National Guidelines for Improvement of Quality and Safety of ...

III. Overall Quality and Safety ImprovementAreas of Concern Standards Measurable Elements17 Leadership and management17.1 Leadershipquality17.2 Public relationsand communitymobilization17.3 Human resourcemanagement17.1.1 Vision and Mission of thehospital available17.1.2 A strategic plan and/or amedium-term plan of thehospital developmentavailable17.2.1 An mechanism to improvecommunity participationand communitymobilization in place17.3.1 Staff training conductedregularly17.3.2 Staff deploymentadequately managed- The Vision and Mission of the hospital are displayed in a visible place.- Hospital staff are aware of the Vision and Mission, and understand them.- A document on strategic plan and/or a medium-term plan of the hospital is available.- An activity plan of the hospital is available and updated.- An annual plan for community activities is available.- All the community activities are recorded and filed.- A staff training annual plan is available.- A staff training record book is available and updated.- A coordinator for staff training is assigned.- Staff deployment record books are available for all categories of staff and updated.- The cadre and the current status of the staff are displayed and updated.17.3.3 Duty lists for all categoriesof staff available17.3.4 Grievance handlingmechanisms in place- Duty lists for all categories of staff are available.- A way of reporting grievances (in verbal or written form) to hospital authorities is available for staff andpatients.- All the grievances of the staff are recorded separately and filed.- The grievances are reviewed at regular meetings.33