Series: Understanding MSDS | Post 17 of 52
Standard 5 (HRM-1) | Indicator 14 | Category: YELLOW (80% required)
“I Watch Them Every Day”
Dr. Adeel Mahmood ran a small specialist clinic in Rawalpindi with four staff: a receptionist, a dispenser, a nurse and a cleaner. The clinic was calm and well organised. Patients rarely complained.
The PHC assessor had already checked the personnel files, which Dr. Adeel had prepared carefully. Then he asked for something else.
“Could I see the performance evaluations of your staff, please?”
Dr. Adeel smiled. “I evaluate them every day, sir. I watch them working. If something is wrong, I tell them at once.”
“Is any of that written down?”
It was not. Each file held a job description signed on the day of hiring, and nothing after it. There was no appraisal form, no record of any review, and no way to show how well each person had performed the duties written in that job description.
Indicator 14 was scored as not met.
What Indicator 14 Requires
The indicator reads: Performance Evaluations are based on the Job Descriptions (JDs).
The surveyor reviews the periodic performance evaluations of the staff, quarterly or yearly as the case may be, carried out with a prescribed checklist, and checks whether those evaluations are based on each person’s job description.
This means two documents must exist for every staff member, and they must be connected:
- A job description setting out the person’s duties
- A periodic evaluation that assesses the person against those duties
An evaluation that ignores the job description, or a job description that is never used for evaluation, does not satisfy the indicator.
The Manual’s Appraisal Format
The guidelines ask each clinic to prepare a performance appraisal system based on the job descriptions of individual employees, and provide a simple format that can be adapted to local needs. It records:
- The name of the employee, the department, the period of appraisal and the date
- A rating from 1 to 5 in four areas: knowledge, skill, attitude and performance, with the grade increasing with the number
- Recommendations
- The names and signatures of both the person appraised and the appraiser
It fits on a single page.
How It Is Scored
This is a YELLOW indicator with three possible outcomes.
Fully met: the record of periodic performance evaluations of the staff is maintained as described.
Partially met: the record is maintained but is deficient by up to 20% only.
Not met: the record of periodic performance evaluations is not maintained.
Why It Matters
In a small clinic, feedback is often spoken and then forgotten. A written evaluation turns it into something both sides can refer back to. It shows the dispenser where he is strong, shows the nurse what needs to improve, and gives the doctor a fair basis for increments or, if needed, difficult decisions.
It also links to a later standard. Under Indicator 17, the duties assigned to staff are to be included in their job descriptions and checked against a quality assurance checklist. Without job descriptions, both indicators suffer.
What Dr. Adeel Changed
He sat with each staff member for twenty minutes and updated the job description in plain English and Urdu. The receptionist’s listed registration, patient slips, the waiting area and the appointment register. The dispenser’s covered dispensing, labelling and stock checks. Each was signed again by both of them.
He then adapted the manual’s one page appraisal form, adding each person’s main duties beneath the four rating areas.
He set a quarterly schedule: the first week of January, April, July and October. At each review he rated the four areas, wrote one recommendation, and both signed. The first round took an evening. By the second it took less than an hour for all four.
At reassessment, the assessor found two completed rounds of evaluations in every file, each linked to a signed job description. Indicator 14 was fully met.
“I was already evaluating them,” Dr. Adeel said. “Now it is written down, and they know what I expect.”
A Quick Self-Check
- Does every staff member have a written job description, signed by both parties?
- Is there a periodic appraisal, quarterly or yearly, for each person?
- Does the appraisal assess the person against the duties in their job description?
- Are the appraisals signed by both the appraiser and the person appraised?
- Are completed appraisals kept in the personnel files?