**Procedure for personnel management ** ^Name^Unique ID^ Edition/Date of Edition ^ |Procedure for personnel management|nchsls:c:pathology:document:19| 03-01-2015| ^Preparing authority^Approving authority^Review period^ |All teaching staff of Pathology Department|HOD Pathology|1 year| |Controlled copy of this document exist in electronic form at IP address 10.207.3.240 of LAN at NCH, Surat| |**Printed copy of this document with signature of authorized person is to be considered controlled. ** | **Processes requiring this procedure** Human resource management process has two main subprocess l . Personnel Management (Process of managing personnel under control of laboratory management). This procedure is required to run this subprocess. 2. Management of consultants not under control of the laboratory (consultants of referral laboratories). There is separate procedure to run this subprocess. ^**Personnel Management subprocesses** ^ |Defining qualifications for each positions | |Defining job descriptions for each personnel | |Introduction to the organizational environment(Induction)| |Training | |Assessment of competence | |Reviews of staff performance | |Continuous Education and personal development | **Personnel using this procedure** All teaching including pathology staff **Procedure** **Defining qualifications for each positions** The process is not under direct control of the laboratory. Qualifications required by department of health and family welfare Gujarat for appointment at various posts are as follows ^**Post** ^**Qualification** ^ |Class 1 Teaching post in Pathology|MD/ DNB (Pathology) | |Class 2 Teaching post in Pathology|MBBS | |Resident |MBBS | |Technician |1 year Certificate course in MLT| |Assistant Technician |BSc in Biological Science | **Defining job descriptions for each personnel** The process is not under direct control of the laboratory. Job descriptions are defined by department of health and family welfare Gujarat for appointment at various posts at the time of appointment. **Personnel introduction to the organizational environment:**\\ When a new personnel start working with the laboratory, HOD of the department l.Introduces new staff to the existing departmental staff

2.Ask existing personnel to a.explain work at >-OPD 10 -indoor and outdoor lab (Procedure of sample receiving, registration, sample processing manually as well as on automated analyzer, sample collection,administration) > >-Histology and cytology section (Procedure of sample receiving, tissue processing and block and slide filing, reporting, staff administration) b.explain common duty hours c.explain leave entitled d.explain arrangement for taking rest and food during duty hours e.show location of fire extinguishers f.explain need for HBV vaccinations and current status of his/her vaccination **NOTE: When new personnel come, try to know about dates of previous vaccination and enter in vaccination data sheet in file for personnel record. If exact dates are not known, right yes and date not known in vaccination data sheet.** g.discuss residential arrangements planned by the new personnel and facilities available h.discuss traveling arrangements planned by the new personnel and facilities available i.discuss extraordinary family duties of the new personnel which may affect performance at the laboratory 3.Explains unacceptable behavior which may adversely affect employment 4.When new staff join to pathology laboratory, should undergo induction training program **Induction training**\\ HOD of the department asks senior staff members to develop and use supervised training cum evaluation modules for at least following subjects. The training is arranged section wise. The content of the training is developed keeping in mind targeted personnel. -the quality management system -assigned work processes and procedures -the applicable laboratory information system -health and safety, including the prevention or containment of the effects of adverse incidents -ethics -confidentiality of patient information -Other topics as required Use these training cum evaluation modules to train and evaluate new personnel. If required, repeat training or tailor training to individual needs. **SOP for induction training** Whenever a new staff is recruited in pathology department, induction training is given to them. First every new staff is evaluated pre induction by mcq test. Then induction training is given. After training, post induction evaluation mcq test is taken. And evaluation of staff is done by seeing results of tests. Induction training includes: * Sample collection * Basic work * Basic information - **Sample collection:** * Tour of the department: > Department of pathology is having following sections: * Clinical pathology * Hematology * Histopathology * Cytopatholopgy * Autopsy Clinical pathology and hematology sections are located at OPD 10. Histopathology, cytopathology and autopsy sections are located at third floor, college building. **OPD-10 contains:** * Separate patient registration windows for outdoor and indoor patients * Sample collection area for outdoor patients * Processing rooms for Outdoor and indoor samples * 2 Reporting rooms * Store room * Eyewash station * Washroom * Report dispatch window for Outdoor patients **Histopathology section contains:** * Sample receiving area * Grossing room * Tissue processing area * IHC room * Slide mounting area * 2 reporting rooms * Slide and block storage area **Cytopathology section contains:** * FNAC procedure room @ OPD 10 * Sample processing room * Reporting room * Slide storage area **Autopsy section contains:** * Receiving and grossing room * Sample storage room * Reporting room

  1. **Basic work**

Work done by technicians, residents and faculties (Job chart)

  1. **Basic information:**

* **Accommodation:** In hospital (staff quarters) Around hospital (rent) * **Duty hours:** Rotational duty hours of each technician. 3 types of duty hours: MON-FRI: Morning: 9 AM- 5 PM Evening: 3 PM- 9 PM Night- 9 PM- 9 AM SATURDAY: Morning: 9 AM- 1 PM Evening: 1 PM- 9 PM Night: 9 PM- 9 AM SUNDAY: Morning: 9 AM- 3 PM Evening: 3 PM- 9 PM Night: 9 PM- 9 AM * **Vaccination:** As we are dealing with infectious samples, staffs are prone to various infections (Pathogens) like Hepatitis B, HIV etc. So, vaccination is very necessary for all staff members. All technicians are asked about their respective vaccination status. Those who have taken it are in no need of vaccination. Non-vaccinated staff will be vaccinated as per vaccination schedule. 1st dose- 0 day 2nd dose- after 1 month of 1st dose 3rd dose- after 6 months of 2nd dose * **About leave:** Permanent technician: EL, CL, Sick leave Contractual technician: No EL, CL, Sick leave (Paid leave) * **Organogram:** First person to contact in any emergencies are the resident doctors. If any of them are unavailable, go upwards with other persons. Head Of the Department ⇓ Additional Professor ⇓ Associate professor ⇓ Assistant professor ⇓ Tutor ⇓ Resident Doctors ⇓ Technicians class III ⇓ Lab Assistant class III ⇓ Class IV Servants Checklist for evaluation: Hematology and clinical pathology: * Receiving of samples * Rejection criteria of sample * Transport and storage of samples * Centrifuge and quality control * Hematology analyzer and quality control * Coagulometer and quality control * Staining and quality control * Spillage and fire safety * Urine processing and quality control * Reagent and their handling * Venipuncture * Troubleshooting in case of major breakdown of instrument Histopathology: * Receiving of samples * Rejection criteria of sample * Formalin preparation and storage * Transport and storage of samples * Processing of samples- * Tissue processing * Microtomy * Staining * Mounting * labelling * Filing of slides, blocks, request forms and reports * Quality control procedures * Spillage and fire safety * Biomedical waste management * Accidental injury management * Following safety protocols or not? * Personal protective equipment Cytopathology: -Receiving of samples -Rejection criteria of sample -Transport and storage of samples -Processing of samples Centrifugation -Staining -Mounting -Labeling of slides -Report dispatch -Filing of slides, blocks, Request forms and reports -Quality control procedures -Spillage and fire safety -Biomedical waste management -Accidental injury management -Following safety protocols or not? -Personal protective equipment **Induction training schedule:** * Sample collection * Processing of samples * Safety protocols * Quality Control procedures * BMW management * Ethics and professionalism * Instrumentation and Troubleshooting * NABL and SOPs * Precautions during covid 19 {{ :nchsls:c:pathology:document:annexure_2_induction_training_performa.docx |}} {{ :nchsls:c:pathology:document:annexure_6_induction_training_schedule_faculty.docx |}} {{ :nchsls:c:pathology:document:annexure_7_inductiontraining_schedule_of_residents.docx |}} **Competence assessment** **For Faculty Competency assessment:** * Competency assessment of faculty is done by section incharge at the time of joining preferably within a month. slides from opd 10 (1bone marrow aspiration and biopsy, 1 peripheral smear, 1 Urine and other body fluid ), 10 slide from histopathology and cytopathology are given for reporting. * After competency assessment found to be satisfactory, person is made eligible as an authorized signatory. {{ :nchsls:c:pathology:document:annexure_3_competency_evaluation_of_junior_medical_faculty_in_pathology_department.docx |}} **For technician Competency assessment:** 1.Competency assessment of technician is done by section incharge 2.Competence of each technical personnel is assessed by the appointing authority (once in a every year). 3.Note following points during competency assessment. 4.Ability to perform routine work processes and quality control including all applicable safety practices 5.Able to operate equipment as well as able to keep check on function and maintenance. 6.Able to keep record maintenance. 7.Able for troubleshooting whenever required. 8.Ask to examine specially provided samples, such as previously examined samples, interlaboratory comparison materials, or split samples. 9.Able to manage biomedical waste disposal. Report the assessment confidentially. After competency is found to be satisfactory, person is able to work independently. If required, repeat training or tailor training to individual needs. {{ :nchsls:c:pathology:document:annexure_4_competency_evaluation_format_for_tachnical_staff.docx |}} **Reviews of staff performance** *This is done by Section incharge on the basis of competency assessment and performance. *review performance of each personnel periodically as required by the appointing authority (generally once a year). *Note following during the review -consider the needs of the laboratory -consider the need of individual in order to maintain or improve the quality of service given to the users and encourage productive working relationships. {{ :nchsls:c:pathology:document:annexure_5_annual_performance_review_record_of_technical_staff.docx |}} **Continuing education and professional development** *This is done by HOD of the department with inputs from other personnel, where relevant. *In addition to in-house training as described above, facilitate training of the personnel by deputing to externally organized training, in consultation with the parent institute. *Arrange for in-house CME and training program for personnel, in consultation with the parent institute. **Personnel records** Make sure that following records are easily available. Performa for keeping this records {{ :nchsls:c:pathology:document:annxure_1-performa.docx |}} ^**Record** ^**Location** ^ |educational and professional qualifications |With the office of the Dean and Medical superintendent, departmental office| |copy of certification or license, when applicable |With the office of the Dean and Medical superintendent, departmental office| |previous work experience |With the office of the Dean and Medical superintendent, departmental office| |job descriptions |With the office of the Dean and Medical superintendent, departmental office| |introduction of new staff to the laboratory environment |Records of personal management | |training in current job tasks |Records of personal management | |competency assessments |Records of personal management | |reviews of staff performance |Records of personal management | |records of continuing education and achievements |Records of personal management | |reports of accidents and exposure to occupational hazards|Records of non-conformities. | |Immunization status |Records of personal management |