RISK ASSESSMENT

1. HR Policies

2. VALUES
Community Centric
Patient Centric
Team Work
VISION
Reaching beyond excellence in
high-end tertiary healthcare,
while doing business with a
soul
MISSION
To become a leading professional
healthcare company in super-
specialty and tertiary care in the
region, leading in health care with a
range of products, services and
quality consistent with the highest
customer expectation.
To maintain the pioneering
leadership in health care in this
region.

3. @ Employees are required to undertake their duties in a
professional, responsible, conscientious and ethical manner, and
to act in the best interest of the organization.
@ Employees should not accept any gift, commission or benefit/s
from any person or organization outside the organization
@ Employees must always be in uniform (where uniform is
provided) during duty hours and must wear/display their
Identity Card, issued by the organization, during office hours in
the office premises.
@ Employees should not be under the influence of alcohol or
other substances while they are at work. Any employee found
disobeying this policy shall be fined by the HR department.
Non-disclosure of confidential information.

4. Service STANDARDS
01
PROFESSIONALI
SM
COMMUNICATIO
N
02
CUSTOME
R
SERVICE
03
COMMO
N
COURTE
SY
04
PATIENT
PRIVACY
05
STANDARD 1: PROFESSIONALISM
 Maintain a professional appearance per department specific dress
code.
 Wear their identification badge in a location easily seen by
customers at all times.
 Strive to exceed customers' expectations.
 Maintain competency and acquire new skills as needed.
 Pick up and dispose of/clean up any litter or spills they find or notify
housekeeping.
 Return all equipment to its proper place and clean their work area
before end of shift.
 Utilize personal protective equipment/safety devices to prevent
injury.
 Report any potential safety issues.
 Refrain from eating food at all times while talking on the phone or in
patient care areas or anywhere visible to patients and visitors.

5. 01
PROFESSIONALI
SM
COMMUNICATIO
N
02
CUSTOME
R
SERVICE
03
COMMO
N
COURTE
SY
04
PATIENT
PRIVACY
05
STANDARD 2: COMMUNICATION
 Answer the phone promptly (within 3 rings) and politely offer name, department and
assistance.
 Ask permission and wait for a response before placing a caller on hold.
 Ask, "Is there anything else I can do for you?" prior to ending a phone call with a
customer.
 Return calls and respond to e-mails in a timely manner.
 Limit personal use of cell phones, texting, and internet to mealtime or breaks in non-
public areas.
 Refrain from using my personal camera phone at all times while at work.
 Communicate in a manner that is positive and builds trust and confidence in the
organization.
 Offer a sincere apology for problems and inconveniences without blaming others.
 Thank patients for choosing our hospital.
 Use "please" & "thank you" often in conversations.
 Reduce noise in every activity, especially at night.
 Discuss personal and work-related issues away from patients and visitors,
always using a low voice.
 Introduce self to patients stating name, department, explain length of procedure/process
and what to expect, and thank the patient.
 Explain things in a way that can be easily understood.
Service STANDARDS

6. 01
PROFESSIONALI
SM
COMMUNICATIO
N
02
CUSTOME
R
SERVICE
03
COMMO
N
COURTE
SY
04
PATIENT
PRIVACY
05
STANDARD 3: CUSTOMER SERVICE
 Promptly respond to patients' requests or seek assistance from another employee.
 Answer the Nurse Call System by the 5th ring.
 Respond to patient requests within 05 minutes or explain to the patient that there will
be a delay.
 Address patients by their preferred name.
 State "Is there anything else that I can do for you?" prior to leaving a patient room.
 Check on patients within one hour of shift change and breaks.
 Provide timely updates to patients and family members on delays.
 Assist co-workers with their assigned duties.
 Provide a courteous and appropriate report to co-workers before leaving the unit.
 Arrive at meetings on time.
 Return from breaks and lunch within the allotted time.
 Explain the purpose of medication before giving it to the patient.
 Ask patients if their pain is under control.
 Prepare patients for discharge by explaining what they should do during their recovery
at home and ensuring the patient or a family member understands the instructions.
Service STANDARDS

7. 01
PROFESSIONALI
SM
COMMUNICATIO
N
02
CUSTOME
R
SERVICE
03
COMMO
N
COURTE
SY
04
PATIENT
PRIVACY
05
STANDARD 4: COMMON COURTESY
 Smile at and greet individuals they encounter.
 Treat others with courtesy and respect.
 Keep hallways free of clutter so they are easily accessible.
 Offer assistance to individuals who need help finding their destination and
escort them if possible.
STANDARD 5: PATIENT PRIVACY
 Knock before entering a room.
 Close doors or draw curtains to ensure privacy.
 Inform patients that they are taking steps to ensure patient privacy.
 Politely ask visitors to step out of patient rooms when necessary to assure
patient privacy.
 Assure a patient is adequately covered when transporting.
 Avoid discussing patient matters in locations where conversation could be
overheard.
 Refrain from discussing any patient-related matter to anyone outside or
inside of Regency Hospital unless there is a work-related reason for the
discussion.
Service STANDARDS

8. Patient rights include determining what information
regarding their care would be provided to self and family.
Respecting special preferences and cultural
needs
Privacy/Dignity during treatment/care
Patient Confidentiality within limits of
Law
Right to information and education
about their healthcare needs
Right to know the tariff list and estimated cost of
treatment, payment schedule for the services provided
Refusal of treatment
Patient and family rights include informed
consent before the transfusion of blood and
blood components, anesthesia, and any other
invasive/high-risk procedures/treatment.
surgery, initiation of any research protocol
Right to seek an additional opinion
regarding clinical care
To be free from mental, physical,
sexual and verbal abuse, neglect
and exploitation
Patient and family rights include a
right to complain and information
on how to
voice a complaint.
Patient and family rights include information on
care plan, progress and information on their
health care needs
Patient’s rights
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2
3
4
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6
7
8
9
10
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12

9. Provide complete and accurate information about
his/her health status including present condition, past
illness, hospitalizations, medications, natural products
and vitamins and any other matter that pertains to his/
her health.
Provide full and accurate name, address and all
other demographic details.
To be on time in case of consultation with doctor.
To pay services billed for, in a timely manner
Abide by the rules of organization
o No Smoking Policy
o Visitor Policy
o No weapon policy
o Treat Doctor and Healthcare team with respect and
courtesy
To provide complete and accurate
information about insurance, medi-claim
policy and institutional patient status
with complete documentation expect
from him/ her.
To respect the fact that other
patient medical condition is
more urgent than yours and
accept that your doctor
need.
Not to take any medication
without the knowledge to
doctor or healthcare team.
To accept the charter of rights and
seek clarification, where required.
PATIENT RESPONSIBILITIES

10. Compromising the privacy
Breaching confidentiality
Disrespect to the religious & cultural needs
Not providing medical records within the stipulated time.
Violation of patient rights
1
2
3
4

11. To be aware of the Hospital policies.
EMPLOYEES RIGHTS
To avail the benefits being extended by the organization.
Can immediately approach to HR if he/she has been the victim
of harassment.
To be treated considerately and respectfully without any
discrimination.
To be aware of the terms and conditions of his/her employment before
joining the organization.
To seek clarity on the targets /job to be performed.
To be aware of all the rights being conferred on an
employee during the course of employment.
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2
3
4
5
6
7

12. Working hours according to the shift.
EMPLOYEES RESPONSIBILITIES
Well planned leave.
Maintenance of equipment.
Do not contact with the Press or make any public statements.
Clean desk policy.
Ethical use of internet.
Professionalism and Confidentiality
To be aware of all the rights being conferred on an employee during the course of employment.
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2
3
4
5
6
7
8

13. WHO DEALS WITH PATIENT COMPLAINTS/FEEDBACKS?
• Medical Administration deals with the complaints of patient.
FROM WHERE I CAN KNOW ABOUT PATIENT RIGHTS AND RESPONSIBILITIES?
• Patients Rights displayed at reception and at prominent areas of hospital
WHAT WILL YOU DO IF YOU SEE PATIENT RIGHTS ARE BEING VIOLATED?
• We will report to our immediate senior with specific details about the incident.
MORE INFORMATION ON PATIENT RIGHTS

14. Objective of Grievance Redressal Policy :
Any discontent and dissatisfaction that affects organizational performance. It can either be stated or unvoiced, written or oral.
Grounds of Grievance :
 It may be unvoiced or expressly stated.
 It may be written or oral.
 It may relate to the organizational work.
Grievnace Redressal Procedure :
Grievance redressal policy
Grievance to be submitted to the Supervisor / HOD. The supervisor / HOD
is expected to address the aggrieved staff within 48 hours.
If the supervisor fails to address the aggrieved staff, the grievance is
escalated to the Unit HR. The Unit HR has address the issue within 3 days of
such escalation.
If the Unit HR fails to address the aggrieved staff, the grievance is escalated
to the Centre Head. The Centre HR has to address the issue within 3 days of
such escalation
In furtherance to the escalation, if a staff member is not addressed on a
given timeline the grievance is escalated to the grievance committee. The
Grievance Committee should address the issue within 7 working days of
such reporting.

15. DISCIPLINARY MECHANISM

17. Redressal Procedure :

18. MEMBER NAME ROLE
Mrs. Vijayalakshmi Gopakumar Presiding Officer
Mrs. Jahnvi Kapoor Internal Member
Dr. Anjali Tewari Internal Member
Dr. Ranjana Bhargava Internal Member
Mr. Ravi Pratap Singh Internal Member
Dr. Vikas Bhargava Internal Member
Dr. Ridhhi Purwar Internal Member
Mrs. Sadhna Ghosh External Member
Mr. Rakesh Kumar Pandey External Member
NOTE :
ANY SUCH INCIDENCE/COMPLAINT SHALL BE SENT DIRECTLY TO COMPLAINTS@REGENCYHEALTHCARE.IN .

19. BROADER CLASSIFICATION OF OCCUPATIONAL
HAZARD
OCCUPATIONAL HAZARD
PHYSICAL HAZARD
CHEMICAL
HAZARD
PSYCHOLOGICAL
HAZARD
BIOLOGICAL
HAZARD

20. S.n Department Hazard Preventive Measures
1. Front office Dry Eyes / Back Pain Take a break from looking at the system. It will help to safeguard back pain
as well.
2. Kitchen Burns / Food Poisoning To be vigilant enough to safeguard from situations where the staff can be
effected by burns. The staff’s health can be at risk, when the food is been
tasted. The staff should inform the HOD immediately it he / she gets effected.
3. Pharmacy Long standing hours can lead to varicose veins. To safeguard the staff from such an hazard, the staff should ensure that he .
She should sit for sometime for striking the balance.
4. Nursing Needle Stick Injury The staff is expected to wash with running water. Further the staff is
expected to take a form from emergency and fill up an Needle Stick Injury
incident reporting form and inform in HR Department as well.
5. Patient Care
Coordinator
Infectious diseases can be caused by coming into contact
with bacteria, viruses, funguses or parasites when
handling patients, contaminated objects, body secretions,
tissue or fluids.
Ensure availability of gloves and other protective
equipment and cleansing agents. Immunization
program for all workers
6. Gas Plant
Technicians /
Laundry / Boiler
High levels of noise are often found in medical gas,
laundries and boiler rooms.
Isolation of noisy machines in a room where workers seldom need to go. Staff
should use noise dampeners. Maintenance of equipment in good working
order. Provide hearing protection

21. S.n Hazard Impact Preventive Measures
1. Radiation Radiation is used in diagnostic
procedures. It is also used in treatments
using radioactive material.
Staff should at all times are expected to wear PPEs, such as
shield aprons and safety glasses.
2. Chemicals Chemicals found in hospitals can be in
the form of dusts, vapors, gases or
liquids.
Eliminate toxic work closely with the workplace health & safety
committee to identify chemicals used and find
out what health effects they may have.
3. Infectious Diseases Hepatitis B, Hepatitis C and Human,
Immunodeficiency Virus (HIV) can be
spread by infected blood and body fluids
when they come into direct contact with
broken, scraped, chapped or inflamed
skin or when skin is punctured by a sharp
object such as a needle.
Ensure availability of gloves and other protective
equipment and cleansing agents. Immunization
program for all workers

22. Whistle blowing is a structured process, which encourages Regency
employees, trainees, contractual staff, vendors and customers to report
any wrongdoings or any unethical or improper practice, which may
negatively impact the image of the organization, without any fear.
The act of reporting such act is known as ‘Whistle Blowing’.
A ‘Whistle Blower’ is a person who exposes any such information or
activity that is deemed illegal, unethical, or not correct within the
organization, like - violation of organization policy/rules, law,
regulation, or threat to public interest/national security, as well as
fraud, corruption and/or unethical behaviour.
Any such incidence/complaint shall be sent directly to
complaints@regencyhealthcare.in .
Whistle Blowers are advised to mention their names and contact nos. to
facilitate proper and timely investigation.
The management assures maintaining confidentiality of the Whistle
Blower/s at all times.
WHISTLE BLOWING POLICY

23. RHL is committed to ensure that all staff have access to learning and development opportunities. This enables
the staff to be suitably knowledgeable and skilled to carry out their role within the company, and to develop
their talents which meets the company’s strategic objectives.
Following steps shall be taken into consideration:
Training needs of the staff members are ascertained according
to the following :
Performance Appraisal
Change in job responsibilities
On installation of a new instrument
On the basis of the training needs we conduct training
sessions by choosing the following modalities
Classroom Training Sessions
On the job Training Sessions
Training needs of the staff members are ascertained
according to the following :
Performance Appraisal
Change in job responsibilities
On installation of a new instrument

24. A performance appraisal gives individual and their manager an opportunity to review performance, so that
we can look back on what has been achieved during the past year/s.
APPRAISAL PROCESS:
GOAL SETTING OF THE STAFF MEMBERS
PERFORMANCE MONITORING
YEARLY PERFORMANCE APPRAISAL
IMPROVEMENT PLANS AND REWARDS

25. Thank You !