Professional Documents
Culture Documents
Policy On Employee Workplace Safety: 1.0 Purpose
Policy On Employee Workplace Safety: 1.0 Purpose
1.0 Purpose
To take care of health and create a healthy environment for staffs to deliver best service
to their organization.
Detection of communicable diseases as per epidemiological studies.
Regular health assessment.
Ensure & Update all relevant vaccinations.
2.0 Scope
Housekeeping Staffs
Kitchen Staff & Food Handlers
Staff exposed to Radiation
Staff working in sound exposed area
Staff clinic shall facilitate the vaccination program for AFC Health Ltd. staff.
Mandatory vaccine:
Chicken pox vaccine for female of child bearing age working in accident and Emergency,
Pediatrics, Internal Medicine and working in and around negative pressure room.
From the above special staff categories can be defined as the staffs who are at risk of exposure to
infectious diseases (this includes Housekeeping Staff, Staff handling food, Kitchen & Non-
Kitchen Staffs, Staff handling samples of blood and body fluids
4.0 Responsibility
Staff Clinic Physician and HR Department are responsible for the implementation and
compliance to the approved policy.
Process
5.1 Immunization Policy for Health Care Workers
History of Child hood immunization status for Polio, Diphtheria, Pertussis, Measles, Mumps,
Rubella, Hepatitis B and Tetanus ascertained.
Mandatory Vaccines Typhoid vaccine for all F & B personnel once in three years and Hepatitis
Health & Medical Surveillance for all F & B Staff Stool routine examination, stool culture and
sensitivity to be done once in 6 months (Mentioned above). Health & Medical Surveillance for
all Microbiology staff
CSSD: staff included in Annual Health Screening Under "Staff exposed to Radiation".
Monitoring the health of employees, working with dangerous pathogens, such as Mycobacterium
tuberculosis by
A pre-employment health check includes Chest X-Ray. For any Pathology detected is,
recommended to consult the Chest Physician who later, does the needful (Mantoux Test, ESR
etc)
A chest X-Ray once a year for employees who are Skin test positive
A chest X-Ray at the time of skin test conversion or at the onset of symptoms suggestive of
respiratory disease, in employees who are Mantoux negative at the time of recruitment. A
detailed evaluation, of employees who are symptomatic, and show radiological evidence of
disease.
5.3
Time line
DOSE
ST
1 dose
Day 01 1 month
6 month
5.4 Tetanus: Recommended every 10 years after initial childhood schedule. All staff with
occupational injuriesis evaluated for Tetanus injection including House keeping staff and
maintenance staff. Chicken Pox: Only Staff with past history of chicken pox infection are
allowed to care for 5.5
Exposure Incidents
5.6
In the event of needle stick injuries, splashing of blood and body fluids over skin and mucous
membranes, after the initial first aid (as elaborated in the Infection Control Manual) all staff are
encouraged to report the incident for risk assessment. A Counseling and baseline serological test
is followed by early initiation of antiretroviral agents if indicated. Based on Hepatitis B antibody
titres, immunization with Immune Glotrulin is also considered. Staffs are periodically followed
up for
6 months to determine conversion. (Please refer to Infection Control Manual for more details).
All staffs are encouraged to strictly adhere to universal precautions. Hand hygiene is advised
before and after handling patients/laboratory samples/linen, etc. Use of protective equipment
when indicated is mandated.
All staff are encouraged and given the option of doing the serology tests and vaccination as
appropriate.
All medical doctors are requested to complete and submit a self-declaration vaccination status
and communicable disease status.
letter detailing their
For injuries incurred, falls while on duty, including exposures to hazardous materials, electrical
burns, shocks, etc., treatment is given as relevant treatment.
5.7
Staff Clinic: Staff reporting their illness to staff clinic after obtaining permission from their
respectivesupervisors. Treatment is given accordingly. Whenever appropriate investigations are
advised and follow up and references to other specialties are carried out if necessary. For Needle
Stick injuries follow the Infection Control Policy.
6.0
Procedure:
6.1
Employee Physical Examination - At the time of employment we have (all selected candidate)
pre employment examinations.
Detailed history regarding immunization status, present and past medical history, personal and
family history is asked for.
Basic Lab investigations done at the time of employment, includes, CBC, RBS, HbsAg, VDRL,
Urine R/E, Stool R/E, Blood Group, X-Ray Chest, ECG, PT (in case of female).
Non-Kitchen Staffs
Regular Vaccination Clinics (Hepatitis-B) for staff at risk of exposure. Laboratory studies, if
indicated i.e., Serological tests is also carried out.
Ophthalmologic examination of staff working in the laser department. Audiometric for staff
working
AFC_HK_BW_01
Issue No. 01
Date.01/01/2015
Page 1 of 4
To describe the Standard Procedure for segregation, handling, storage, transportation and
disposal of
2.0 Scope:
3.0 Responsibility:
The responsibility matrix of the steps of Bio-medical waste management in the hospital will be
as follows:
Sr.No.
1.
Segregation of Waste
Agency
Licensing
Responsibility
Housekeeping
Housekeeping, Security
Administration
Charge
MS, CON
Head- Admin
Head-Admin
2.
3.
4.
Head-Admin
4.0 Abbreviations:
Abbreviation
FEHI
SOP
QA
FD
MS
CON
Head Admin
GDA
Expanded Form
Quality Assurance
Facility Director
Medical Superintendent
Chief of Nursing
Head Administration
The waste generated in the hospital is segregated under the following categories: (As per the
local
5.1.1 Waste sharps (both used and unused): These include needles, scalpels, blades, broken or
unbroken glass items including vials, ampoules and glass bottles and other sharp items like
aluminum
.1.2 Laboratory waste: This includes waste from laboratory cultures, stocks of microorganisms
and other
5.1.3 Soiled waste: This includes disposable items contaminated with blood or body fluids
including
cotton dressing gauze, gloves, dressings, disposable linen, and other disposable material
contaminated with blood and body fluid. 5.1.4 Solid waste (disposables): Waste generated from
disposable items other than sharps such as
5.1.5 Anatomical waste: This includes human tissues, organs, body parts, amputated limbs etc.
5.1.6 Liquid waste: This includes blood, other body fluids and waste generated from laboratory
and
5.1.7 Chemical waste: This includes chemicals used in disinfection including insecticides/
pesticides
5.1.8 Discarded medicines and cytotoxic drugs: This includes outdated, contaminated and
opened but
This includes mainly discarded paper, packaging material, empty bottles of drugs other than
intravenous fluids, not contaminated with blood / other potentially infections material.
5.4 Color coding followed at FEHI, Khulna is according to local NGO named "PRODIPON"
Sr. No.
1.
Type of Waste
Color Coding
Type of Container
Red
Yellow Dustbin
Yellow
Yellow Dustbin
Yellow Dustbin
Black Dustbin
Yellow
Yellow
Black
2.
General waste(Degradable)
5.5.1 All type of hospital waste is collected and stacked and is sent to a designated agency
"PRODIPON" where it is treated as per requirement.
5.5.2 Waste Sharps: All sharps are collected in the designated, puncture proof sharps disposal
container. To prevent the reuse of needle & syringes, tip of the needle is burned and hub of the
syringe is cut before
discarding.
5.5.3 Liquid and Chemical Waste: The liquid waste is drained into the hospital drains after
treating with 1% sodium hypochlorite.
5.7.1 Doctors, nurses, technicians and everyone who is generating the waste. At the source of
generation, wastes with distinct characteristics are placed in separate waste streams by using
collection containers designated for each kind of waste.
5.7.2 The containers are placed as close as possible to the points of waste production. The
number of
bins placed depends on the type of waste generated in that area. 5.7.3 These containers are lined
with polythene bag.
5.8.1 The housekeeping personnel collect, waste at regular intervals. Frequency of collection of
waste
depends upon the amount and rate of generation of waste. 5.8.2 Periodically, the housekeeping
personnel take out the bag ties them and is transported to central storage area near the gate of the
hospital building.
Bags containing biomedical waste, when three-fourths full, are tied and transported through the
lift/designated times, directly to the central storage area located near the gate of the hospital
building. No untreated Bio-medical waste shall be kept stored in the hospital premises beyond a
period of 48 hours. In addition, all possible precautions must be taken to ensure that the waste
does not adversely affect human health and the environment.
5.10 Regular Disinfection of this storage area is an integral part of the hospital waste
management
programme.
5.11 Head Administration shall look after the licensing requirements for Bio-Medical waste
management.
Revision No.
Effective Date
Reason
00
New SOP
7.0 Reference Log
Sr. No.
Title of references
01
Prodipon
Dear Sir,
It's a great pleasure to inform you that we, A FC Health LTD. (Fortis Escorts Heart Institute) are
interested to be a regular client of Prodipan to conserve our clinical waste. Fortis Escorts Heart
Institute is a Joint Venture organization of A F C Health Ltd & Fortis Escort. Fortis Escorts
Heart Institute is the leading integrated healthcare delivery provider in the Pan Asia-Pacific
region. Fortis Escorts Heart Institute is delivering in tweive (12) countries by 76 specialized
hospitals. As per proper official policy we want to conserve our clinical waste by taking help by
Prodipon like others in Khulna. We also want to go for an agreement with Prodipan to continue
this process properly.
To conserve our clinical Waste & to make a good corporate relation with Fortis Escorts Heart
Institute, your kind cooperation is expected.
Best Regards
08/07/2014
Receivede 06-07-2014
POLICY ON SAFETY & HAZARDOUS MATERIAL HANDLING
1.0 PURPOSE:
To provide a safe and healthy environment for all patients, visitors and employees of AFC
Health Ltd.
2.0 Scope: Entire compound of AFC Health Ltd. And it's hospitals
3.0 POLICY:
3.1.1 AFC Health Ltd. Dh aims to provide a safe facility for all its occupants. This shall be
accomplished by Environmental Care Committee, which shall oversee all aspects of Facility
safety. Head of the Department (HOD), Facility Management shall be responsible for the day-to
day facility safety management with necessary development of the safety structure & policy
including training of the staffs..
The applicable rules and regulations e.g. utility installation, operation, expansion or termination,
fire safety system shall be complied with the local & government regulatory bodies. HOD,
facility management will ensure that those compliances have met completely & related licenses
& permits are renewed & remains valid.
3.3.1. There shall be preventive maintenance schedule for every units in operations & for every
establishment. The findings of the inspection shall be brought under the attention of Facility
Management Department. If, In case any safety related issue is raised, the matter shall be
discussed with the environmental committee members or who ever is concerned to handle the
situation.
3.3.2 A comprehensive safety inspection will be carried out twice a year in patient care areas and
once in other areas in a regular manner.
3.4 Hazardous Materials Handling
3.4.1 Adequate practical training will be provided by AFC Health Ltd. on the
3.4.2
appropriate signage marked for the same. Dedicated Team will take care of hazardous materials
spillage in the hospital/office area. The composition of the team shall be known all over 3.4.3
3.5 AFC Health Ltd. Dhaka will take all possible measures to protect every individual
from preventable injuries and accidents. The Hospital will undertake safety
awareness programs & trainings to all staff & related groups for prevention &
3.6 Safety & awareness training programs will offered to the staff depending on their
4.0 TRAINING
Required annually for all employees performing laboratory operations. Training includes hazard
recognition, protective measures and emergency procedures; this is often combined with Right-
To-Know training.
Required for all employees working on or around live electrical equipment, such as in
mechanical or electrical equipment rooms. Training is primarily oriented towards identifying
potential risks and protective measures.
Required for all employees. Topics covered include fire prevention, recognition of fire hazards,
classes of fire, fire extinguishers, how to report a fire, fire alarm systems, and emergency
evacuation procedures.
4.5 Radiation Safety Training:
Required for all employees who work with or around radiation; covers hazard recognition, safe
practices, and risk determination.
Required for all employees who are responsible for the disposal of biomedical waste; training
includes hazard recognition, source separation, protective measures and programmatic
requirements.
POLICY ON SUPPLY CHAIN (QUALITY ASSURANCE)
The Store In-Charge plays an important role in quality assurance and inventory control system.
The Store In-Charge must have technical knowledge & wide experience in store management.
The Store In-Charge is responsible for all functions relating to receiving, quality checking,
issuing and storing of material/medicines; maintenance of stocks-and stores.
materials/medicines purchased from suppliers into the store, after inspection and
checks by the Store In-Charge's immediate supervisor will ensure proper quantity with the
Purchase Order and then will send for storage Quality Check of Materials: The Store In-Charge
is required to check the quality of the materials/medicines purchased from suppliers. Materials
will send for storage only after inspection and quality check done by the store In-Charge
authorized person.
Proper Placement: Placement of different material/medicines in proper places in the store should
be ensured, so that the material/medicines can be handled in convenient way. The
material/medicines should be kept in cold rooms, cold boxes, deep freezes, bins, racks, shelves,
almirah, etc. for safekeeping and easy identification.
Medicine Preservation: The medicines must be preserved as per standard medicines preservation
rules and instructions which we received from the WHO, UNICEF and GOB in order to ensure
the effectiveness of the medicines.
Request for replenishment of stocks: Issue the material/medicine replacement request for the
replenishment of material/medicines to the Purchase Department at the proper time.
Stock Verification: Physical verification of stock of each material/medicine at periodic intervals
and compare it with store ledger to minimize the loss, wastage, etc.
The primary reason for conducting periodic physical inventories is to ensure accuracy of the
inventory records and to account for stock items. Physical inventory checking responsibility
usually falls upon the store In-Charge and AFC Finance who should be sure that sound
techniques are used to get the greatest outcome.
POLICY ON HUMAN RESOURCES (MATERNITY LEAVE)
In the event of pregnancy, female employees with a service length of at least 4 months will be
entitled to 4 months of Maternity Leave with full pay and benefits, for the first two living
children. Application for Maternity Leave must be made 2 months before the commencement of
EDD. Female employees can apply for ML at any time during pregnancy. This application needs
to be placed with the Line Manager supported by a registered medical practitioner's endorsement
indicating the EDD. If a staff member, after delivery, wants to join earlier than spending 8
weeks, she will be allowed to do so. For third or subsequent children (provided she has two
surviving children) the female employee will only be entitled to 16 weeks of Leave Without Pay
(LWOP). In case the employee suffers a miscarriage within 28 weeks, she can avail of SL to
recover.
POLICY ON EMPLOYEE SUPPLEMENTARY BENEFITS
1. Objective:
The Objective of this policy is to ensure standard benefit packages for the employees of AFC
Health Ltd.
2. Scope:
This policy is applicable for all the permanent employees of AFC Health Ltd. 3. Benefits:
The benefit plan is designed to reinforce specific needs of an employee in addition to his/her
regular remunerations. It does not represent salary but a wide range of benefits and services are
part of the total compensation package.
3.1.1. AFC Health Ltd. picks up patients from long distance through well equipped ambulance
with Doctors and Paramedics/Nurses. This is a hardship for the doctors, paramedics/nurses and
also drivers who are under taking the said activities.
3.1.2. This policy applies to the Doctors, Paramedics/Nurse and ambulance drivers
3.1.3. To become eligible for Hardship Allowance the total distance traveled (up & down) must
be more than 200 kilometers. In such case the Ambulance Driver will be entitled to get Tk.200
per trip while the Paramedics/Nurses will be entitled to Tk.300. The accompanying Doctor will
be entitled to get Tk. 1000 per trip.
3.1.6. The Ambulance Driver, Paramedic and Doctor will also be reimbursed for food as per the
travel policy 3.1.7.If the emergency team needs to stay over night for any valid reason then they
will get reimbursement of accommodation allowance as per the travel policy. 3.1.8. The
concerned doctors, paramedics and drivers will submit their claim with the approval of
respective Head of Department within 7 days of the trip to Finance Department who will ensure
the payment of the claim accordingly.
3.2 Cell Phone Allowance:
3.2.1 3.2.2 This policy will be applicable for the employees provided with official cell phone.
The following category of employees listed in the table will be entitled to get a cell phone from
AFC Health Ltd. with specified types of connection and will be
SI Designation/Category
4,000
3,000
Consultant
2,000
1,500
Maximum Limit
3.2.3 Chairman/MD/Directors have the right to set individuals limit in some cases
based on functional requirement. Common cell phone provided to the department must be
assigned to an 3.2.4
employee in the department who will be the custodian of this cell phone and
3.2.5 On call mobile phone can be replaced based on the present condition of the phone set. If an
on call mobile phone is out of order Admin/Support Services Department will repair the
particular set and the cost will be paid by the company.
3.2.6 However, if 'On call' mobile phone is damaged fully or partially by the designated user of
the mobile, then the user/users will be solely responsible for such damage and will also bear the
liability of repairing or replacement cost for the damage.
3.2.7 AFC Health Ltd. will make arrangements for the payment of the ceiling amount as per the
eligibility defined. Any amount exceeding the eligible ceiling limit will be paid by the user.
3.2.8 If any of the assigned users get transferred, terminated or resign from a department, this
information should be delivered to the Admin/Support Services Department immediately for
further processing.
4.1. This policy will be applicable for the employees during duty time. 4.2. The following
category of employees listed in the table will be entitled to get a
SI
Designation/Category
Payable %
60%
Consultant
60%
50%
40%
Other Staffs
4.3. Chairman/MD/Directors have the right to set subsidy limit in some cases
5. Transport Facility:
5.1. AFC Health Ltd. will provide Transport facility to some selective employees duly decided
by Chairman/MD/Directors
5.2.
Chairman, MD & Directors will be provided with full time car. Other staffs of
different categories will get pick & drop facility through prior written
5.3. The Transportation Expense will be paid to the employees who are not using company
provided vehicles for official purpose
POLICY ON EMPLOYEE BENEFITS
1. Objective:
The objective of this policy is to facilitate in-patient and out-patient care to the employees of
AFC Health Ltd. within an agreed and acceptable framework.
2. Scope:
This policy is applicable for all the permanent employees of AFC Health Ltd.
3. Eligibility of Facility:
The Health Care Facilities will be provided to the employees according to the below mentioned
criteria;
3.1. Self and Family (ie. Self, spouse (only one), children up to the age of 21 years:For staffs
from Manager level to higher grades. All Non Consultant Physicians (NCPS) and above are
also eligible for this privilege. Self only: For staffs from Deputy Manager level to below Grades.
3.2.
3.3. All entitled employees must submit the picture of their family (who are eligible as per clause
3.1) to Human Resources Department for availing the hospitalization benefit for them. Billing
department will verify with Human Resources Department before allowing the discounts as per
hospitalization policy. The nominated persons by respective employees must be verified every 6
months by the concerned departments.
4.1. Any employee or his/her spouse and children, who are entitled to have OP treatment, must
go to the Staff Clinic first. However, Only Senior Management and consultants will have the
privileges to visit consultants directly without any authorization from the staff clinic.
Consultation Fee is free in the Staff Clinic.
4.2. Staff clinic will refer to Consultant OPD for management of chronic and stable conditions
requiring specialized care if indicated.
4.3. The concerned employee will have to show the referral letter to the appointment desk to get
further consultant's appointment.
4.4. If the Staff Clinic does not refer any employee (or his/her spouse, children, direct parents
who are entitled) to the consultant, in that case the patient can visit the consultant by paying
consultation fee.
4.5. Discount will be given to entitled employees for OPD services as given below:
Registration
Consultation
Fee when
Consultation
fee when
Investigation/ procedure
referred by
Staff Clinic
not referred
by Staff
Clinic
50% discount
No discount
100% discount
100% Discount
No discount
5.1. Staff clinic will refer to Accident and Emergency for management of acute illness requiring
admission. 5.2. Employees will be charged 100% for Medicine and Consumables and 50% for
investigation
5.3. Consultation Fee, Surgery, Procedures are free of charge for eligible employees as per
entitlement.
5.4. Only 10% of Bed Charges will be realized in case of IPD patients.
5.5. During hospitalization of any employee room allotment will be made as given below and
subject to availability of defined category of rooms:
Room
Level of Employee-AHD
Single Cabin
Chairman-AVP
General Ward
3.3. In case of emergency and unavailability of specialized category of room the Hospital
Authority can provide any room to any level of employee.
6. Exceptions from Medical Facility:
6.1. Discount will not be applicable for Health Package and Vaccinations
6.2 Discount will not be applicable for hospitalization related to maternity unless the concerned
female employee has served AFC Health Ltd. for at least 1 (One) year. Discount will also not be
applicable to female employee who has two or more surviving children at the time of availing
this benefit. The same applies to the male employees for availing discount for their spouse.
6.3. Individuals / Departments are not allowed to make any interpretation regarding this policy
on
their own. Any matter of confusion / concern should be brought to the notice of Human
6.4. Employee or his/her family will not be charged for any bills for the death of self or his/her
spouse, children or direct parents (if they are entitled for treatment).
7.1: On-duty means when employees clock-in to the time they clock-out. An employee in an
official trip and tour will also be deemed on-duty.
7.2. In case of any accidents occurring during official duty, the employee will receiveall kinds of
Outpatient and In-patient Treatment free of charge until recovery.
7.3. Employees who get injured by an accident whilst on duty will be granted Accident/Special
Leave with full pay for a period required for full recovery. 7.4. Any accident leading to Partial or
Permanent Disablement and Death will be covered by the
As per hospital policy it is important that Staff clinic should facilitate annual health check of
staff.
9. Staff Vaccination:
a. Staff clinic will facilitate vaccination program of AFC Health Ltd. staffs. HR department will
ensure personnel records are updated accordingly and will coordinate with Staff Clinic for
budgeting purposes. Typhoid vaccine is mandatory for all F&B personnel. b.
C.
Hepatitis B vaccine is mandatory for all staffs that are at the risk of exposure.
d. Chicken pox vaccine is mandatory for female staffs who are of child bearing age working in
accident and Emergency and working in and around negative pressure room. Staff Clinic will
maintain liaison with other departments to ensure vaccination of the above
Amendments in the eligible list of vaccination can be made with the approval of MD or Director
Operations recommended by Staff Clinic from time to time.
10. Privilege of Taking Treatment outside: In case of emergency and unavailability of specialty
care which is not available in any hospital under the coverage of AFC Health then the authority
can send the employee for specialty care.