 3 Staffing: Each health worker is fully aware Each health worker has received a copy of of his/her job his/her job description 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 4 Performance: The performance of each A staff appraisal process is implemented member of staff is annually evaluated 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. Hospital s Manual Afghanistan 3 of 8
Meeting Salary increments and promotion are based on results of performance appraisal 5 Ensuring 4 hour coverage: There is appropriate 4 hour coverage by staff in the Each department in the hospital has developed weekly/ monthly staff rosters (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 6 Strengthening All management and supervisory staff have been appropriately trained and are receiving further capacity building (appropriate training). 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 All training attended by staff is relevant to Section 5: Administration and Management. Hospital s Manual Afghanistan 4 of 8
Meeting 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 7 Personnel Procedures: All health workers have completed the All health workers are registered with the MOPH General directorate of Human Resources. 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 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 8 Personnel Verify whether Procedures: There is a There are clear disciplinary procedures process for Staff are informed of health professional implementing staff ethics Section 5: Administration and Management. Hospital s Manual Afghanistan 5 of 8
Meeting disciplinary measures Staff are informed of how the disciplinary process is implemented The procedures are implemented correctly 9 Personnel Procedures: There is There is a process for monitoring staff an effective process for attendance and hours worked monitoring staff There is a process is applied accurately attendance and staff are on duty as indicated by the 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. staffing roster and the leave applications. 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 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. Hospital s Manual Afghanistan 6 of 8
Personnel Procedures: There is an adequate system of Personnel Management within the hospital Meeting Personnel records are well organized and maintained securely to ensure confidentiality Personnel records are updated regularly Administration There is a regular reporting of information required for updating of MOPH General Directorate of Human Resource central database 3 Personnel Procedures: There is a There is a system in place to deal with system for dealing with staff complaints about staff members complaints by the The staff complaint system is in line with public about individual CSC regulations health workers The staff system for dealing with complaints about staff is utilized (review of process used) Section 5: Administration and Management. Hospital s 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 ( compliance =, compliance = and Non-compliance =) C Score of, and Non-compliance (Multiply Row A times Row B) D TOTAL: Sum of scores for, and Non-compliance (Add all three columns in Row C) E Score possible (Total criteria times less any N/A) 86 F Percentage Compliance with these standards (Divide Row D by Row E) % Total criteria 43 x pts = maximum 86 point s possible (less any N/A) Section 5: Administration and Management. Hospital s Manual Afghanistan 8 of 8