Hospital Standards for Accreditation for Afghanistan
Section 5: Administration and Management
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. This may include skills testing and /or
written examination 2 1 0
Recruitment: Staff have been recruited utilizing a competitive recruitment process (e.g.. Civil Service Commission PRR)
• An interviewing panel of a minimum of 3 persons interviews the short-listed
candidates 2 1 0
Human Resource Management in Hospitals
StandardNumber
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. 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
• 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). 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
Human Resource Management in Hospitals
StandardNumber
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:
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
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. 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
Human Resource Management in Hospitals
StandardNumber
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
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)
