STRUCTURE

Dimension 2: Human Resources Management and Development

Human resource management in the health-care industry necessitates human resource experts
navigating the industry's ever-changing landscape. HR managers are primarily in charge of
ensuring that administrative personnel, clinicians, and patients receive high-quality services. To
solve all of these issues, HR managers must look at the larger picture and possess the
organizational abilities needed to manage these various sectors. In Le Germain they follow
protocols and standards that would be a basis in achieving quality care by providing the best
medical staff to cater the needs of the clients.

Standard Requirements Score (tick off the Remarks

appropriate box)
2.1 The health Each professional field Yes
facility is has its own set of No
adequately staffed basic requirements for
as per the obtaining a patient's
established norms history and doing a
and standards. physical examination.
Facility has a Yes
documented No
procedure for task
shifting or
responsibility sharing
between different
professional staff.
2.2 The health Facility has an up-to
facility maintains date personnel file that
an updated record contains the following
of all staff. at a minimum:
Registration with Yes
relevant professional No
bodies. P

Relevant academic Yes

certificates. No
P
Current curriculum Yes
vitae  No
P

Yes
Letters of No
appointment  P

Yes
No
 Signed job description P

2.3 The health Management staff Yes

facility implements have signed their No
staff performance annual performance P
appraisal. contracts (HR records
for updated
performance
contracts)

Staff appraised at Yes

least once in a year No
(personnel file with P
appraisal documents)

Recommendations of Yes
the appraisals No
implemented by the P
HR (documented
actions on
recommendations)

2.4 Facility staff Facility implements a Yes

engage in continuous medical No
continuous medical education program
education. (HR records and
schedule and file with
minutes on CME
session)

Staff who provide Yes

direct patient care No
have received training P
in basic
cardiopulmonary
resuscitation and the
training is repeated at
least every two years
(HR records)

2.5 Facility has staff Facility has a system Yes

motivation for recognition and/or No
program. rewards of high
achievers
Team building activity Yes
carried out at least No
 Motivation plan Yes
communicated to all No
staff

2.6 There shall be There is an induction Yes

an induction into schedule for all the No
the service new staff. Induction to P
program for all new include but not limited
staff. to the organizational
structure, work area,
staff facilities, health &
safety requirements,
and occupational
hazards.
Induction report Yes
countersigned by new No
staff and by the P
designated staff in the
various departments
within the health
facility.
2.7 The health Annual training needs Yes
facility shall assessment No
allocate funds for conducted and
training of staff as documented (Training
informed by needs assessment for
capacity needs the current calendar or
financial year)
Costed training Yes
schedule in place No
(Training schedule)
Budget allocated for Yes
training (Administratio No
n records)
2.8 The health The facility has a Yes
facility has in place documented procedure No
a mechanism for for sharing of new P
knowledge knowledge which
includes schedule of
management.
knowledge management
activities including
feedback from training,
2.9 The facility There is evidence of Yes
provides internship approval of the health No
program in facility to act as an NA
accordance with internship center.
DOH and other
relevant guidelines
There is a Yes
documented No
 Memorandum of NA
Understanding (MoU)
between the health
facility and training
institution on
internship programs
There are documented Yes
guidelines for interns, No
students, and NA
registrars on
attachments. There is Yes
an up-to-date register No
for interns and NA
students.
2.10 Staff The facility assesses Yes
satisfaction shall and monitor job No
be assessed and satisfaction.
monitored

Dimension 3: Policies, Standards and Guidelines

To provide quality of care and have a collegial atmosphere and environment in Le Germain
Hospital policies and procedures hold personnel accountable for following the proper processes
when caring for patients. They ensure that every patient receives the same level of treatment by
standardizing practices across the organization. Patients are kept safe by standardized
procedures across the institution.

Standard Requirements Score (tick off the Remarks

appropriate box)
3.1 Health care The operation plan Yes
facilities shall align for the health facility No
their operations is aligned to the
with the current current Health Act, in
Health Act, in the the Philippines.
Philippines. The
Magna Carta of
Public Health
Workers (Republic
Act or RA 7305)
3.2 Health facilities The facility has in Yes
shall, at the place all key policy No
minimum, have the documents and
relevant policy and strategic plan
strategic including but not
documents limited to the
available on site following: (confirm
availability of
 documents or
internet access)
Human Resources Yes
Norms and No
Standards
Infrastructure Norms Yes
and Standards No

Previous year’s Yes

annual performance No
report(s)

3.3 A management SOPs strategically Yes

system shall be in displayed (SOPs in No
place for the each service delivery P
implementation and area)
regular review of
standard operating
procedures
Evidence that Yes
standard operating No
procedures and are P
reviewed at least
once a year (SOP
with date of update
displayed)
3.4 Staff members There is a Yes
are regularly documented plan for No
updated on the updating staff on the
current policies, current policies,
standards, and standards, and
guidelines. guideline
(documented plan)
3.5 Facility shall The facility has Yes
ensure the relevant standard No
availability of clinical treatment
standard clinical guidelines. (Confirm
treatment physical or virtual
guidelines. access)
Use and adherence Yes
to guidelines is No
monitored.
(monitoring report)