Internal Staff Duty Policy

Policy Statement

This Policy forms part of the Human Resource Management framework of Sri Lakshmi Multi Speciality Hospital and shall be read together with the employee's Appointment Letter, Employment Contract, Hospital Service Rules, Departmental Standard Operating Procedures (SOPs), applicable Hospital Policies and prevailing statutory requirements. Where any provision of this Policy is inconsistent with applicable law, the applicable law shall prevail to the extent of such inconsistency.

Expected Outcomes

• Improved patient safety and quality of care.
• Clear roles, responsibilities and accountability.
• Consistent Human Resource Management practices.
• Higher employee engagement and professional development.
• Reduced employment-related disputes and operational risks.
• Compliance with applicable statutory and regulatory requirements.
• Strengthened organisational governance and NABH compliance.
• A culture of integrity, teamwork and continuous improvement.

Key Definitions

• Hospital means Sri Lakshmi Multi Speciality Hospital, including all its departments, units and facilities.
• Management means the Board of Directors, Managing Director, Hospital Administrator, Medical Superintendent and other authorised management representatives.
• Employee means any person employed by the Hospital, whether permanent, probationary, temporary, contractual, trainee or part-time, unless otherwise stated.
• Department Head means the person responsible for supervising and managing a specific department.
• Supervisor means any authorised person responsible for overseeing the work of employees.
• Duty Hours means the scheduled working hours assigned to an employee.
• Shift means the designated working period allocated to an employee, including Morning, Evening and Night shifts.
• Duty Roster means the officially approved schedule allocating employees to shifts or duties.
• Attendance means the official record of an employee's presence at work through approved attendance systems.
• Biometric Attendance means attendance recorded using the Hospital's authorised biometric device.
• Overtime means authorised work performed beyond the employee's approved duty hours.
• Emergency Duty means duties performed during emergencies, disasters, pandemics or other situations requiring immediate staffing.
• On-Call Duty means a period during which an employee is required to remain available to report for work if called upon.
• Patient Care Area means any location where patients receive clinical assessment, treatment, observation or nursing care.
• Confidential Information includes patient information, employee information, Hospital records, financial information, passwords and any non-public organisational information.
• Gross Misconduct means serious misconduct that may warrant major disciplinary action, subject to applicable law and due process.
• No Call–No Show means failure to report for duty without notifying the appropriate supervisor or obtaining prior approval.
• Hospital Property includes all buildings, equipment, furniture, medicines, medical devices, computers, documents, software, uniforms, identification cards and other assets owned or controlled by the Hospital.
• Workplace means any Hospital premises or any location where an employee performs duties on behalf of the Hospital.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force by the appropriate Government).
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• National Medical Commission Regulations, 2023 (where applicable).
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.
• NABH Care of Patients (COP) Standards.
• NABH Facility Management & Safety (FMS) Standards.

Operational Requirements

• Employees shall report for duty as per the approved duty roster.
• Departments shall maintain adequate staffing to ensure patient safety.
• Emergency services shall receive priority staffing at all times.
• Shift changes shall be approved only by authorised personnel.
• Employees may be required to perform emergency or additional duties where reasonably necessary for patient care and permitted by applicable law.
• Every shift shall ensure complete clinical and administrative handover before relief.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• Digital Personal Data Protection Act, 2023 (where applicable).
• National Medical Commission Regulations, 2023 (where applicable).
• NABH Human Resource Management (HRM).
• NABH Governance & Leadership (GL).

Labour & Employment Laws

• Tamil Nadu Shops and Establishments Act, 1947 and the Rules made thereunder.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force by the appropriate Government).
• Employees' State Insurance Act, 1948.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Payment of Gratuity Act, 1972.
• Maternity Benefit Act, 1961.
• Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.

Healthcare Laws & Professional Regulations

• National Medical Commission Act, 2019.
• National Medical Commission (Registered Medical Practitioner) Professional Conduct Regulations, 2023 (where applicable).
• Digital Personal Data Protection Act, 2023.
• Biomedical Waste Management Rules, 2016 (where applicable).
• Drugs and Cosmetics Act, 1940 and applicable Rules (where applicable).
• Narcotic Drugs and Psychotropic Substances Act, 1985 (where applicable).

NABH Standards

• Human Resource Management (HRM).
• Governance & Leadership (GL).
• Access, Assessment & Continuity of Care (AAC).
• Care of Patients (COP).
• Medication Management (MOM).
• Hospital Infection Prevention & Control (HIC).
• Information Management System (IMS).
• Continuous Quality Improvement (CQI).
• Facility Management & Safety (FMS).

Order of Precedence

Unless otherwise required by law, the following order of precedence shall apply when interpreting employment matters:

1. Applicable Acts, Rules, Government Notifications and binding judicial directions.
2. Terms and conditions contained in the Employee's Appointment Letter or Employment Contract.
3. This Human Resource Management, Employment, Duty, Attendance & Workplace Conduct Policy.
4. Hospital Service Rules.
5. Departmental Standard Operating Procedures (SOPs).
6. Official circulars, administrative instructions and authorised operational guidelines issued by Hospital Management.

Management Authority

Subject to applicable law, contractual obligations and principles of fairness, the Hospital reserves the right to organise work, assign duties, prepare duty rosters, rotate shifts, transfer employees, introduce new technologies, issue operational instructions and revise policies to meet patient care requirements, statutory obligations and organisational needs.

Policy Amendments

Hospital Management may amend, revise, withdraw or replace this Policy, in whole or in part, whenever necessary to reflect changes in applicable laws, accreditation standards, operational requirements or organisational objectives. Employees shall be notified of significant revisions through approved communication channels.

Principles of Interpretation

• References to any Act, Rule or Regulation shall include amendments, replacements or successor legislation.
• Words importing the singular shall include the plural and vice versa where the context permits.
• Words referring to one gender shall include all genders.
• Headings are provided for convenience only and shall not affect interpretation.
• Where any provision becomes invalid or unenforceable, the remaining provisions shall continue to remain in force.
• Nothing contained in this Policy shall restrict any statutory obligation imposed by applicable law.

Core Governance Policies

• Code of Ethics & Professional Conduct Policy.
• Data Privacy & Patient Confidentiality Policy.
• Information Technology & Cyber Security Policy.
• Medical Records Management Policy.
• Patient Rights & Responsibilities Policy.
• Consent & High-Risk Procedure Policy.
• Incident Reporting & Sentinel Event Policy.
• Medication Management & Safety Policy.
• Infection Prevention & Control Policy.
• Biomedical Waste Management Policy.
• Emergency Preparedness & Disaster Management Policy.
• Medico-Legal Case (MLC) Policy.
• Fire Safety & Facility Management Policy.
• POSH (Prevention of Sexual Harassment) Policy.
• Whistle-blower Policy.
• Grievance Redressal Policy.
• Attendance & Payroll Procedures.
• Departmental Standard Operating Procedures (SOPs).

Employee Responsibility

• Read and understand all policies applicable to your role.
• Seek clarification from your Department Head or Human Resources whenever required.
• Comply with departmental SOPs and official administrative instructions.
• Participate in mandatory policy orientation and refresher training programmes.
• Report suspected policy violations through the appropriate reporting channels.

Administration Responsibilities

• Maintain the latest approved version of this Policy.
• Communicate policy updates to all affected employees.
• Provide policy orientation during employee induction.
• Conduct periodic awareness and refresher training.
• Monitor policy compliance through internal audits and supervisory reviews.
• Review the effectiveness of this Policy and recommend improvements where necessary.
• Maintain records relating to policy revisions and approvals.

Employee Acknowledgement

Every employee shall acknowledge receipt of this Policy during induction or whenever a revised version is issued. Employees are expected to read, understand and comply with the requirements of this Policy. Failure to read this Policy shall not exempt any employee from compliance with its provisions.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Employees' State Insurance Act, 1948.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• NABH Human Resource Management (HRM) Standards.

Permanent Employees

Employees who have successfully completed the prescribed probation period and whose services have been confirmed in writing by the Hospital. Permanent employees are eligible for applicable statutory and organisational benefits in accordance with Hospital policy and applicable law.

Probationary Employees

Newly appointed employees shall ordinarily be placed on probation for the period specified in their Appointment Letter. During probation, performance, conduct, attendance, professional competence and suitability for continued employment shall be evaluated. The probation period may be confirmed, extended or employment discontinued in accordance with applicable law and contractual terms.

Contract Employees

Employees appointed for a fixed duration or specific assignment under a written contract. Their employment, benefits and renewal shall be governed by the terms of the contract and applicable statutory provisions.

Temporary Employees

Employees engaged for temporary operational requirements, seasonal workload, leave replacement or special projects. Temporary employment shall not automatically result in permanent employment unless specifically approved by Hospital Management.

Consultants & Visiting Medical Practitioners

Consultants and Visiting Medical Practitioners shall provide professional services under separate consultancy or professional service agreements. Unless expressly stated, they shall not be treated as regular employees of the Hospital. However, they shall comply with applicable Hospital policies, patient safety requirements, ethical standards, confidentiality obligations and professional regulations while working within the Hospital.

Trainees & Interns

Trainees and interns may undergo structured training programmes under authorised supervision. They shall comply with Hospital policies, confidentiality requirements, infection control practices and workplace conduct standards throughout the training period.

Outsourced Personnel

Personnel engaged through third-party agencies, including housekeeping, security, maintenance or other support services, shall remain employees of their respective contractors. While working within Hospital premises, they shall comply with applicable Hospital policies relating to safety, discipline, confidentiality, infection control and workplace conduct.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Employees' State Insurance Act, 1948.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Digital Personal Data Protection Act, 2023.
• National Medical Commission Regulations, 2023 (where applicable).
• NABH Human Resource Management (HRM) Standards.

Recruitment Principles

• Recruitment shall be based on merit, competency and organisational requirements.
• Equal opportunity shall be provided without unlawful discrimination.
• Selection shall be based upon qualifications, experience, professional competence and suitability.
• Only approved vacancies shall be filled.
• Recruitment shall be conducted through authorised Hospital representatives.

Selection Process

• Application screening.
• Qualification verification.
• Experience verification.
• Personal interview.
• Technical or departmental assessment (where applicable).
• Reference verification, where considered necessary.
• Management approval before appointment.

Mandatory Documents

• Government-issued Photo Identity Proof.
• Address Proof.
• Recent Passport Size Photographs.
• Educational Certificates.
• Professional Registration Certificates (where applicable).
• Experience Certificates.
• Relieving Letter from previous employer (where applicable).
• PAN Card.
• Aadhaar Card (where voluntarily provided or otherwise lawfully required).
• Bank Account Details.
• Any additional documents required by Hospital Management.

Medical Fitness

Appointment may be subject to the candidate being medically fit to perform the duties of the position. The Hospital may require a pre-employment medical examination, vaccination records or occupational health assessment depending upon the nature of the role and applicable infection prevention requirements.

Appointment Letter

Every selected candidate shall receive a written Appointment Letter specifying the designation, department, reporting authority, date of joining, probation period (where applicable), salary, working hours, employment category, notice period and other applicable terms and conditions of employment.

Misrepresentation & False Information

Any candidate or employee who knowingly submits false information, forged documents, inaccurate qualifications, concealed disciplinary history or misleading employment records may have the offer of employment withdrawn or, if already employed, may be subject to disciplinary action up to and including termination of employment, after following applicable legal requirements and the Hospital's disciplinary procedures.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• NABH Human Resource Management (HRM) Standards.

Duration of Probation

• The probation period shall be specified in the Appointment Letter.
• The standard probation period is ordinarily six (6) months unless otherwise approved by Hospital Management.
• The Hospital may extend the probation period where additional time is reasonably required to evaluate performance, subject to applicable law and contractual terms.
• Any extension of probation shall normally be communicated in writing.

Performance Evaluation During Probation

• Professional competence and technical skills.
• Attendance and punctuality.
• Patient care and service quality.
• Compliance with Hospital policies and SOPs.
• Communication and teamwork.
• Professional ethics and behaviour.
• Discipline and workplace conduct.
• Learning ability and adaptability.
• Documentation standards.
• Overall suitability for the assigned position.

Management Responsibilities

• Provide appropriate induction and orientation.
• Assign a reporting supervisor or Department Head.
• Monitor employee performance objectively.
• Provide guidance and feedback where improvement is required.
• Conduct periodic probation reviews.
• Recommend confirmation, extension or other appropriate action based on documented performance.

Completion of Probation

Successful completion of the probation period does not automatically result in confirmation of employment. Confirmation shall become effective only upon written approval issued by the Hospital through the Human Resources Department or other authorised authority. Where performance or conduct is unsatisfactory, the Hospital may extend probation or take other action consistent with applicable law, contractual obligations and the Hospital's disciplinary procedures.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• NABH Human Resource Management (HRM) Standards.

Eligibility for Confirmation

An employee may be considered for confirmation upon successful completion of the prescribed probation period, subject to satisfactory performance, attendance, professional conduct and the recommendation of the reporting Department Head.

• Successful completion of the probation period.
• Satisfactory attendance and punctuality.
• Acceptable performance evaluation.
• Compliance with Hospital policies and SOPs.
• Professional behaviour and ethical conduct.
• Successful completion of mandatory induction and training programmes.
• No unresolved serious disciplinary issues.

Confirmation Review Process

• Performance appraisal by the immediate supervisor.
• Recommendation by the Department Head.
• Review by the Human Resources Department.
• Verification of attendance and disciplinary records.
• Final approval by the authorised Hospital authority.
• Issue of a written Confirmation Letter where approved.

Extension of Probation

Where additional time is required to evaluate an employee's suitability, the Hospital may extend the probation period. The employee shall ordinarily be informed of the extension in writing, together with the areas requiring improvement and the revised review period.

Non-Confirmation

If an employee fails to meet the required standards of performance, conduct, attendance or professional competence during probation, the Hospital may decide not to confirm the employment. Appropriate action shall be taken in accordance with applicable law, the Appointment Letter and the Hospital's disciplinary procedures.

Confirmation Letter

Confirmation of employment shall be valid only upon issuance of a written Confirmation Letter by the Human Resources Department or other authorised Hospital authority. No verbal assurance or informal communication shall constitute confirmation of employment.

Applicable Laws & Standards

• Digital Personal Data Protection Act, 2023.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• Code on Wages, 2019.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.

Personnel File Contents

• Employment Application.
• Curriculum Vitae / Resume.
• Appointment Letter.
• Employment Agreement (where applicable).
• Educational Certificates.
• Professional Registration Certificates.
• Experience Certificates.
• Identity and Address Proof.
• PAN Card details.
• Aadhaar details (where voluntarily provided or otherwise lawfully required).
• Bank Account Details.
• Nomination Forms.
• PF and ESI records.
• Medical Fitness Records (where applicable).
• Training Records.
• Performance Appraisals.
• Attendance Records.
• Leave Records.
• Disciplinary Records (if any).
• Promotion, Transfer and Increment Orders.
• Resignation and Exit Documents.

Employee Responsibilities

• Provide accurate and complete employment information.
• Inform the Human Resources Department promptly of any changes to personal details, address, contact information or statutory records.
• Submit required documents within prescribed timelines.
• Cooperate during verification of employment records.
• Ensure that declarations made to the Hospital are truthful and complete.

Hospital Responsibilities

• Maintain accurate and up-to-date personnel records.
• Protect employee confidentiality and personal information.
• Maintain statutory employment records as required by law.
• Implement appropriate physical and electronic security measures.
• Retain and dispose of records in accordance with applicable legal and Hospital record retention requirements.

False Information or Forged Documents

Submission of false information, forged documents, concealment of material facts or fraudulent declarations relating to employment records may result in disciplinary action, including termination of employment, after following applicable legal requirements and the Hospital's disciplinary procedures. The Hospital also reserves the right to initiate appropriate legal action where warranted.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Occupational Safety, Health and Working Conditions Code, 2020 (where applicable).
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.

Types of Transfer

• Department Transfer.
• Shift Transfer.
• Temporary Deployment.
• Emergency Deployment.
• Promotion-based Transfer.
• Administrative Transfer.
• Inter-unit or future branch transfer, where applicable.

Reasons for Transfer

• Patient care requirements.
• Staff shortage or manpower balancing.
• Expansion of Hospital services.
• Operational or administrative requirements.
• Employee competency or specialised skills.
• Training and professional development.
• Performance improvement.
• Health or medical considerations (where appropriate).
• Disciplinary or administrative reasons, where legally permissible.

Employee Responsibilities

• Cooperate with approved transfer or rotation decisions.
• Report to the assigned department or work location on the specified date and time.
• Complete proper handover before transfer.
• Protect Hospital property, records and confidential information during transfer.
• Complete any orientation or departmental training required for the new assignment.

Refusal of Transfer

Employees are expected to comply with lawful transfer or deployment instructions issued by authorised Hospital Management. Unreasonable refusal to accept a lawful transfer, failure to report to the assigned department or deliberate obstruction of operational requirements may be treated as misconduct and dealt with in accordance with the Hospital's disciplinary procedures and applicable law.

Transfer Documentation

• All permanent transfers shall normally be communicated in writing.
• Temporary or emergency deployments may be communicated verbally, followed by written confirmation where practicable.
• Human Resources shall update the employee's personnel records following approved transfers.
• Department Heads shall ensure proper handover and acceptance of responsibilities.

Applicable Laws & Standards

• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.

Eligibility for Promotion

• Satisfactory performance appraisal.
• Demonstrated professional competence.
• Consistent attendance and punctuality.
• Good disciplinary record.
• Successful completion of mandatory training programmes.
• Possession of qualifications required for the higher position.
• Availability of suitable vacancy or organisational requirement.

Performance Assessment Criteria

• Patient care quality.
• Clinical or technical competency.
• Professional ethics and behaviour.
• Communication and teamwork.
• Leadership ability.
• Problem-solving skills.
• Attendance and discipline.
• Compliance with Hospital policies.
• Initiative and continuous improvement.
• Contribution to departmental objectives.

Promotion Process

• Identification of vacancy or organisational requirement.
• Performance review by the reporting supervisor.
• Recommendation by the Department Head.
• Review by the Human Resources Department.
• Approval by the authorised Hospital Management.
• Issue of a formal Promotion Order where approved.

Merit-Based Advancement

Promotion decisions shall be based upon merit, organisational requirements and the employee's demonstrated ability to perform higher responsibilities. Completion of a specific period of service shall not automatically entitle an employee to promotion.

Promotion Benefits

A promoted employee may receive a revised designation, salary revision, modified duties, reporting structure or additional responsibilities, as specified in the Promotion Order and subject to applicable Hospital policies.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Payment of Gratuity Act, 1972 (where applicable).
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• NABH Human Resource Management (HRM) Standards.

Resignation Procedure

• Resignation shall be submitted in writing to the Reporting Manager or Human Resources Department.
• The resignation shall clearly mention the proposed last working day.
• Employees shall continue performing their duties until officially relieved unless otherwise approved.
• Submission of a resignation does not automatically terminate employment.
• Employment shall cease only after acceptance of resignation and completion of the prescribed relieving process.

Notice Period

• The applicable notice period shall be as specified in the Appointment Letter or Employment Contract.
• Employees are expected to serve the full notice period unless specifically waived in writing by Hospital Management.
• The Hospital may, at its discretion and subject to contractual terms, accept payment in lieu of notice or waive the notice period.
• Any waiver or reduction of the notice period shall be communicated in writing.

Return of Hospital Property

• Identity Card.
• Uniforms (where applicable).
• Access Cards and Keys.
• Laptops, Tablets or Mobile Devices issued by the Hospital.
• Medical Equipment assigned to the employee.
• Hospital Documents, Records and Confidential Information.
• Any other Hospital property entrusted to the employee.

Abandonment of Employment

Failure to report for duty for a prolonged period without prior approval or reasonable explanation, and without communication to the Hospital, may be treated as abandonment of employment. Appropriate action shall be taken only after following the Hospital's disciplinary procedures and applicable legal requirements.

Management Rights

Hospital Management reserves the right to determine the relieving date, require completion of pending duties, recover Hospital property, recover lawful dues where contractually or legally permissible and ensure uninterrupted patient care before accepting the employee's separation from service.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Payment of Gratuity Act, 1972 (where applicable).
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.

Mandatory Exit Clearance

Before an employee is relieved from service, written clearance shall ordinarily be obtained from the following departments, where applicable:

• Immediate Reporting Supervisor.
• Department Head.
• Human Resources Department.
• Finance & Accounts Department.
• Information Technology Department.
• Medical Records Department (where applicable).
• Pharmacy Department (where applicable).
• Biomedical Engineering Department (where applicable).
• Administration Department.
• Security Department.

Return of Hospital Property

• Employee Identity Card.
• Uniforms (where issued).
• Access Cards, Keys and Security Tokens.
• Hospital-issued Mobile Phones.
• Laptops, Tablets and Computers.
• Medical Equipment.
• Official Documents and Registers.
• Patient Records in the employee's possession.
• Hospital Files and Confidential Documents.
• Any other Hospital property entrusted to the employee.

Continuing Confidentiality Obligations

Separation from employment does not release an employee from obligations relating to patient confidentiality, Hospital confidential information, trade secrets, passwords, financial information, proprietary documents or other sensitive organisational information. Such obligations shall continue after separation to the extent required by applicable law, contractual commitments and Hospital policies.

Final Settlement

Final settlement of salary, leave encashment (where applicable), statutory dues and other eligible payments shall ordinarily be processed after completion of the Exit Clearance Process, subject to applicable law, contractual obligations and lawful deductions, if any.

Relieving Letter & Experience Certificate

Upon successful completion of all exit formalities, return of Hospital property and settlement of outstanding obligations, the Hospital may issue a Relieving Letter, Experience Certificate or Service Certificate, as applicable and in accordance with Hospital policy.

Pending Dues & Recovery

Where an employee has outstanding financial liabilities, unreturned Hospital property or other recoverable obligations, the Hospital may take appropriate action to recover such amounts or property in accordance with applicable law, contractual terms and Hospital policies before completing the final settlement.

Applicable Laws & Standards

• Code on Wages, 2019.
• Payment of Gratuity Act, 1972.
• Employees' Provident Funds and Miscellaneous Provisions Act, 1952.
• Employees' State Insurance Act, 1948.
• Income Tax Act, 1961 (where applicable).
• Digital Personal Data Protection Act, 2023.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.

Full & Final Settlement

Subject to completion of all exit clearance formalities, the Hospital shall process the employee's Full and Final Settlement in accordance with applicable law and organisational procedures.

• Salary payable up to the last working day.
• Approved overtime payments, where applicable.
• Leave encashment, if eligible under Hospital policy.
• Incentives or other approved payments, where applicable.
• Lawful deductions authorised by law, contract or written employee consent.
• Recovery of outstanding advances, loans or other dues, where applicable.

Statutory Benefits

• Employees' Provident Fund (EPF) benefits shall be processed in accordance with applicable EPF regulations.
• Employees' State Insurance (ESI) benefits shall continue or cease as provided under the ESI Act and applicable regulations.
• Gratuity shall be paid to eligible employees in accordance with the Payment of Gratuity Act, 1972.
• Income tax deductions and statutory certificates shall be issued where applicable.
• Any other statutory benefit shall be administered in accordance with applicable law.

Non-Solicitation & Protection of Business Interests

During and after employment, employees shall not misuse confidential information, patient databases, Hospital records or proprietary business information for personal benefit or to cause harm to the Hospital. Nothing in this Policy shall restrict any lawful right of an employee under applicable law; however, employees remain responsible for complying with confidentiality obligations and any valid contractual commitments that survive termination of employment.

Employment Records & Certificates

• Relieving Letter (where applicable).
• Experience Certificate.
• Service Certificate.
• Salary Certificate, if requested.
• Statutory employment documents required by law.

Recovery of Losses

The Hospital reserves the right to recover any outstanding lawful dues, financial liabilities, unreturned Hospital property or losses caused by proven misconduct, negligence or breach of contractual obligations, subject to applicable law, principles of natural justice and the employee's contractual terms.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.

Standard Working Hours

• Standard working hours shall ordinarily be eight (8) hours per shift.
• Total duty hours, including authorised breaks, shall ordinarily not exceed nine (9) hours per shift unless otherwise permitted by applicable law.
• The normal working week shall ordinarily not exceed forty-eight (48) hours, subject to statutory provisions and operational requirements.
• Employees shall be provided with weekly rest days in accordance with applicable labour laws and Hospital duty rosters.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.
• NABH Care of Patients (COP) Standards.

Standard Shift Timings

• Morning Shift: 06:00 AM – 02:00 PM
• Evening Shift: 02:00 PM – 10:00 PM
• Night Shift: 10:00 PM – 06:00 AM
• Shift timings may be revised by Hospital Management based upon operational requirements.
• Certain departments may operate customised shift timings where clinically or operationally necessary.

Duty Roster Preparation

• Duty rosters shall ordinarily be prepared weekly or monthly.
• Department Heads shall prepare rosters in consultation with the Human Resources Department where required.
• Duty rosters shall be communicated sufficiently in advance whenever practicable.
• Employees are responsible for verifying their assigned duties and reporting any discrepancy promptly.
• The latest approved roster shall supersede all previous schedules.

Shift Exchange

• Employees shall not exchange shifts without prior written approval from the Department Head or authorised supervisor.
• Unauthorised shift swapping is prohibited.
• Approved shift exchanges shall be documented in the duty roster.
• Employees remain responsible for their assigned shift until an authorised change has been confirmed.

Rest Between Shifts

• The Hospital shall endeavour to provide an adequate rest interval between consecutive shifts.
• Ordinarily, employees should receive at least ten (10) hours of rest between scheduled shifts unless emergency circumstances require otherwise and applicable law permits.
• Employees shall promptly inform their supervisor if fatigue may compromise patient safety.

Double Shift & Extended Duty

• Double shifts shall not be assigned as a routine practice.
• Extended duty or double shifts may be permitted only during emergencies, disasters, public health incidents, staff shortages or other exceptional operational circumstances.
• Prior approval from authorised Hospital Management shall ordinarily be required.
• Applicable overtime provisions and employee safety considerations shall be observed.

Emergency Deployment

During emergencies, mass casualty incidents, disease outbreaks, disasters or other situations affecting Hospital operations, employees may be required to report for additional duty, remain on duty beyond scheduled hours or be temporarily reassigned to another department. Such deployment shall be coordinated by authorised Hospital Management in accordance with applicable law and patient care priorities.

Responsibilities of Department Heads

• Prepare and maintain accurate duty rosters.
• Ensure adequate staffing for all shifts.
• Minimise excessive working hours wherever reasonably practicable.
• Approve shift changes only where operationally appropriate.
• Maintain records of emergency deployments and roster amendments.
• Ensure proper clinical and administrative handover between shifts.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.

Biometric Attendance

• Biometric attendance is mandatory for all employees unless exempted in writing by Hospital Management.
• Employees shall record attendance personally at the beginning and end of every shift.
• Attendance shall not be recorded by another employee under any circumstances.
• Proxy attendance, buddy punching or manipulation of attendance records constitutes gross misconduct.
• Employees shall ensure successful biometric verification before commencing duty.

Reporting Time

• Employees are expected to report at least 10 minutes before the scheduled commencement of duty.
• Duty officially begins at the scheduled shift time and not at the time of biometric registration.
• Employees must be ready to commence work immediately upon the start of their shift.
• Preparation activities such as changing into uniform or storing personal belongings shall be completed before the scheduled duty time.

Early Departure

• Employees shall not leave the workplace before completion of scheduled duty hours without prior approval.
• Proper duty handover shall be completed before leaving the department.
• Unauthorised early departure may be treated as absenteeism for the corresponding period.

Absenteeism & No Call–No Show

• Employees unable to report for duty shall notify their reporting supervisor as early as reasonably practicable.
• Failure to report for duty without prior intimation or reasonable explanation may be treated as unauthorised absence.
• A "No Call–No Show" incident may constitute misconduct and may result in disciplinary proceedings.
• Repeated unauthorised absence may lead to Loss of Pay, suspension or other disciplinary action after following applicable procedures.

Attendance Corrections

• Attendance correction requests shall be submitted promptly through the prescribed procedure.
• Corrections require verification and approval by the authorised supervisor.
• False attendance correction requests may constitute misconduct.

Disciplinary Action for Attendance Violations

Attendance violations shall be addressed based on their nature, frequency and seriousness, while following the principles of natural justice and the Hospital's disciplinary procedures.

• First instance – Verbal counselling or advisory.
• Repeated violation – Written warning.
• Persistent or serious violations – Salary deduction or Loss of Pay where legally permissible.
• Habitual absenteeism, proxy attendance or attendance fraud – Formal disciplinary enquiry which may result in suspension or termination, subject to applicable law.

Responsibilities of Supervisors

• Monitor daily attendance of employees.
• Verify attendance correction requests.
• Report attendance irregularities promptly to Human Resources.
• Maintain accurate attendance records.
• Ensure adequate staffing despite unexpected absences.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.
• NABH Care of Patients (COP) Standards.

Overtime Policy

• Overtime shall be performed only with prior approval from the authorised supervisor or Department Head, except during emergencies.
• Unauthorised overtime shall not automatically qualify for overtime payment or compensatory benefits.
• Overtime shall be recorded through the Hospital's approved attendance and duty recording system.
• The Hospital shall comply with applicable legal provisions governing overtime work and compensation.
• Overtime shall be minimised through effective manpower planning wherever reasonably practicable.

Overtime Compensation

• Eligible employees may receive overtime wages or compensatory off in accordance with applicable law and Hospital policy.
• Overtime payments shall be processed only after verification and approval by the authorised Department Head.
• Certain managerial or contractual positions may not be eligible for overtime payments where specified in the employment contract and permitted by law.
• No employee shall manipulate attendance or working hours to claim unauthorised overtime.

Weekly Off

• Employees shall ordinarily receive one (1) weekly day of rest in accordance with applicable labour laws and approved duty rosters.
• Weekly off days may vary depending upon departmental operations and shift schedules.
• Operational requirements may occasionally require rescheduling of weekly off, subject to applicable law and compensatory arrangements where required.

On-Call & Emergency Duty

• Certain employees may be assigned on-call responsibilities depending upon their role and departmental requirements.
• Employees assigned to on-call duty shall remain reasonably available and respond promptly when contacted.
• During disasters, epidemics, pandemics, mass casualty incidents, fire emergencies or other Hospital emergencies, employees may be required to report for duty beyond normal working hours.
• Failure to respond to authorised emergency duty without reasonable cause may constitute misconduct.

Fatigue Management

• Department Heads shall monitor employee workload to minimise fatigue.
• Where reasonably practicable, adequate rest periods shall be provided between consecutive shifts.
• Employees who believe fatigue may compromise patient safety shall immediately notify their supervisor.
• Patient safety shall always take precedence when determining extended duty assignments.

Operational Authority During Emergencies

During emergencies, Hospital Management may modify duty schedules, cancel leave, recall employees, extend working hours within applicable legal limits, temporarily reassign staff or implement emergency staffing arrangements necessary to protect patients, employees and Hospital operations.

Applicable Laws & Standards

• Digital Personal Data Protection Act, 2023.
• Information Technology Act, 2000 (where applicable).
• National Medical Commission Professional Conduct Regulations, 2023 (where applicable).
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.
• NABH Care of Patients (COP) Standards.
• Hospital Data Privacy & Patient Confidentiality Policy.
• Hospital Cyber Security Policy.

General Rule

Personal mobile phones are strictly prohibited during working hours while employees are on duty, except where prior authorisation has been granted by Hospital Management for official purposes or genuine emergencies.

Prohibited Activities

• Making or receiving personal telephone calls during duty hours.
• Using WhatsApp, Telegram, Signal or other personal messaging applications.
• Browsing social media platforms including Facebook, Instagram, X (Twitter), Snapchat or similar applications.
• Watching YouTube or other streaming services.
• Playing games or using entertainment applications.
• Online shopping or personal banking during working hours.
• Recording photographs, videos or audio inside Hospital premises without written authorisation.
• Using personal devices to store, photograph or transmit patient information.
• Charging personal devices using Hospital electrical facilities without permission.

Photography & Recording

• No employee shall photograph, video record or audio record any patient without lawful authority and the required consent.
• No employee shall photograph confidential Hospital documents, computer screens, medical records or internal systems.
• Sharing Hospital photographs or videos on social media without written approval is strictly prohibited.
• Violation may result in disciplinary action and legal proceedings where applicable.

Official Devices

Mobile phones, tablets or communication devices issued by the Hospital shall be used exclusively for official duties. Employees shall protect such devices, maintain confidentiality and immediately report any loss, theft or security incident.

Emergency Family Contact

Family members requiring urgent communication with an employee during working hours should contact the Hospital Reception, Nursing Station or Human Resources Department. Genuine emergencies shall be communicated to the concerned employee through the appropriate official channel.

Disciplinary Action

Unauthorised use of personal mobile phones during working hours shall be treated as a workplace misconduct. Depending upon the seriousness, frequency and impact on patient care, disciplinary action may include:

• First Violation – Verbal counselling or written warning.
• Second Violation – Final written warning and appropriate disciplinary action in accordance with Hospital policy.
• Repeated Violations – Domestic enquiry, suspension or other disciplinary measures, up to and including termination of employment, in accordance with applicable law.
• Where the misconduct results in breach of patient confidentiality, data privacy or other legal obligations, the Hospital may also initiate appropriate legal action.

Employee Responsibilities

• Keep personal mobile phones switched off or on silent mode and stored securely during duty hours unless authorised otherwise.
• Use Hospital communication systems only for official purposes.
• Immediately report accidental disclosure of patient information or loss of an official communication device.
• Protect patient privacy, confidentiality and Hospital information at all times.
• Cooperate with authorised investigations relating to misuse of electronic devices.

Applicable Laws & Standards

• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Biomedical Waste Management Rules, 2016.
• NABH Human Resource Management (HRM) Standards.
• NABH Hospital Infection Prevention & Control (HIC) Standards.
• NABH Facility Management & Safety (FMS) Standards.

Uniform Policy

• Employees shall wear the prescribed Hospital uniform while on duty.
• Uniforms shall be clean, properly fitted and maintained in good condition.
• Only Hospital-approved uniforms shall be worn during duty hours.
• Employees shall not alter or modify the prescribed uniform without approval.
• Uniforms shall not be worn outside official duties except while travelling directly to or from work where appropriate.

Personal Grooming

• Maintain good personal hygiene at all times.
• Hair shall be neat, clean and appropriately secured where required.
• Fingernails shall be clean, short and suitable for clinical work.
• Strong perfumes or fragrances shall be avoided.
• Employees shall maintain a professional appearance throughout their duty hours.
• Clinical staff shall comply with infection prevention requirements regarding grooming.

Employee Identification Card

• The official Hospital Identity Card shall be worn prominently during duty hours.
• Identity Cards remain the property of the Hospital.
• Loss of an Identity Card shall be reported immediately to Human Resources.
• Identity Cards shall not be altered, duplicated or shared with any other person.
• Identity Cards shall be surrendered upon separation from employment.

Prohibited Attire

• Casual or inappropriate clothing during duty hours.
• Slippers or unsafe footwear unless specifically permitted.
• Excessive jewellery that may interfere with patient care or infection control.
• Clothing displaying offensive, political or commercial messages.
• Any attire considered unsafe, unhygienic or inconsistent with professional healthcare practice.

Non-Compliance

Employees who fail to comply with the Hospital's uniform, grooming or identification requirements may be instructed to correct the deficiency before commencing duty. Repeated violations may result in counselling, written warnings or disciplinary action in accordance with the Hospital's disciplinary procedures and applicable law.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force).
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.
• NABH Care of Patients (COP) Standards.

Expected Standards of Conduct

• Treat every patient with dignity, compassion and respect.
• Maintain professional communication at all times.
• Respect colleagues regardless of designation or department.
• Maintain honesty, integrity and accountability.
• Protect patient confidentiality and Hospital information.
• Follow lawful instructions issued by authorised supervisors.
• Promote teamwork and cooperate across departments.
• Maintain a calm, courteous and patient-focused attitude.

Tobacco-Free Hospital

• Smoking, vaping and use of tobacco products are strictly prohibited inside the Hospital premises.
• The prohibition applies to employees, consultants, contractors, visitors and attendants unless a specifically designated area exists outside patient care areas and is permitted by law.
• Employees shall not report for duty smelling strongly of tobacco where it may affect patients or the professional image of the Hospital.

Alcohol & Drug-Free Workplace

• Reporting for duty under the influence of alcohol is strictly prohibited.
• Possession, consumption or distribution of alcohol within Hospital premises is prohibited unless specifically authorised for official purposes permitted by law.
• Possession, use or distribution of illegal drugs or narcotic substances is strictly prohibited.
• Employees using prescribed medication that may impair their ability to work safely shall promptly inform their reporting supervisor where appropriate.
• The Hospital may take appropriate action where an employee's fitness for duty is reasonably in question, consistent with applicable law.

Political & Religious Activities

• Employees shall not engage in political campaigning during working hours.
• Religious practices shall not interfere with patient care or Hospital operations.
• No employee shall pressure another person regarding political or religious beliefs.
• Hospital premises shall not be used for unauthorised political meetings, campaigns or demonstrations.

Respect for Hospital Property

• Employees shall use Hospital property responsibly and only for authorised purposes.
• Waste, misuse or intentional damage to Hospital property is prohibited.
• Hospital equipment shall not be removed from the premises without written authorisation.
• Employees shall immediately report any damage, loss or unsafe condition.

Disciplinary Action

Violations of this Policy shall be investigated fairly and confidentially. Depending upon the nature and seriousness of the misconduct, disciplinary action may include counselling, written warnings, suspension, domestic enquiry or termination of employment, in accordance with the principles of natural justice, applicable labour laws and the Hospital's disciplinary procedures.

• Minor misconduct may result in counselling or written warning.
• Repeated misconduct may result in final warning or suspension.
• Gross misconduct, including violence, serious harassment, intoxication while on duty or conduct endangering patient safety, may result in immediate suspension pending enquiry and may lead to dismissal after due process.

Applicable Laws & Standards

• Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
• National Medical Commission Act, 2019 and applicable Professional Conduct Regulations.
• Indian Nursing Council Standards and applicable State Nursing Council Regulations.
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Industrial Relations Code, 2020 (where brought into force).
• NABH Care of Patients (COP) Standards.
• NABH Hospital Infection Prevention & Control (HIC) Standards.
• NABH Human Resource Management (HRM) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.

Employee Duty of Care

• Provide safe, competent and timely patient care.
• Perform only those duties for which the employee is trained, authorised and competent.
• Follow Hospital policies, SOPs and clinical protocols.
• Immediately seek assistance where patient safety may be compromised.
• Protect patients from avoidable harm.
• Report unsafe conditions without delay.

Shift Handover Responsibilities

• Every employee shall complete a proper handover before leaving duty.
• Critical patient information shall be communicated accurately and completely.
• Pending investigations, treatments, medications and procedures shall be clearly handed over.
• Medical records and nursing documentation shall be updated before completion of duty.
• Failure to conduct an adequate handover may constitute professional negligence.

Incident Reporting

• Employees shall immediately report clinical incidents, near misses and patient safety events.
• Reporting shall be made through the Hospital's Incident Reporting System.
• No employee shall conceal, alter or destroy incident-related records.
• Timely reporting enables corrective action and quality improvement.

Abandonment of Duty

Employees shall not abandon their assigned duties, leave patients unattended or leave the Hospital premises during scheduled working hours without obtaining prior authorisation from the appropriate supervisor. Abandonment of duty that compromises patient safety shall be treated as serious misconduct.

Investigation & Disciplinary Action

Allegations of negligence shall be investigated fairly, objectively and confidentially. Depending upon the seriousness of the incident, disciplinary action may include:

• Performance counselling and retraining.
• Verbal or written warning.
• Final written warning.
• Temporary suspension pending enquiry.
• Domestic enquiry in accordance with the principles of natural justice.
• Termination of employment for proven gross negligence or serious misconduct.
• Referral to statutory or professional authorities where required by law.

Hospital Responsibilities

• Provide appropriate orientation and competency-based training.
• Maintain adequate staffing wherever reasonably practicable.
• Investigate incidents impartially.
• Implement corrective and preventive actions.
• Promote a culture of patient safety and continuous quality improvement.
• Ensure disciplinary action is proportionate and consistent with applicable law.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Code on Wages, 2019.
• Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.

Employee Accountability

• Perform assigned duties with competence, diligence and integrity.
• Comply with all Hospital policies, SOPs, departmental manuals and clinical protocols.
• Follow lawful instructions issued by authorised supervisors and Hospital Management.
• Protect patients, visitors, colleagues, Hospital property and confidential information.
• Maintain accurate documentation and official records.
• Immediately report unsafe practices, hazards, incidents or policy violations.
• Participate in mandatory training, drills, audits and competency assessments.
• Maintain professional registration, licences and certifications where applicable.

Cooperation During Audits & Inspections

• Employees shall cooperate fully during NABH assessments, statutory inspections and internal audits.
• Requested records and information shall be provided accurately and promptly.
• No employee shall conceal, alter or destroy official records.
• Employees shall cooperate during quality improvement initiatives, investigations and corrective action programmes.

Compliance with Policies

• Employees shall read and comply with all Hospital policies and procedures.
• Ignorance of Hospital policies shall not ordinarily be accepted as a defence for non-compliance.
• Updated policies shall become effective from the date notified by Hospital Management.
• Employees may be required to acknowledge revised policies in writing or electronically.

Amendments to Policies

Sri Lakshmi Multi Speciality Hospital reserves the right to amend, revise, replace or withdraw any provision of this Human Resources Policy Manual to reflect changes in applicable laws, accreditation requirements, organisational structure, patient care standards or operational needs. Such amendments shall take effect from the date specified by the Hospital unless otherwise stated.

Non-Compliance

Failure to comply with this Policy, Hospital procedures, lawful management instructions or statutory obligations may result in counselling, retraining, written warnings, suspension, domestic enquiry or termination of employment, depending upon the nature and seriousness of the violation and in accordance with applicable law and the principles of natural justice.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Social Security, 2020 (where brought into force by the appropriate Government).
• Maternity Benefit Act, 1961 (as amended).
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.

General Principles

• Leave shall ordinarily be planned and approved in advance.
• Grant of leave is subject to patient care requirements and departmental staffing.
• No employee shall proceed on leave without obtaining approval from the competent authority, except in genuine emergencies.
• Submission of a leave application does not constitute approval.
• Employees shall remain responsible for reporting to duty until leave is formally approved.
• The Hospital reserves the right to approve, defer, modify or refuse leave based on operational requirements, subject to applicable law.

Misuse of Leave

• Providing false reasons or forged medical certificates is strictly prohibited.
• Undertaking employment elsewhere while on approved sick leave is prohibited unless legally permitted and specifically authorised.
• Failure to return after expiry of approved leave without valid reason may be treated as unauthorised absence.
• Misuse of leave may result in disciplinary action in accordance with Hospital policy and applicable law.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Social Security, 2020 (where brought into force by the appropriate Government).
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.

Eligibility

• Casual Leave shall be available only to employees eligible under Hospital policy.
• Eligibility during probation shall be governed by the Appointment Letter or applicable Hospital rules.
• The annual Casual Leave entitlement shall be notified separately by Hospital Management in accordance with applicable law.
• Part-time, temporary or contract employees shall be governed by their respective employment terms.

Application Procedure

• Leave shall ordinarily be applied for in advance using the prescribed leave application procedure.
• The leave request shall clearly specify the reason and duration of absence.
• Leave shall commence only after formal approval by the authorised supervisor.
• In emergency situations, the employee shall notify the reporting supervisor at the earliest possible opportunity and submit the prescribed leave application upon returning to duty.

Utilisation Rules

• Casual Leave shall ordinarily be utilised for short-duration personal requirements.
• Employees shall avoid frequent or repetitive Casual Leave that disrupts departmental operations.
• Casual Leave may be combined with weekly off or public holidays only where specifically approved by the competent authority and permitted under Hospital policy.
• Carry forward or encashment of Casual Leave shall be governed by Hospital policy and applicable law.

Unauthorised Leave

• Proceeding on leave without approval shall constitute unauthorised absence.
• Failure to report for duty after expiry of approved leave without reasonable explanation may be treated as misconduct.
• Repeated unauthorised leave may result in Loss of Pay (LOP), disciplinary proceedings or other action in accordance with applicable law.

Misuse of Casual Leave

• Providing false information to obtain leave is strictly prohibited.
• Submitting forged documents in support of leave shall constitute serious misconduct.
• Using Casual Leave for unauthorised employment or commercial activities that conflict with Hospital interests may result in disciplinary action.
• Habitual misuse of Casual Leave may lead to counselling, written warning or disciplinary proceedings.

Management Rights

Hospital Management reserves the right to approve, defer, cancel or recall approved Casual Leave in exceptional circumstances involving patient safety, public health emergencies, disasters, statutory inspections or critical operational requirements. Wherever reasonably practicable, affected employees shall be informed promptly.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Social Security, 2020 (where brought into force).
• Employees' State Insurance Act, 1948 (where applicable).
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.
• NABH Hospital Infection Prevention & Control (HIC) Standards.

Eligibility

• Sick Leave shall be available to eligible employees in accordance with Hospital policy and applicable law.
• The annual Sick Leave entitlement shall be notified separately by Hospital Management.
• Eligibility during probation, temporary employment or contractual service shall be governed by the applicable employment terms.
• Employees covered under the Employees' State Insurance (ESI) Scheme shall also be governed by applicable ESI provisions.

Notification of Illness

• An employee unable to report for duty due to illness shall inform the Reporting Supervisor or Department Head at the earliest possible opportunity.
• Notification should ordinarily be made before the commencement of the scheduled shift.
• Failure to provide timely information without reasonable cause may result in the absence being treated as unauthorised.
• Notification by a family member may be accepted where the employee is medically unable to communicate.

Fitness to Resume Duty

• The Hospital may require a Fitness Certificate before permitting an employee to resume duties after prolonged illness, surgery or infectious disease.
• Employees shall not return to duty if medically unfit or where doing so may endanger patients or colleagues.
• The Occupational Health Team or authorised Medical Officer may assess fitness for duty where necessary.

Infectious Diseases

• Employees diagnosed with communicable diseases shall promptly inform the Hospital where patient safety may be affected.
• Employees shall comply with Hospital Infection Prevention & Control (IPC) requirements before returning to work.
• The Hospital may temporarily modify duties or restrict clinical work where medically necessary.

Misuse of Sick Leave

• Using Sick Leave for non-medical purposes is prohibited.
• Working elsewhere while on Sick Leave without lawful authorisation is prohibited.
• Submission of false medical documents or concealment of relevant medical information may result in disciplinary action.
• The Hospital may initiate verification or disciplinary proceedings where misuse is suspected.

Management Rights

Hospital Management reserves the right to seek additional medical information, require an independent medical assessment where legally permissible, modify work assignments, approve or refuse Sick Leave based upon available evidence and take appropriate action in cases of misuse, subject to applicable law and principles of natural justice.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Social Security, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.

Eligibility & Accrual

• Earned Leave shall accrue only to eligible employees in accordance with applicable law and Hospital policy.
• Eligibility shall ordinarily commence after completion of the minimum qualifying period prescribed under applicable law or Hospital policy.
• The annual Earned Leave entitlement shall be determined by the Hospital in accordance with statutory requirements.
• Probationary, temporary or contract employees shall be governed by their respective employment terms unless otherwise provided.

Application & Approval

• Earned Leave shall ordinarily be applied for well in advance through the prescribed leave application process.
• Long-duration leave should normally be planned sufficiently in advance to facilitate manpower planning.
• Approval shall depend upon departmental workload, patient care requirements and availability of suitable replacement staff.
• Employees shall not proceed on Earned Leave until written approval has been granted by the competent authority.

Leave Encashment

• Earned Leave encashment shall be governed by applicable law and Hospital policy.
• Encashment may be permitted upon separation from employment or in other circumstances approved by Hospital Management.
• Encashment shall be calculated based on applicable statutory provisions and approved salary components.
• No encashment shall be payable where expressly prohibited by law or the employee's contract of employment.

Combination with Other Leave

• Earned Leave may be combined with other eligible categories of leave where approved by the competent authority.
• Prefixing or suffixing Earned Leave with weekly off days or public holidays shall be governed by Hospital policy.
• The Hospital may restrict long continuous leave where patient care or departmental functioning may be adversely affected.

Recall or Cancellation of Leave

In exceptional circumstances involving patient safety, public health emergencies, disasters, statutory inspections or critical manpower shortages, Hospital Management reserves the right to defer, cancel or recall approved Earned Leave. Wherever reasonably practicable, affected employees shall receive prior notice and any unused leave shall be restored in accordance with Hospital policy.

Restrictions

• Employees serving a notice period may not ordinarily avail Earned Leave unless specifically approved by Hospital Management.
• False leave applications or misuse of Earned Leave shall constitute misconduct.
• Unauthorised extension of Earned Leave without approval may result in Loss of Pay (LOP) and disciplinary action.
• Employees shall remain contactable during extended leave where reasonably necessary for official communication.

Management Rights

Hospital Management reserves the right to regulate, approve, postpone or refuse Earned Leave based upon statutory requirements, patient safety, departmental workload, staffing availability and operational necessity. Such decisions shall be made fairly, consistently and in accordance with applicable law.

Applicable Laws & Standards

• Maternity Benefit Act, 1961 (as amended by the Maternity Benefit (Amendment) Act, 2017).
• Code on Social Security, 2020 (where brought into force by the appropriate Government).
• Employees' State Insurance Act, 1948 (where applicable).
• Code on Wages, 2019.
• NABH Human Resource Management (HRM) Standards.
• NABH Hospital Infection Prevention & Control (HIC) Standards.

Maternity Leave

• Eligible female employees shall be entitled to maternity benefits in accordance with the Maternity Benefit Act, 1961 and applicable amendments.
• Leave duration, eligibility and payment shall be governed by the applicable statutory provisions in force at the relevant time.
• The employee shall submit the prescribed application together with supporting medical documentation.
• The Hospital may require reasonable medical certification confirming pregnancy and the expected date of delivery.
• Maternity Leave shall be recorded and administered by the Human Resources Department.

Adoption & Commissioning Mother Benefits

Eligible employees adopting a child or employees recognised as commissioning mothers shall be entitled to maternity-related benefits to the extent provided under applicable law. Applications shall be supported by the prescribed legal and medical documentation.

Nursing & Child Care Support

• Eligible employees shall receive nursing breaks and related benefits as required by applicable law.
• Department Heads shall make reasonable operational arrangements to facilitate statutory nursing breaks without compromising patient safety.
• The Hospital may provide additional child care facilities or support wherever available and operationally feasible.

Paternity Leave

Where approved by the Hospital as an employee welfare benefit, eligible male employees may be granted paternity leave in accordance with the Hospital's internal policy. As there is presently no universal statutory requirement for private-sector employers to provide paid paternity leave, the duration, eligibility and conditions shall be determined by Hospital Management.

Protection Against Discrimination

• No eligible employee shall be denied statutory maternity benefits.
• No employee shall be discriminated against solely on the grounds of pregnancy or maternity.
• Employment decisions relating to maternity shall comply with applicable labour laws.
• The Hospital shall endeavour to facilitate a safe and appropriate return-to-work process following maternity leave.

Documentation Requirements

• Prescribed leave application.
• Medical certificate from a Registered Medical Practitioner, where required.
• Expected Date of Delivery (EDD) certificate, where applicable.
• Birth certificate, adoption documents or other supporting records where required.
• Fitness Certificate before resuming duty where medically necessary.

Management Responsibilities

• Process maternity-related benefits promptly and confidentially.
• Protect employee medical information and privacy.
• Ensure compliance with statutory maternity benefit provisions.
• Coordinate departmental staffing during the employee's absence.
• Facilitate a safe and orderly return to work following maternity leave.

Applicable Laws & Standards

• Tamil Nadu Industrial Establishments (National and Festival Holidays) Act, 1958 and applicable Rules.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.

National & Festival Holidays

• The Hospital shall observe National Holidays and Festival Holidays as required under applicable law.
• The annual holiday list shall be notified by Hospital Management.
• Holiday schedules may differ between departments depending upon operational requirements.
• Emergency and essential services shall continue to function during all holidays.

Holiday Duty

• Employees may be rostered for duty on National Holidays, Festival Holidays or Weekly Off days where required.
• Duty allocation shall be based upon patient care requirements, staffing availability and departmental needs.
• Employees assigned to holiday duty shall report punctually and perform their duties in accordance with Hospital policies.
• Unauthorised absence from assigned holiday duty may constitute misconduct.

Weekly Off

• Employees shall ordinarily receive one weekly day of rest in accordance with applicable labour laws and approved duty rosters.
• The weekly off may vary depending upon shift schedules and departmental requirements.
• Weekly off days may be rescheduled where operational necessity so requires.
• Employees shall not assume a fixed weekly off unless officially notified.

Operational Requirements

Hospital Management reserves the right to require employees to work on holidays, recall employees during emergencies, modify duty rosters or postpone weekly off days where patient safety, statutory obligations, public health emergencies, disasters or other operational requirements necessitate such action. Wherever reasonably practicable, employees shall receive advance notice.

Misuse of Holiday Benefits

• False claims for Compensatory Off or holiday benefits are prohibited.
• Unauthorised absence before or after holiday duty to extend leave may result in disciplinary action.
• Employees shall accurately record attendance during holiday duties.
• Any attempt to manipulate duty rosters or attendance records shall constitute misconduct.

Management Responsibilities

• Publish the annual holiday calendar.
• Ensure equitable distribution of holiday duties wherever reasonably practicable.
• Maintain accurate records of holiday attendance and Compensatory Off.
• Process holiday-related benefits in accordance with applicable law and Hospital policy.
• Ensure continuity of essential patient care during all holidays.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• Code on Social Security, 2020 (where brought into force).
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.

Leave Without Pay (LWP)

• LWP may be granted only after all eligible leave balances have been exhausted, unless otherwise approved by Hospital Management.
• LWP requires prior written approval from the competent authority.
• Grant of LWP shall depend upon departmental staffing, patient care requirements and operational necessity.
• The period of LWP may affect salary, statutory benefits, leave accrual and other employment benefits, subject to applicable law.
• Approval of one LWP request shall not create a precedent or entitlement for future requests.

Unauthorised Absence

• Failure to report for duty without prior approval or reasonable justification shall constitute unauthorised absence.
• Proceeding on leave without approval is strictly prohibited.
• Failure to report after expiry of approved leave without proper communication may be treated as unauthorised absence.
• Repeated unauthorised absence adversely affects patient care and departmental operations.

Extension of Leave

• Employees requiring an extension of approved leave shall apply before the expiry of the existing leave period wherever reasonably practicable.
• Leave extension is not automatic and requires fresh approval.
• Failure to obtain approval may result in the additional period being treated as unauthorised absence.
• Employees shall remain available for official communication during extended leave where reasonably required.

Absconding from Duty

An employee who remains absent without authorised leave, fails to communicate with the Hospital for a prolonged period or fails to respond to official notices may be treated as having abandoned service, subject to applicable labour laws, contractual obligations and the principles of natural justice. Appropriate notices and enquiry procedures shall be followed before any final decision is taken.

False Documentation & Leave Fraud

• Submission of forged medical certificates or false supporting documents is strictly prohibited.
• Providing false information to obtain leave constitutes misconduct.
• The Hospital reserves the right to verify the authenticity of documents submitted in support of leave applications.
• Leave fraud may result in disciplinary proceedings and, where appropriate, legal action.

Disciplinary Action

Misuse of leave, habitual absenteeism or unauthorised absence shall be dealt with in accordance with the Hospital's disciplinary procedures, applicable labour laws and the principles of natural justice.

• Verbal counselling for minor first-time violations.
• Written warning for repeated violations.
• Loss of Pay (LOP) where legally permissible.
• Domestic enquiry for serious or repeated misconduct.
• Suspension or termination where misconduct is established after due process.

Management Rights

Hospital Management reserves the right to approve, refuse, postpone or cancel Leave Without Pay, investigate suspected leave misuse, verify supporting documents and take appropriate disciplinary action in accordance with applicable law, contractual obligations and Hospital policy. All actions shall be undertaken fairly, consistently and in compliance with the principles of natural justice.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Code on Social Security, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Industrial Relations Code, 2020 (where brought into force).
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Information Management System (IMS) Standards.

Leave Approval Authority

• All leave applications shall be submitted through the prescribed Hospital procedure.
• Leave shall be approved only by the competent authority authorised by Hospital Management.
• Department Heads shall ensure that leave approvals do not adversely affect patient care or departmental operations.
• Human Resources shall maintain official records of all approved leave.
• No employee shall approve his or her own leave.

Leave Records

• The Human Resources Department shall maintain complete leave records for every employee.
• Leave balances shall be updated periodically through the approved HR system.
• Employees may request information regarding their available leave balance through the prescribed procedure.
• Leave records shall be retained in accordance with statutory record retention requirements and Hospital policy.
• Confidentiality of employee leave records shall be maintained at all times.

Leave During Probation & Notice Period

• Leave during the probation period shall ordinarily be restricted unless specifically approved or required by law.
• Employees serving notice of resignation may not ordinarily avail long-duration leave unless expressly approved by Hospital Management.
• Hospital Management may require an employee to complete the applicable notice period before relieving from service.
• Statutory leave entitlements shall continue to be governed by applicable law.

Recall or Cancellation of Leave

Approved leave may be cancelled, postponed or an employee may be recalled to duty where patient safety, public health emergencies, natural disasters, statutory inspections, mass casualty incidents, epidemics, pandemics or other critical operational circumstances require immediate staff availability. Wherever reasonably practicable, advance notice shall be provided and appropriate leave adjustments shall be made.

Responsibilities

Employees shall:

• Submit leave applications within the prescribed timelines.
• Provide supporting documents whenever required.
• Maintain truthful and accurate information.
• Complete proper duty handover before leave.
• Report back to duty immediately upon expiry of approved leave.

Department Heads & Human Resources shall:

• Process leave applications fairly and consistently.
• Maintain accurate leave records.
• Ensure adequate staffing during employee absence.
• Monitor leave trends and potential misuse.
• Ensure compliance with statutory labour requirements.

Non-Compliance

Any misuse of leave, falsification of records, repeated unauthorised absence or violation of the Hospital's leave procedures may result in counselling, written warning, Loss of Pay (where legally permissible), domestic enquiry, suspension or termination of employment, depending upon the nature and seriousness of the misconduct and in accordance with applicable law and the principles of natural justice.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• NABH Human Resource Management (HRM) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.
• NABH Governance & Leadership (GL) Standards.

Objectives of Performance Management

• Promote high standards of patient care and service quality.
• Align employee performance with Hospital goals and values.
• Encourage continuous professional development.
• Recognise and reward good performance.
• Identify performance gaps and training requirements.
• Support fair decisions regarding confirmation, promotion, increments and career progression.
• Enhance teamwork, accountability and operational efficiency.

Scope

This Policy applies to all employees of Sri Lakshmi Multi Speciality Hospital, including clinical, nursing, technical, administrative, support and contractual employees, to the extent applicable under their employment terms and Hospital policy.

Shared Responsibility

• Employees are responsible for performing assigned duties to the best of their ability.
• Supervisors are responsible for providing guidance, feedback and fair evaluation.
• Department Heads shall monitor departmental performance and competency.
• Human Resources shall coordinate the Performance Management System and maintain official records.
• Hospital Management shall promote a culture of continuous improvement and professional excellence.

General Provisions

• Performance Management shall not be used as a punitive process.
• Employees shall be provided reasonable opportunities to improve performance where deficiencies are identified.
• Serious misconduct shall be addressed under the Hospital's Disciplinary Policy and not solely through performance management.
• Performance records shall remain confidential and accessible only to authorised personnel.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• NABH Human Resource Management (HRM) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.
• NABH Governance & Leadership (GL) Standards.

Types of Performance Appraisal

• Probation Performance Review.
• Confirmation Assessment.
• Annual Performance Appraisal (APA).
• Mid-Year Performance Review, where applicable.
• Special Performance Review for employees requiring performance improvement.
• Competency Assessment as required under NABH standards.

Key Performance Indicators (KPIs)

Departments may establish role-specific Key Performance Indicators (KPIs) based upon clinical, technical or administrative responsibilities. KPIs shall be measurable, relevant, achievable and aligned with the Hospital's strategic objectives and patient care standards.

• Patient care quality.
• Patient satisfaction.
• Documentation compliance.
• Attendance and punctuality.
• Clinical outcome indicators.
• Department-specific productivity measures.
• Compliance with statutory and NABH requirements.

Employee Participation

• Employees may be invited to complete a self-assessment before the formal appraisal.
• Employees shall have an opportunity to discuss appraisal findings with the reporting supervisor.
• Employees may provide comments or clarification where appropriate.
• Acknowledgement of the appraisal does not necessarily indicate agreement with the evaluation.

Responsibilities of Appraisers

• Conduct evaluations fairly, objectively and without bias.
• Use documented evidence and measurable performance indicators.
• Provide constructive feedback and development guidance.
• Identify training and competency improvement needs.
• Maintain confidentiality of appraisal records.
• Avoid discrimination, favouritism or personal bias.

Performance Ratings

The Hospital may utilise a structured rating system to evaluate employee performance. Rating categories, scoring methodology and evaluation forms shall be prescribed by Human Resources and approved by Hospital Management. Performance ratings shall serve as one of several factors considered for confirmation, promotions, increments, training and career development and shall not constitute an automatic entitlement to any employment benefit.

Performance Improvement Plan (PIP)

• Employees whose performance falls below expected standards may be placed on a Performance Improvement Plan (PIP).
• The PIP shall identify specific improvement areas, measurable objectives, support mechanisms and review timelines.
• Coaching, mentoring or additional training may be provided during the improvement period.
• Failure to demonstrate satisfactory improvement may result in further administrative or disciplinary action, as appropriate.

Records & Confidentiality

• Performance appraisal records shall be maintained confidentially by the Human Resources Department.
• Access shall be limited to authorised personnel.
• Performance records shall be retained in accordance with Hospital policy and applicable statutory requirements.
• Unauthorised disclosure of appraisal records is prohibited.

Review & Appeal

Employees who believe that their appraisal contains factual inaccuracies or has not been conducted fairly may submit a written representation to Human Resources within the prescribed timeframe. The Hospital may review the appraisal and, where appropriate, conduct a secondary evaluation. The decision of Hospital Management following such review shall ordinarily be final.

Applicable Laws & Standards

• Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
• Occupational Safety, Health and Working Conditions Code, 2020 (where brought into force).
• Biomedical Waste Management Rules, 2016.
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.
• NABH Hospital Infection Prevention & Control (HIC) Standards.
• NABH Facility Management & Safety (FMS) Standards.

Employee Orientation Programme

Every newly appointed employee shall undergo a structured orientation programme before assuming independent responsibilities. Orientation shall familiarise employees with the Hospital's mission, policies, safety procedures, ethical standards and departmental functions.

• Hospital Vision, Mission and Values.
• Organisation Structure.
• HR Policies and Code of Conduct.
• Patient Rights and Responsibilities.
• Patient Safety Goals.
• Hospital Emergency Codes.
• Fire & Disaster Management.
• Confidentiality and Data Privacy.
• Department-specific orientation.

Continuing Professional Education

• Doctors shall participate in Continuing Medical Education (CME) programmes wherever applicable.
• Nursing personnel shall participate in Continuing Nursing Education (CNE).
• Technical staff shall undergo role-specific competency enhancement programmes.
• Administrative employees shall receive periodic training relevant to their functions.
• The Hospital may sponsor or nominate employees for external training programmes where appropriate.

Competency Assessment

• Competency assessments shall be conducted at induction and periodically thereafter.
• Employees shall demonstrate competence before independently performing critical procedures.
• Clinical competencies shall be reassessed whenever new equipment, technology or procedures are introduced.
• Competency assessments may include written tests, practical demonstrations, direct observation or simulation exercises.
• Employees who do not meet competency standards may undergo retraining before reassessment.

Refresher Training

• Mandatory refresher training shall be conducted periodically as determined by Hospital Management.
• Attendance at mandatory refresher programmes is compulsory.
• Additional refresher training may be organised following incidents, audit findings, regulatory changes or introduction of new systems.
• Department Heads shall ensure employee participation in scheduled refresher programmes.

Employee Responsibilities

• Attend all mandatory training programmes.
• Actively participate in competency assessments.
• Maintain professional licences, registrations and certifications applicable to their role.
• Apply acquired knowledge in daily practice.
• Promptly report any training needs to the Reporting Supervisor.
• Comply with revised procedures introduced through training programmes.

Hospital Responsibilities

• Develop an annual Training Calendar.
• Conduct mandatory induction programmes.
• Identify departmental training requirements.
• Provide competency-based education.
• Maintain training infrastructure and qualified trainers.
• Evaluate training effectiveness.
• Maintain complete documentation for accreditation and statutory compliance.

Non-Compliance

Failure to attend mandatory training programmes, refusal to participate in competency assessments or failure to maintain required professional competence may result in temporary restriction of duties, retraining, suspension of specific clinical privileges, performance counselling or disciplinary action in accordance with Hospital policy, applicable law and NABH requirements.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force by the appropriate Government).
• Code on Wages, 2019.
• Tamil Nadu Shops and Establishments Act, 1947 and applicable Rules.
• Equal Remuneration principles under applicable labour laws.
• NABH Human Resource Management (HRM) Standards.
• NABH Governance & Leadership (GL) Standards.
• NABH Continuous Quality Improvement (CQI) Standards.

Promotion Policy

• Promotions shall be based upon merit, competency, experience, performance, integrity and organisational requirements.
• Vacancies shall ordinarily be filled through internal promotion wherever suitable candidates are available.
• The Hospital reserves the right to recruit externally whenever appropriate internal candidates are unavailable.
• Promotion shall become effective only after written approval by the Competent Authority.
• A change in job title shall not automatically result in salary revision unless specifically approved.

Salary Increment Policy

• Annual salary increments, where applicable, shall be based upon performance, organisational performance, financial sustainability and Management approval.
• Performance ratings may be considered while determining increment eligibility.
• Employees under disciplinary proceedings or Performance Improvement Plans (PIP) may have increments deferred, subject to applicable law and Hospital policy.
• No employee shall claim salary increment as a contractual right unless specifically provided in the employment contract or required by law.

Recognition & Reward Programmes

The Hospital may recognise exceptional employee contributions through formal or informal recognition programmes designed to encourage excellence, innovation, teamwork and outstanding patient care.

• Employee of the Month.
• Employee of the Year.
• Clinical Excellence Awards.
• Long Service Awards.
• Quality Improvement Recognition.
• Patient Appreciation Recognition.
• Special Achievement Awards.

Succession Planning

• The Hospital may identify employees with leadership potential for succession planning.
• Successor identification shall be based upon competency, performance and organisational requirements.
• Participation in succession planning does not guarantee future promotion.
• Development plans may be prepared for identified employees.

Management Discretion

Hospital Management retains the sole discretion to determine promotions, salary revisions, designation changes, special increments, incentive schemes and recognition programmes based upon organisational requirements, employee performance, available vacancies, financial considerations and applicable laws. Nothing contained in this Policy shall be interpreted as creating an automatic entitlement to promotion, increment or advancement.

Non-Discrimination & Fairness

• Promotion and increment decisions shall be made without unlawful discrimination.
• Assessment shall be based upon objective and documented performance criteria.
• Employees shall not be disadvantaged on the basis of gender, religion, caste, disability, age or any other protected characteristic under applicable law.
• Records supporting promotion and increment decisions shall be maintained by Human Resources.

Applicable Laws & Standards

• National Medical Commission Act, 2019.
• National Medical Commission Registered Medical Practitioner Regulations.
• Indian Nursing Council Act, 1947 and applicable State Nursing Council Regulations.
• Pharmacy Act, 1948.
• National Commission for Allied and Healthcare Professions Act, 2021.
• Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable).
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.
• NABH Care of Patients (COP) Standards.
• NABH Information Management System (IMS) Standards.

Professional Registration

• All regulated healthcare professionals shall maintain valid registration with the appropriate statutory council or regulatory authority.
• Employees shall provide copies of registration certificates, licences and renewal documents whenever requested.
• Professional registrations shall remain valid throughout employment.
• Employees shall immediately notify Human Resources of any suspension, cancellation, restriction or disciplinary action affecting their professional registration.

Clinical Privileging

Clinical privileges shall be granted only to appropriately qualified and credentialed medical professionals after assessment of education, training, experience, competency and professional registration. Clinical privileges may be revised, restricted or withdrawn where patient safety, professional competency or regulatory compliance so requires.

• Privileges shall correspond to demonstrated competency.
• Special procedures may require additional credential verification.
• Periodic review of clinical privileges may be conducted.

Licence Renewal

• Employees are personally responsible for timely renewal of professional registrations and licences.
• Renewed registration documents shall be submitted to Human Resources before expiry wherever practicable.
• The Hospital may issue reminders; however, responsibility for renewal remains with the employee.
• Failure to renew a required licence shall not relieve the employee of this responsibility.

Continuing Professional Development

• Employees shall participate in Continuing Medical Education (CME), Continuing Nursing Education (CNE) or other professional development programmes where required.
• Employees shall comply with continuing education requirements prescribed by their professional regulatory bodies.
• Evidence of completed educational programmes may be requested for credential maintenance.
• The Hospital may facilitate professional development programmes wherever operationally feasible.

Expired, Suspended or Invalid Registration

• An employee whose professional registration or licence has expired, been suspended or cancelled shall immediately inform Human Resources.
• The Hospital may temporarily restrict or suspend clinical duties until valid registration is restored.
• No employee shall independently perform duties requiring statutory registration without a valid licence.
• Knowingly practising without valid registration may constitute serious misconduct and may attract legal consequences.

False Qualifications & Misrepresentation

• Submission of forged certificates, false qualifications or fabricated experience documents is strictly prohibited.
• Misrepresentation of professional credentials shall constitute gross misconduct.
• The Hospital reserves the right to verify any qualification at any stage of employment.
• Where fraud is established, disciplinary action, termination of employment and appropriate legal proceedings may be initiated.

Hospital Responsibilities

• Maintain updated records of professional registrations and licences.
• Conduct periodic credential reviews and verification.
• Ensure only appropriately credentialed personnel perform regulated clinical duties.
• Maintain confidential credential files.
• Comply with NABH credentialing and privileging requirements.
• Support professional development and continuing education wherever feasible.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force).
• Tamil Nadu Shops and Establishments Act, 1947.
• Code on Wages, 2019.
• Occupational Safety, Health and Working Conditions Code, 2020.
• Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.

Disciplinary Process

Depending upon the nature and seriousness of the misconduct, the Hospital may adopt one or more of the following disciplinary measures:

• Verbal counselling.
• Written warning.
• Final written warning.
• Performance counselling or retraining.
• Suspension pending enquiry where appropriate.
• Domestic enquiry in accordance with applicable law.
• Termination of employment for proven serious misconduct.

Principles of Natural Justice

• The employee shall be informed of the allegations.
• A reasonable opportunity shall be provided to submit an explanation.
• An impartial enquiry may be conducted where required.
• Evidence shall be considered before arriving at a decision.
• Disciplinary action shall be proportionate to the nature of the misconduct.

Management Rights

Hospital Management reserves the right to investigate allegations of misconduct, suspend an employee pending enquiry where justified, initiate disciplinary proceedings, recover losses where legally permissible and impose appropriate disciplinary action in accordance with applicable law, employment terms and Hospital policy. Misconduct involving criminal offences may also be reported to the appropriate statutory or law enforcement authorities.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force).
• Tamil Nadu Shops and Establishments Act, 1947.
• Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.
• Occupational Safety, Health and Working Conditions Code, 2020.
• NABH Human Resource Management (HRM) Standards.

Grievance Resolution Process

1. Discuss the matter with the Immediate Supervisor wherever appropriate.
2. If unresolved, submit the grievance to the Department Head or Human Resources.
3. Human Resources may conduct discussions or investigations where necessary.
4. The employee shall be given an opportunity to explain the concern.
5. The Hospital shall endeavour to resolve the grievance fairly and promptly.

Confidentiality & Non-Retaliation

• All grievances shall be handled confidentially to the extent reasonably practicable.
• No employee shall be subjected to retaliation for reporting a genuine concern in good faith.
• Knowingly false or malicious complaints may result in disciplinary action.

Applicable Laws & Standards

• Industrial Relations Code, 2020 (where brought into force).
• Code on Wages, 2019.
• Tamil Nadu Shops and Establishments Act, 1947.
• NABH Human Resource Management (HRM) Standards.

Resignation Procedure

• Resignation shall be submitted in writing to the Reporting Manager and Human Resources.
• The applicable notice period shall be governed by the Appointment Letter or employment contract.
• Employees shall continue performing assigned duties until officially relieved.
• The Hospital may accept, defer or waive the notice period in accordance with organisational requirements and applicable law.

Handover & Clearance

• Employees shall complete proper handover of duties before leaving service.
• All Hospital property including identity cards, uniforms, access cards, keys, files, equipment, laptops and documents shall be returned.
• Departmental clearance shall be obtained before final relieving.
• Pending responsibilities shall be completed or appropriately transferred.

Final Settlement

• Full & Final Settlement shall be processed after completion of all clearance formalities.
• Salary, leave encashment and other eligible payments shall be settled in accordance with applicable law and Hospital policy.
• Hospital may recover outstanding dues where legally permissible.
• Experience Letter and Relieving Letter shall ordinarily be issued after successful completion of the exit process.

Applicable Laws & Standards

• Tamil Nadu Shops and Establishments Act, 1947.
• Industrial Relations Code, 2020 (where brought into force).
• Code on Wages, 2019.
• Code on Social Security, 2020 (where brought into force).
• Digital Personal Data Protection Act, 2023.
• NABH Human Resource Management (HRM) Standards.

Resignation & Exit Process

• Employees intending to resign shall submit a written resignation to the Reporting Manager and Human Resources.
• The applicable notice period shall be governed by the Appointment Letter or employment contract.
• Employees shall continue performing assigned duties until formally relieved.
• Proper handover of duties shall be completed before leaving service.
• Hospital property including identity card, uniforms, access cards, keys, equipment, files, documents and electronic devices shall be returned.
• Departmental and HR clearance shall be completed before final settlement.
• Experience Certificate and Relieving Letter may be issued after successful completion of all exit formalities.

Separation from Employment

Employment may cease due to resignation, retirement, completion of contract, medical unfitness, abandonment of service, organisational restructuring, termination or dismissal in accordance with applicable labour laws, contractual obligations and Hospital policies.

Policy Administration

• Hospital Management reserves the right to interpret, amend, modify or withdraw any provision of this Human Resources Policy Manual.
• Policy revisions may be issued whenever required due to changes in law, NABH standards, organisational requirements or patient safety considerations.
• Human Resources shall maintain the official version of this Manual.
• Where any provision conflicts with mandatory statutory requirements, the applicable law shall prevail.
• If any provision is declared invalid by a competent authority, the remaining provisions shall continue in force.

Employee Acknowledgement