RBH HR Manual

Human Resources Manual

Prepared By Hasna Zavrak
Human Resources Head-
Signature Middle East
Approved by:
Signature Dr. Sheriff Sahadulla
Checked by Chief Executive Officer

Version 1 ADD NAME
Quality Systems
January 2020

Table of Contents

Page

1. INTRODUCTION.................................................................................................................... 1
2. OBJECTIVES .......................................................................................................................... 1
3. CONFIDENTIALITY OF THE MANUAL .......................................................................... 1
4. CUSTODIAN OF THE MANUAL......................................................................................... 1
5. GOVERNING LAW................................................................................................................ 1
6. ORGANIZATION STRUCTURE.......................................................................................... 2
7. STAFFING ............................................................................................................................... 2

7.1 MANPOWER ESTIMATION ................................................................................................2
7.2 RECRUITMENT AND SELECTION ................................................................................... 3
7.3 EMPLOYEE REFERRAL POLICY .....................................................................................7
7.4 CREDENTIALING AND PRIVILEGING ........................................................................... 8
7.5 REHIRE POLICY ................................................................................................................. 12
7.6 DEPUTATION AND HARDSHIP POLICY....................................................................... 12
7.7 JOB DESCRIPTION ............................................................................................................. 13
8. PERFORMANCE MANAGEMENT................................................................................... 14
8.1 TRAINING ............................................................................................................................. 14
8.2 OBSERVERSHIP .................................................................................................................. 18
8.3 RETENTION ......................................................................................................................... 21
8.4 PERFORMANCE APPRAISAL .......................................................................................... 23
9. CONDUCT ............................................................................................................................. 26
9.1 CODE OF CONDUCT (NHRA)........................................................................................... 26
9.2 EMPLOYEES RIGHTS AND RESPONSIBILITIES........................................................ 34
9.3 EMPLOYEE GRIEVANCE HANDING ............................................................................. 36
9.4 DISCIPLINARY ACTIVITIES............................................................................................ 37
9.5 ANTI-CORRUPTION POLICY .......................................................................................... 40
9.6 SEXUAL HARASSMENT .................................................................................................... 42
9.7 WHISTLE BLOWER POLICY ........................................................................................... 46
9.8 DRESS CODE ........................................................................................................................ 49
9.9 SOCIAL MEDIA POLICY................................................................................................... 51
10. EMPLOYEE ENGAGEMENT ............................................................................................ 60
10.1 EMPLOYEES’ HEALTH ..................................................................................................... 60
10.2 HOLIDAYS AND LEAVE.................................................................................................... 61
10.3 ORGANIZATIONAL EVENTS AND ACTIVITIES......................................................... 67
11. GOVERNANCE..................................................................................................................... 68
11.1 HUMAN RESOURCES AUDIT........................................................................................... 68
11.2 EMPLOYEES’ FILES........................................................................................................... 69

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1. INTRODUCTION

This Human Resources Manual (the “Manual”) is applicable to Royal Bahrain Hospital, Royal Bahrain
Medical Center and all its present and future affiliated Medical Centers. (“RBH” or “the Unit” or Hospital
or KIMS”).

This Manual is intended to provide all staff, supervisors and senior management an access to homogenous
information and instructions in order to ensure unbiased and consistent application of the policies in its daily
functions.

2. OBJECTIVES

Royal Bahrain Hospital recognizes the importance of human capital in achieving its objectives and fulfilling
its commitment. Royal Bahrain Hospital Human Resources (“HR”) policies have been developed with this
as the underlying principle and are aimed at being consistent, transparent and fair to all employees.

The objective of the Human Resources Manual (the “Manual”) is to:

 Document the Human Resources policies of Royal Bahrain Hospital;
 Provide and maintain an up-to- date reference guide;
 Enable uniformity and consistency in applying the policies for all employees; and
 Provide continuity of Human Resources policies regardless of changes in personnel.
The provisions of this Manual apply to all permanent and temporary employees of RBH as well as those
under probation. All employees shall be deemed to have read, understood and agreed to follow all provisions
of this Manual. This Manual shall not apply to experts, external consultants and employees who work on a
contract basis unless otherwise stated.

3. CONFIDENTIALITY OF THE MANUAL

This Manual is the property of RBH. It is a contravention of RBH policy to reproduce any of part of the
Manual’s contents without the prior permission of the Human Resources Department. The contents of the
Manual should not be shared with any person not employed at RBH.

4. CUSTODIAN OF THE MANUAL

The Human Resources Department is responsible for safekeeping, maintenance and uniformly implementing
the Human Resources policies laid out in this Manual across the Units.

5. GOVERNING LAW

The contents of this Manual have been prepared in line with the Bahrain Labour Law for the Private Sector in
the Kingdom of Bahrain (Law No. 36 of 2012) (as amended, the “Labour Law”). In the event of
amendments to the Law, the Manual will be amended to incorporate the changes. If any conflict arises
between the contents of this Manual and the Labour Law, the latter shall prevail.

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6. ORGANIZATION STRUCTURE
The organization structure of RBH consists of departments and functional groups within each department.
Minor changes and amendments to the organization structure will be approved by the Chief Executive
Officer (“CEO”).

7. STAFFING
7.1 MANPOWER ESTIMATION
To describe the process established by the hospital for determination of the staff requirement of the
hospital for various clinical, paramedical, administrative & support staff positions; on both short term
and long-term basis.
This procedure shall be applicable for estimation of all types of staff and all departments / functional
areas of the hospital.
The Human Resources Management staff is responsible for coordinating the process for manpower
estimation.
The in-charges of various department / functional area are responsible for assisting the HR department
by providing information on their manpower needs/ skill sets as required.

7.1.1. Annual Manpower Plan
Staff requirement for each department will be assessed on yearly basis.
Each department will be given a Manpower Estimation Form (F-HR-22) in which the in-charge of the
department / functional area has to give details about present staff strength and the required strength
for ensuing year.
The requests from all departments will be analyzed against cost and anticipated increase in workload
by the HR & Finance departments.
Based on manpower estimate an Annual Manpower Plan will be developed and submitted for the
approval of the management. On approval by the management this plan shall be operational during
the year.
Recruitment to each post will be made by Human Resources Department based on the Annual
Manpower Plan.

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Any additional requirement for recruitment over & above the approved manpower budget has to be
requested in Manpower Requisition Form (F-HR-23) with adequate justification by the head of the
Department and the same has to be approved by HR Department and sanctioned by Executive Director,
Chief Executive Officer and Chief Operating Officer.

7.1.2. Monthly Manpower Statements

Department wise Monthly Manpower Statements will be generated by the Human Resources
Department for review by top management.

The statement will contain the

 Number of staff joined during the month
 Staff resigned during the month
 Total strength as on date
 Nationality
 Salary details
 Age Profile
 Baharainization ratio
 Department wise list

This statement shall be drawn up for the preceding month in the second week of each month and
copies of the same submitted to the Executive Director, Chief Executive Officer and Chief Operating
Officer.

7.2 RECRUITMENT AND SELECTION

7.2.1. Manpower Requisitions:

 Department Heads in need of resources shall raise a Manpower Requisition Form
with clear and detailed justification for recruiting any new person whether for an
additional resource or as replacement to the Human Resources Department.

 Requisition forms shall contain, job description, Job grade and targeted start date.
 The Human Resources Department within the unit will secure all necessary approvals

from the unit head and the regional corporate office.

7.2.2. Approvals:

 No recruitment effort can start prior to securing all necessary approvals. Unit level
approvals shall not suffice to start sourcing for resumes.

 Final approvals lie with the Regional Executive and Director Chief Executive Officer
and.

7.2.3. Sources of CVs:

 Resumes are obtained through Job Portals, Company Website, Walk-Ins, References
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7.2.4. from existing employees, Advertisements, Data Banks (Digital / Manual).
 Advertisements and Placement Agencies involving additional budget shall be pre-

approved for each position.
Selection Committee :

 The shortlisted candidates will be called for an interview. The Human Resource
Department coordinates the interview along with respective department head and
other relevant people depending on the nature of the Job and the seniority as below:

 Interviews with overseas candidates should include at least one Video Call.
 The Unit Head shall interviewed with the candidates prior to the final interview with

the Chief Executive Officer and the Executive Director if applicable.
 The Interviewing Committee shall record their findings in Interview Evaluation Form
 Depending of the function and the seniority of the position, the authorized personnel

responsible for recommending the selection of a candidate may change.
o Medical Centers: Department Heads requesting the resource, Human

Resources representative, Medical Superintendents/ Chief Medical Officer

(for Doctors) and Head of Medical Centers s hall interview candidates and

provide their decision to hire. Although Chief Executive Officer and/or

Executive Director may only interview at Manager Level, the final decision

for all hires remains with them.

o Hospitals: In addition to the above interviewers, Chief Executive Officer

shall interview consultants, specialist physicians and provide their decision to

hire.

7.2.5. Decision Making :

 Collectively, the information: obtained in the CV, collated during the interview and
selection tests and references will allow candidates to be assessed on their potential
fit for the given post.

 Both the Human Resources Department and the concerned Department are required
to produce a recommendation regarding the considered candidate’s recruitment.

 To ensure a consistent and fair approach is adhered to during the recruitment and
selection process, the Human Resources Department must ensure that a written
description of the reasons for selection or rejection of candidates is completed and
placed on record.

 All recruitment and selection proceedings are confidential.
7.2.6. Reference Check :

All candidates shall be asked to provide references from their existing and

previous employer. The contact details provided should be of a person in a Line

Manager of Supervisor position

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7.2.7. Informing Candidates

 The outcome of the selection process is communicated to all candidates considered
and interviewed as soon as reasonably possible.

 The selected candidate shall be asked to provide up to three names as references.
7.2.8. Provisional Offers

 Employment offers are always provisional, subject to the fulfilment of certain
conditions which are set out in the offer letter. These conditions may include receipt
by RBH of a candidate’s educational qualifications, professional qualifications (if
applicable), health authority’s approvals, work permits and immigration entry visas
and satisfactory professional references, background check, medical clearance etc.

 The candidates shall be advised not to resign from their current position unless
expressly informed by RBH.

 The Provisional Employment Terms must be in accordance with the salary structure
set for the Unit and the region and submitted for the final approval of the Chief
Executive Officer and the Executive Director

7.2.9. Grade and Salary Scale

 All jobs are classified under RBH grade and salary scale. The salary scale and pay
is generally benchmarked against companies within the same sector in each country.

 The scale provides salary bands which recognize differences in competencies,
responsibilities and experience by individual employees. Information relating to any
individual employee’s grading and salary scale is highly confidential and is not to be
discussed with external entities or any other employees (even if those employees are
within the same department as the employee).

7.2.10. Pre-employment health check ups

Every prospective candidate who is provisionally selected for appointment will be sending

for pre -employment health check-up. Appointment to a position in the Unit will be based on

the fitness certificate and clearance by the medical committee.

7.2.11. Joining Procedure:

The HR department shall open an employee personal file for each employee on his/her joining

the organization. The new employee on reporting for joining shall be asked to undergo a pre-

employment medical checkup, after which they fill in the joining report and other relevant

joining forms.

The details of the new employee shall be recorded using Employee Data Sheet. The new

employee shall be requested to fill in all the relevant details as detailed in the Employee Data

Sheet.

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The HR department shall verify the various details of the employee as per the New Employee
File Checklist. HR shall ensure all the documents listed in the checklist are received from the
new recruit. The original documents shall be returned to the candidate after due verification
with copies by HR personnel.

On completion of the joining formalities are completed the concerned Head of Department
and the HR Department representative shall introduce the new employee to other relevant
employees in the organization. Unit rounds are given to top level management personals
joining. A joining announcement with a brief profile is sent through intranet to all employees.
Visiting cards, Official seal, Name boards… etc. are arranged through support service to
eligible employees.

7.2.12. Induction of the Employee:
A detailed induction program shall be conducted for all new employees joining the Unit. The
following inputs shall be provided to the new recruit through the induction program.

A. Organization Information
 History and Evolution of the unit and the Organization as a group
 Organization Philosophy, Mission and objectives
 Growth in the Region

B. Organization Structure
 Top/ Regional Management Team
 Medical and Surgical Specialties
 Glance at all Departments
 Hospital Information System

C. Working Protocol
 Work timings
 Leaves, Weekly off, holidays, Attendance system
 Organization Policies including Quality Policy and Objectives
 System of Performance appraisals and annual reviews
 Employee Rights and Responsibilities
 Employee grievances handling system
 Arrangements for Tea/ Coffee/ Lunch

7.2.13.Orientation of the employee
A detailed orientation of the employee shall be planned for each employee by the respective
representatives in consultation with the HR department.

The orientation program for each employee shall be planned in covering the following factors

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 Nature of the job
 Roles & Responsibilities
 Standard Operating Protocols / Technical Memoranda for the unit / specialty.
 Employees previous training and experience
 Department work schedules
 Documentation / Records etc.
 Orientation to Hospital Information System

7.3 EMPLOYEE REFERRAL POLICY

7.3.1. Purpose

To outline Employee Referral policy for providing an attractive scheme of incentives to reward

and acknowledge eligible employees for contributing towards Company's efforts in hiring trusted

,high quality doctors by referring suitable candidates for existing job openings.

This policy is applicable to all entities of KIMS and its subsidiaries Middle East.

This scheme is applicable only for KIMS employed staff.

7.3.2. Exclusion

 Contracted Staff
 Trainees
 HR Staff
 Heads of Departments for their own department
 Senior employees of the Regional Office
 Referral of Family Members
7.3.3. Description

Employees are encouraged to refer qualified staff for an open position within the organization.

This program is applicable for referring candidates across geographies as well.

Employee will be eligible for the reward as per the respective categories mentioned in the below table:

Type Designation Referral Incentive
A Consultants 800 USD
A Senior Administrative / Management 800 USD

B Specialists 650 USD

B General Practitioner 550 USD
C Nurses 250 USD
C Para Medical Staff 250 USD
C Administrative Staff 250 USD

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7.3.4. Valid Referral Recommendations
Referral/s made by Employee must be through his/her own contacts and any reference without

deriving any connections:

 Incentive is only payable when the referred employee is hired and his/her trial period
successfully completed.

 Incentive amount will be paid through the Salary account /Cheque.
 The maximum earnings from referral is USD 2,000 /- per year for A Type positions,

USD 1,500 for Type B positions and 1000 for Type C positions.
7.3.5. Invalid Referral Recommendations (Exclusions)

 Any candidate who has been evaluated through other sources in past 12 months.
 Any candidate from a Newspaper Advertisement, Walk-in.
 Employees will not get employee referral reward benefit if the candidate referred has

worked for any of the KIMS entities in the past.
 Referrer making the referral will not, in any way, be involved with short listing,

interview and/ or salary fixation of the candidate.
 Employees will not raise any claim against the decision of the Company with respect

to this Program including eligibility and/or reward which shall be binding upon them.
 Duplicate referral will not be considered for the Program. Only the first source to

refer a candidate in accordance with prescribed procedure will be entitled to receive
credit for the candidate
 Any Employee whose employment relationship with the Company is under notice of
termination (whether given by the employee or the Company), the Company
reserves complete discretion and right not to pay any Reward or the amount thereof
and the same can also be adjusted against the dues as may be recovered from the said
employee

7.4 CREDENTIALING AND PRIVILEGING

Credentialing & privileging has relevance for all health professionals and the principles are generic,

although the process may differ between professions. This policy is applicable to all medical staff &

technicians.

Implementing this policy is the responsibility of HR & Credentialing & privileging Committee

Credentialing & privileging is the process used to assign specific clinical responsibilities (scope of

practice) to health professionals on the basis of their training, qualification, experience and current

practice, with the facilities provided by the organization.

 Competency: What is the practitioner capable of doing with sufficient knowledge,
skill and judgement.

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 Performance: What the practitioner actually does in day-to-day practice
7.4.1. Limitations of Credentialing & privileging
Credentialing & privileging will not eliminate the occasional medical error. The re-credentialing &
privileging process will help to reduce this risk by identifying the areas, which require attention

Credentialing & privileging should not be used to:
 Limit responsible professional initiatives designed to improve standard of practice
 Restrict the use of exceptional measures taken in emergency situations
 Credentialing & privileging should not condone individual practice in isolation (in
variation with accepted practices elsewhere) without reassurance that adequate
professional linkages, peer review, audit and continuing reassurance medical
education facilities are established for that practitioner
 Discriminate against practitioners on economic grounds

7.4.2. The process of Credentialing & privileging
1. How to apply:
 On joining all practitioners are given the credentialing & privileging form which
needs to be filled and submitted to Human Resource Department (R-HR-14). For
additional privileges also the same procedure is applicable.
 HR Department shall submit it for review of the HOD /Chief Medical Officer
 On recommendation by the coordinator C & P Committee submits it for approval.
 Intimation to the applicant is submitted regarding the same on all privileges granted.

2. Verification:
 Qualification: The medical council provides the validity and acceptability of

qualification & Valid Bahrain NHRA License
 Training: Specialist societies certify training
 Experience: Trainers, Peers and peer review committees can provide the details on

training, experience and past performance
 Professional record scrutiny
 Check of criminal record

Practitioners themselves provide the credentialing & privileging committee with details of training,
trainers, specialist bodies, referees and offer updated data on facilities that have become available and
facilities required to modify their own scope of practice. The organization and hence the committee
has the implicit consent of the practitioner on accessing data on patient outcomes.

3 Determination of scope of practice on appointment

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The scope of practice determines what the practitioner will do in the organization, at the current time,
given a specific set of circumstances. It is based on professional judgment which in turn is determined
by:

 The log of experience and training
 Needs of the organization
 Facilities and support available
 Services the organization intends to provide Credentialing & privileging at

appointment proceeds through:
- The acceptance that the verified documentation provided by the practitioner meets

requirements detailed in the position description.
- Reference checks, evidence of competence (such as log book, outcome data),

interpersonal skills and fit with the skill mix of the existing team.
- Agreement with practitioner regarding the scope of practice to be undertaken

between the period of appointment and the next review date
- If required, the determination of any conditions, including preceptor ship

requirements for a probationary period (if a probationary period is agreed, the
purpose, length and evaluation of a probation should be documented)
- Agreement with the practitioner on the terms of review of scope of practice

4. Ongoing data collection to monitor professional practice

This deals with the quality of current practice and accumulates information for re-credentialing &
privileging.

 Peer review and self-review of specific skills related to the area of current practice
and future aspirations in scope of practice

 Record of clinical activity
- Clinical audits including volumes and outcomes

 Professional interaction and clinical service provision
- Feedback from other health professionals
- Complaints and incident reporting
- Patient satisfaction

 Continuing medical education, post graduate study, teaching & research
 Training and experience gained since the last review, including medical college or

specialist society requirements

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5. Credentialing & privileging review

Scope of practice for a new appointment should be reviewed at the end of the first year of employment

and thereafter at least every five years

 Formal review of information for re-credentialing & privileging
 Status of service or department concerned

- The clinical work the service wishes and is funded to provide

- The adequacy of facilities

- The composition and skill level of the clinical team, including other health

Professionals

- Practitioner workload

When scope of practice is reduced due to a competence issue, the employing organization has the

Responsibility to offer retraining where appropriate. Ongoing service quality assurance activities

should identify and remedy developing pattern of poor performance so that the formal re-credentialing

& privileging process presents no surprises.

6. Privileging

In order to deliver patient care within, one must hold a faculty appointment and have privileges

approved by RBH Credentialing & Privileging Committee.

 Temporary privileges: Temporary privileges are not automatic and may only be
granted to those who fulfill an important patient care need that cannot otherwise be
met by the existing members of the Medical Staff. Upon written request of the
Coordinator where the privileges will be exercised, the Managing Director, or his/her
designee may grant temporary privileges to the person who meets the basic
requirements and has submitted a completed application and a request for specific
clinical privileges. All items must be verified prior to these privileges being granted.
Unless otherwise provided, temporary privileges are granted for a period not to
exceed thirty- (30) days.

 Single day Temporary privileges are also granted for visiting consultants
 Disaster privileges: In a disaster situation, as defined in the Hospital safety manual,

any physician who presents a current medical license and already employed by the
hospital will be granted Disaster Staff Status. These are typically volunteer
physicians. They are granted clinical privileges in accordance with their clinical
privileges that they hold at their primary institution. When the disaster no longer
exists, care of the patient is assigned to a medical staff member with the appropriate
clinical privileges to provide the care needed by the patient. These privileges can only
be granted by the Managing Director.

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7.5 REHIRE POLICY

Our employee policy defines rules for rehiring former employees. This policy will outline
circumstances under which former employees might be rehired either within the same medical unit or
in any other medical units operated by KIMS in India and or Middle East and any relevant guidelines.

This policy will not prohibit any former employee from applying to a position. But, it’ll outline in
which cases it can consider this employee for rehire.

When an employee applies for a position or contacts our company about rehiring, the following
procedure should be followed:

 HR department reviews personnel and separation records of the employee to decide
whether the employee is eligible for rehired.

 Explicit approval of Regional Management to be obtained.
 Hiring managers decide whether the employee is qualified for a particular position.
 Recruitment Process to follow as set by KIMS Recruitment Policy.

7.5.1. Legibility & Exclusion
Legibility

All employees with clean employment separation records are legible to apply. Final decision lay with
Executive Director and Chief Executive Officer.

Exclusion

 Former employees who were terminated with cause are not eligible for re-hire.
 Former employees with low performance rating are not eligible for re-hire.
 Former Employees who abandoned their job are not eligible for re-hire.
 Employees who didn’t complete their trial period successfully are not eligible for re-

hire.
 Employees who accepted a job offer but didn’t show up on their first day are not

eligible for re-hire unless they have provided a timely explanation.
 Employees who left the company without finalizing their legal notice period are not

eligible for re-hire.

7.6 DEPUTATION AND HARDSHIP POLICY

To outline Deputation & Hardship Assignments Policy for providing an attractive scheme of
incentives and other benefits to reward and acknowledge employees for their contribution towards

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Company's efforts in reaching for business opportunities in increasingly challenging regions and
taking difficult assignments.
7.6.1. Definitions

A. Outposting

Any assignment located in a remote or site specific location where job site is far away from the closest
city with limited or non-existing options for accommodation or schooling.

These locations can be Oil & Gas fields, labor camps, offshore sites…etc.
A. Hardship Locations

The criteria used to determine a hardship location include climate, environmental risk, political
instability, security risks, availability of goods and services, cultural isolation, lack of social amenities
or medical facilities, heavy pollution, risk of disease, etc.
7.6.2. Description

Employees under this category are entitled to a special allowance for the duration of the assignment.
This allowance although not part of their salary is to be paid at the end of every month.

In accordance with the company internal policy, the employee will no longer be entitled to these
additional payment and other benefits in the event that the assignment is finished or the employee’s
assignment is changed as it may be from time to time.

The amount of the allowance is to be decided at the unit level and approved by Executive Director and
Chief Executive Officer.

7.7 JOB DESCRIPTION

RBH will develop and maintain current job descriptions for all established and authorized positions
below line managers. The human resource (HR) department will develop all job descriptions in
coordination with the head of department.
7.7.1. Procedures

 Job description should be given to the staff at the time of joining / at the time of
revising the job descriptions

 Copy of the signed job descriptions will be handed over to the employee as well as
to the department head

 Copy of the signed job description will be kept in the employee file
 Job descriptions are prepared based on the skills required and is verified by the

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department head
 Should a new or revised job description be required within a department, the line

manager will send a written statement outlining the job requirements and minimum
qualifications to the HR representative at least 15 days prior to the desired effective
date of the proposed job description.
 The HR representative, on receipt of the statement requesting a new job description,
will prepare the same and reviewed by the HOD / CMO and approved by the COO /
Group Director – Operations & Projects (GCC) / Executive Director
 Job descriptions will be revised every two years with the format approved by COO /
Group Director – Operations & Projects (GCC) / Executive Director
 Job description, should contains the following:
- Department
- Job title
- Job classification number.
- Reporting authority, supervising details and job summary
- Essential functions of the job (or Responsibilities and duties)
- Authority
- Interfaces (Internally and Externally)
- Job qualifications
- Minimum Experience
- Training required
- Skills
 The conduct of care expected for all levels of staffs will be mentioned in the job
description
 Professional conduct, handling ethical issues etc. mentioned in the job description
 Basic and mandatory information mentioned below will also be included in the job
descriptions
 Identification of Risk and developing contingency plan
 Employee safety
 Attending mandatory training programs / meetings etc.
 Any other responsibilities assigned by the management from time to time

8. PERFORMANCE MANAGEMENT

8.1 TRAINING

This procedure shall be applicable to all kinds of training undertaken or utilized by RBH (both internal

and external training programs).

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The Human Resource staff is responsible for planning, monitoring and coordinating the internal and
external training programs.

The respective Departmental Heads are responsible for identification of training requirements,
planning for the nature of training to be provided and forwarding to the HR, the annual training
requirements for all staff assigned under him.
8.1.1.Fire safety & Disaster Management
Safety Officer / Fire & Security Officer is responsible for coordinating, monitoring and evaluating the training
program.
8.1.2. Infection Control
Infection control Team is responsible for coordinating, monitoring and evaluating the training program.

Nurse Educator is responsible for training and development of nursing staff in the hospital.

Departmental Heads are responsible for analyzing the training need in their department
8.1.3. Job Orientation & Training
To be provided to all new employees joining the organization with a view of orienting them to job, work
environment and department procedures / protocols. Orientation program shall cover safety, infection control
training.
8.1.4.In-service Education & Training
Includes ongoing educational activities like CME and CNE, in services training, on the job training etc; aimed
at maintaining and improving competence. In-service training is expected to focus on issues / subjects pertaining
to the functioning of the specific functional areas and units. In-service training also occurs when job
responsibility or duties change and routinely covers aspects like infection control, safety, quality improvement,
reporting of adverse events / incidents etc.
8.1.5. Mandatory Training programs
The training programs which shall be attended by all the staff in RBH including contract staff are called
mandatory training programs. These include Safety, Disaster management & Infection control training.
8.1.6. External Training Programs
External Training programs are used to help employees acquire specific knowledge and skill in new topics /
areas. This is planned with a view of upgrading the organizational knowledge and continuously introducing
new services and technology to upgrade the hospital’s treatment facilities and services.
8.1.7. Common Internal Training Programs
These are aimed at improving in-house staff skill, knowledge and attitude in areas linked to patient interaction.
These shall include programs on communication, patient handling skills, service quality, patient safety,
professional ethics and conduct etc.

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A. Staff Competence

The Departmental Head in each area shall define and update competence and qualification for each
staff positions under them.

The assessment of competence for a staff providing care, treatment and services will be based on type
of population served, techniques involved, technology, equipment and skills needed for performing
the job.

The Departmental Heads shall assess and reassess the staff competencies on an ongoing basis from
the time of employee orientation. Reassessments shall also be done in case of changes in job content,
responsibilities, technology & equipment etc.

The in-service training programs shall be closely aligned with the competency assessments to provide
adequate training in case of a competency mismatch. Both the training needs identification and
performance appraisal system shall be based on the required competency for the position. These
exercises shall also reflect and record the competency improvement / deficiency of the concerned
employee.
B. Identification and Planning for Training Needs

The respective Departmental Head will be responsible for identification of the training needs of the
employees assigned under him. This shall ideally be done in conjunction with the annual performance
appraisal.

The training needs assessment shall take into consideration the following factors.
 Employee knowledge, skill and competence pertaining to the job
 Changes in job responsibilities and duties.
 Technology Utilization / Up gradation
 Changes in methodology
 New scientific developments in the field
 Performance and Quality Improvement

Respective Departmental Heads shall forward the Training Needs Identification Form (R-HR-05) for
their department / area to the HRM Department.

The HR Department will hold consultations with the various Departmental Head regarding the various
training methodologies, programs and faculty identification involved in planning for the conduct of
the required training.

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An Annual Training Plan will be developed based on the training requirements and discussions with
the various departments.

The Annual training Plan shall be submitted for the approval of the COO/Executive Director.
C. Guidelines for conduct of Internal Training Programs

The Departmental Head will identify suitable trainers for various programs.

The Departmental Head will coordinate with the trainer in finalization of the program contents,
methodology, additional materials / accessories and duration. The details of the program, dates, venue
and timings shall be conveyed to the HR department. A list of the participants of program shall also
be provided batch / session wise. The total number of participants to be included for a program will
be divided into different batches. Each batch / participant will be intimated about the training at least
3 days prior to the date.

The training attendance for each session shall be denoted in a Training Attendance Sheet (R-HR-06)
and forwarded to the HR department.
D. Guidelines for conduct of external training programs

As per the needs from Departmental Heads, HR Department / COO, shall identify external
trainers/organization and shall contact these organizations to obtain details about the program and
invite proposals / quotations for the programs. Proposals received from outside professional agencies
for various training programs will be scrutinized initially by the HR Department and suitable programs
will be forwarded to Executive Director / COO for approval.

The details of the training program will be given to the Departmental Head concerned for proposing
the names of participants.

All staff attending an external training program shall submit a training feedback /report to the
Departmental Head detailing the content, methodology, salient benefits / knowledge & skill acquired.

He / she shall share the knowledge and special skills attained from the training among the other staff
members in that department so as to educate others. These sessions will be organized by the
Departmental Heads.
E. Mandatory training programs

All staff including contract staff working at RBH shall undergo mandatory training programs once in

a year. This is in addition to the orientation program at the time of joining. Mandatory training

programs are

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 Fire, safety & disaster management
 Infection Control
 Risk Management
 Occupational Health & Safety
 BLS (All Healthcare Professional)
 ACLS / PALS (All CPR team, ICU Physicians and nurses, ER Physicians, Trauma

team, Paramedics & ambulance nurses and Anesthetists)
 ATLS (All ER Physicians, Trauma team, Paramedics and ambulance nurses)
 PHTLS (All Paramedics and ambulance nurses)
 NRP (All Neonatal ICU physicians and nurses)
F. Nursing training
8.1.8. Orientation program for new staff
This is a one day / one week training program of which the checklist is attached. This shall be coordinated by
Nurse Educator and he/she is responsible for evaluating the effectiveness of the training program. Department
orientation will be given fifteen days to one month
On the job training program / Bed side clinics

Nurse Educator is responsible for coordinating on the job training programs. This training program shall be
conducted along with Nursing In charges and Nurse Educator is responsible for monitoring and measuring the
effectiveness of the training programs.
Procedural Trainings

Procedural Training on all clinical nursing procedures, such as catheterization, venipuncture etc. shall be given
by in charges and Nurse Educator is responsible for monitoring the same.

8.2 OBSERVERSHIP

To define guidelines for observer ship and training of observers in KIMS Bahrain Healthcare Group
(RBH / RBHMC / KBMC)

8.2.1 Types:
 Course Observership : means observer as a part of their curiculum
 Observership: After course completion they are coming for observation
 Shadowing Doctor : To plan the future studies by +2 students
 Elective placement: Abroad Medical students are coming as observers
 Project Study: Projects / Feed back / Data collection as a part of their curriculum

8.2.2 Approval:
 All the approvals for Observer ship from Chief Operating Officer/ Chief Medical

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Officer and then final approval from Chief Executive Director or from Executive
Director – Operations & Projects (GCC)

 For Doctors observer ship & elective placements will be approved by Chief Medical
Officer/ Chief Executive Officer

8.2.3 FEE Structure
 Caution Deposit : For any candidate applied for Observer ship / Shadowing Doctor
need to deposit BD. 50/- as caution deposit and will be refunded after completion of
training / Observer ship

 Shadowing Doctor :

a. No payment for +2 students

b. One Week (4 hours per day) : BD. 25
c. One Week (6 hours per day) : BD. 40
d. One Week (8 hours per day) : BD. 50
e. Two Weeks (4 hours per day) : BD. 50
f. Two Weeks (6 hours per day) : BD. 80
g. Two Weeks (8 hours per day) : BD. 100

 Attendance will be monitored strictly
 Feedback from the Supervisor / HOD will be considered

 A certificate will be released after completion of training period

h. Students Training recommended by Ministry of Education : Free

 Attendance will be monitored strictly

 Feedback from the Supervisor / HOD will be considered

 Evaluation from MOE will be filled after completion of training period based
on the feedback.

i. Department Observer ship / Training (Laboratory, Biomedical, Radiology,
Physiotherapy, Finance, Insurance, HR)

Two Weeks : BD. 75
One Month : BD. 100

 Attendance will be monitored strictly

 If absent during the observer ship period, amount will be deducted from the
caution deposit

 Feedback from the Supervisor / HOD will be considered

 A certificate will be released after completion of training period based on the
feedback

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j. Project study : BD. 100 for one month (Needs to submit the project report and
approved by the Guide / Mentor)

 Department head should assign the observer with topic on “Project”
 The Project report should submit to HOD / HR Department by the observer
 Final approval should be taken from COO / CMO before publishing the project

report
 A certificate of observer ship will be released after completion of their project

and period of observer ship

k. Doctors observer ship / Internship : BD. 200/- per month

 Will be on rotation with different departments
 Department heads needs to submit the feedback to CMO / CEO after

completion of their one month training
 Attendance will be monitored
 A certificate will be released after completion of training period

l. Elective placement: BD. 300/- for one month.

8.2.4 Notes:
 Maximum 4 numbers will be allowed at a time
 The observer ship application will be considered on the basis of first come first
serve basis
 Payments should be made on the day of starting training / observer ship
 Payments cannot be reimbursed or cancelled under any circumstances
 Payment is accepted in cash or by credit card only
 RBH will issue a certificate, after completion of successful observer ship /
training
 Project reports needs to be submitted after completion of the training (if
applicable)

8.2.5 Terms & Conditions

Candidates needs to submit the following details / documents, which are mandatory for the selection

of Observer ship / Training

 Confirm duration of the Elective Training
 Department from which you would like to get training.
 Scan copy of Bonafide letter from your University / College / School
 Updated Resume/CV
 Relevant pages of passport
 Candidates from Bahrain needs to submit the CPR
 At the time of joining originals of the certificates should be produced for

verification (if required).
 1 Passport size Photograph
 Hospital does not provide accommodation & transportation.
 Confirm the duration of training with exact start & end date and department

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from which you would like to get training, to enable HRM staff to take consent
from the concerned department.
 During Observership period, observers are not permitted to take any leave /
holidays, unless decided by the competent authority.
 Observers should not make any entry in patients file, should not order
medication, lab or radiology, not permitted to assist the doctors for any
procedures.
 Observers have to be very punctual on timing.
 Observers have to sign in the Observers attendance register available in the
Human Resources Department.
 Observers have to wear ID card, Coat / Uniform, which will be provided from
Human Resources Department.
 You have to surrender ID card, Coat / Uniform after the period of Observer
ship / Training to HR Department.
 If the hospital sustains any loss or damage due to the negligence of the
observer, the hospital has the right to recover the same from the observer.
 Royal Bahrain Hospital has the right to terminate the observer ship training
period without any notice on violating patient confidentiality Policy of
Hospital.
Important protocols which we need to follow:
a. Observers can enter patient care area only in the presence of the consultant to whom you are assigned.

b. No hands on training is allowed
c. Can take history in the presence of Consultant / Medical team, involve in the discussion and attend

clinical meetings.
d. Operation theatre entry is strictly prohibited. If required, permission needs to be taken from CEO /

Executive Director – Operations & Projects (GCC).
e. Any other points imposed by the management from time to time

8.3 RETENTION

Hospital staff has a very high turnover. The cost of recruitment and training of a new staff member is
about one and half times their annual salary. Apart from this financial burden, the quality of service is
also affected. Thus, appropriate retention policies have to be adopted.

Retaining the best staff ensures customer satisfaction, increased product sales, satisfied colleagues and
reporting staff, effective succession planning and deeply imbedded organizational knowledge and
learning. The costs associated with turnover include lost customers, business and damaged morale.

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Effective staff retention is a systematic effort by employers to create and foster an environment that
encourages current staff to remain employed by having policies and practices in place that address
their diverse needs. Staff retention is a process in which the employees are encouraged to remain with
the organization for the maximum period of time. Staff retention is beneficial for the organization as
well as the staff.

8.3.1 Induction & Orientation
All new staff will be given an induction that includes one day orientation program. This is the
responsibility of Human Resources Department. All the Department heads are giving induction to all
the new joiners about the Department and Functions.

8.3.2 Incentives/Motivation
Based on the successful performance, the employee is eligible for an increment after completion of
their Contract. All the employees are getting the increment after completion of two years’ service.
This is the responsibility of Human Resource Department and the Coordinator of the concerned
Department to make sure that the Performance Appraisal forms are filled and the staffs are getting
increment on time.

8.3.3 Accommodation
All staff members who require accommodation will be provided with hostel facilities to ease their
relocation. Staff has to sign the Hostel Rules & Regulations on the same day of availing hostel
facilities. The cost of electricity and water will be borne by the Employee if it exceeds the minimum
amount. There will be a deduction from salary as Hostel fee, if the employee is using the Hospital
provided accommodation.

8.3.4 Additional Exgratia :
To retain staff, Management will pay an additional exgratia to exceptionally good staff. Coordinator
of the concerned Department shall forward the details of staff member who is to be retained, if she /
he plan to leave, to the Human Resource Department. The Human Resource Department shall be
responsible for analyzing the competencies of the staff and shall forward the details to Executive
Director – Operations / Chief Executive Officer and if she / he deem to satisfy the requirement for
retention. Executive Director – Operations / Chief Executive Officer will be the final authority to
approve the same. Approval of retention shall be the discretion and prerogative of the Management.
Schemes for retention as follows

a. Promotion
b. Salary hike

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c. Other benefits like annual air ticket, Air ticket for Family members, family status visa etc

Management has all the rights to deny, minimize or enhance the scheme without any notice or reason
thereof.

8.4 PERFORMANCE APPRAISAL

To describe the procedure established by the organization to review and plan performance, objectives /
goals for the employees and to define performance assessment method for each category of employees.
This procedure aims to facilitate individual training need analysis, career planning & development within
the organization.

This procedure shall be applicable to all categories of employees within the organization.

The respective Functional In-charge shall be responsible for defining objectives / goals for the employees
& to assess their performance based on achievements as per preplanned objectives / goals.

The HRM Department shall be responsible for coordinating periodic performance assessment activities
and collating the result of such assessment.

HRM department shall also be responsible for deciding career options & growth path of employees in
the organization in consultation with the Director/ COO and the concerned Functional in-charge.
8.4.1 Description:
Periodic assessment of employee’s performance is a vital factor in performance and quality oriented
management process. The Performance Appraisal System followed at RBH has three main objectives.

 Employee Performance Planning through goals and target setting for the individual
in alignment with departmental and organizational objectives

 Assessment of the Employee Performance for the period under assessment in relation
to the preset goals and targets; and overall organizational performance

 Career Planning and Training Needs Assessment for identifying potential leadership
qualities and equipping employees for better performance.

8.4.2 Performance Appraisal System
The assessment year for all confirmed employees shall be every year except in the cases of new recruits
for whom the assessment shall be done after their probation period.

The Functional In-charges shall define the objectives / goals of the new employees after the completion
of the probation period.

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The assessment of the new employees shall be done depending on the employment status such as Trainee/
Probationer / Contracts etc.

The assessment of physician’s clinical performance indicators will also be taken into consideration at the
time of performance appraisal. The process of reappointment and re-credentialing of physicians are
evidence based confirmation ie, knowledge, skills, ability and behavior are satisfactory. This can be done
through professional peer review practice evaluation that depends on reliable outcome and data of clinical
performance indicators from quality department

The assessment for all contract employees shall be every year except in the cases of new employees for
whom the assessment shall be done after six months

Based on the successful performance, the employee is eligible for an increment after completion of their
Contract. All the employees are getting the increment after completion of two years’ service. This is the
responsibility of Human Resource Department and the Coordinator of the concerned Department to make
sure that the Performance Appraisal forms are filled and the staffs are getting increment on time.

8.4.3 Performance Planning
The HR Department shall coordinate to conduct the appraisal in a cordial environment.

The Functional In-charges shall discuss with the employee, finalize and record the objectives / goals with
mutual agreement on Employee Performance Appraisal Form (R-HR-11). Whenever possible, the date
of the completion of the objectives / goals shall also be finalized.

The objective / goals shall serve the purpose of measuring the results achieved by the employees during
the assessment year with the standard of performance accepted by both i.e. Assessor and Assessed.

The Functional In-charge shall take care to see that the objectives / goals to be achieved are neither over
- ambitious nor underestimated. In short, the targets shall be achievable without compromising potential
improvements.

At the end of the exercise, the objectives / goals shall be signed by the Functional In-charge and by the
employee.

8.4.4 Assessment of Performance
The Functional In-charge shall ensure proper counseling of the employee on the objectives of the
performance appraisal exercise.

He / She shall provide objective feedback to the employee about their performance, areas of strength,
concerns and the areas for improvement during the appraisal process.

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The appraisal session shall be very open and informal. Reasonable opportunity shall be given to the
employees to give their views on their current performance, constraints experienced by the employee’s
in achieving the results.

The appraisal session shall close with the action plans to be agreed by both the appraiser and the employee
to improve the performance and reduce the constraints that affect the performance.

Overall performance of the employee will be graded as below:
1. Outstanding
2. Very Good
3. Good
4. Average
5. Poor

This will be in accordance to the score attained. The employees will be informed about their grades at
the end of exercise. In-case of poor performers, special instructions shall be / will be provided to improve
their performance before the next annual review.

The results shall be recorded in the Employee Performance Appraisal Form (R-HR-11)
8.4.5 Career Planning and Training Needs Assessment

The Functional In-charge plan and shall record the career planning and training needs of each employee
in Employee Performance Appraisal Form.

The plan shall highlight
a. Current performance levels
b. Potential for higher responsibilities
c. Training & Development needs keeping in mind the current and future role

The Functional Heads shall submit the completed Employee Performance Appraisal Form after
completion of the appraisal process.
8.4.6 Monitoring of the Performance Appraisal System
The success of the appraisal system lies in its implementation - primarily in spirit rather than on paper.
This system is to be perceived as a key instrument in development and growth of employees in the
organization.

The grades in the performance appraisals will also reflect in the calculation of increment, thereby
achieving a performance reward linkage.

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To balance skews in performance appraisal system each functional managers shall be informed in
advance about the ratios of each grade that can be awarded in each functional area. This shall be
calculated based on an overall organizational ratio arrived upon by the HRM department in advance
linked to the overall organizational performance.

Each employee shall be provided an opportunity to air his / her grievances regarding the grade awarded
directly in writing to Head – HR Department. The Head – HR Department shall scrutinize all such
grievances and shall mediate a discussion of the assessment together with both the assessor and assesse.
Based on this discussion the In-charge HRM shall decide on awarding an improved grade or retaining
the existing grade. This decision shall be separately informed to both assessor and assesse with reasons
for the decision.

No employee shall be encouraged to approach any other functionary of the management with his / her
grievances on the grades awarded.

A summary of the performance appraisal exercise shall be submitted to the Chairman / Director / COO
& by the Manager -HRM Department. They scrutinize the exercise by going through individual cases if
necessary and recommend changes to appraisal findings if found necessary. The grades shall be
officially confirmed on their approval and communicated to each employee by the HRM Department.

9. CONDUCT

9.1 CODE OF CONDUCT (NHRA)

The aim of these instructions is to demonstrate the rules of job conduct, including the establishment of job
discipline, transparency, integrity, objectivity, efficiency, loyalty and effectiveness in the conduct of the
employees of Royal Bahrain Hospital and RBHMC in the course of performing their duties and job tasks
entrusted to them.

This code is meant as an ethical guide for healthcare professionals practicing in the Kingdom of Bahrain
within the public and private sectors. It is based on fundamental ethical principles to define the general
responsibilities of all healthcare providers towards their patients, colleagues, profession, society, and
themselves.

9.1.1 Description:
There are certain professional values on which healthcare providers base their practice in ensuring that
they provide safe, compassionate, competent, and ethical care.

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Healthcare providers are expected to make the care of patients their main priority and to practice safely
and effectively.

Patient management must be evidence-based and healthcare providers are expected to promote the health
and well-being of patients, preserve the dignity of patients, and respect their informed decisions. The
relationship between a healthcare provider and a patient is a privileged one that depends on the patient’s
trust. Patients trust their healthcare providers not only to be competent, dependable, and compassionate,
but also to respect their privacy and to maintain the confidentiality of personal health information. Good
practice involves a partnership with patients, which is based on mutual respect, honesty, good
communication, sensitivity to different cultures and beliefs, and good judgment.

Healthcare practice also involves good communication and collaboration with other healthcare
professionals to maximize the health benefits to patients, recognizing and respecting the knowledge, skills,
and perspective of all.

Healthcare providers should be aware of the legal requirements that govern their practice in the Kingdom.
The code will be used by NHRA in its role in setting and maintaining standards of practice and patient
safety. Therefore, if your conduct departs from the code, you must be prepared to explain and justify your
conduct. Serious and repeated failure to meet these standards may have serious consequences for your
licensure.

9.1.2 General Duties:
Providing safe care:

1. Always maintain the highest standard of professional conduct.
2. Always provide proven medical treatments for your patients only.
3. Do not allow personal profit to influence your judgment.
4. Maintain and improve your professional knowledge, skills, and attitude through your engagement in

lifelong learning.
5. Recognize and admit your limitations and seek consultation from other more experienced colleagues.
6. Assume responsibility for any services or treatment delegated to your staff including standards of

hygiene, disinfection, sterilization, and cross-infection control.
7. Ensure that you keep clear, accurate, legible, and comprehensive records of patient care including

details of relevant clinical findings, decisions made, information given to patients, and any medication
prescribed or other investigations or treatments provided.

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8. Ensure that all equipment you use in the care of your patients are safe, operated only by competent
trained staff, and are subject to regular quality control inspections.

9. If you develop or become aware that you have a serious condition that might be transmitted to patients,
or if the condition may impair your judgment or performance, must stop practicing to avoid risk to
patients, take advice from your treating doctor and report immediately to NHRA.

Managing adverse events:
10. Take reasonable precautions and steps to prevent harm to the patient.
11. If an adverse event occurs, act immediately to ensure the patients are protected from harmful

consequences as far as possible.
12. Acknowledge and explain clearly to patients and their families the adverse event and offer an apology

where appropriate.
13. Comply with NHRA policies and procedures about sentinel events reporting.
14. If a patient complains, offer an open, honest, constructive response to ensure that the complaint does

not adversely affect patient’s care.

Emergency care:
15. Give emergency care as a humanitarian duty.
16. In emergency life threatening or organ threatening situations, where consent cannot be obtained,

treatment may be provided as long as it is necessary to save the patient’s life.

Respect for patients:
17. Do not discriminate against any patient based on age, gender, ethnic background, physical or mental

disability, political affiliation, religion, socioeconomic status, or any other reason.
18. Always treat your patients with the respect that they deserve as human beings.
19. Practice in a manner that maintains the patients’ dignity.
20. Deal honestly with patients.
21. Listen to your patients, respect their views and respond to their concerns.
22. Do not use patients for your personal gain or advantage.
23. Always place the well-being and best interest of the patient first.
24. Recognize and disclose conflict of interest to the patient and resolve it in the best interest of the patient.
25. Do not enter into an inappropriate relationship with a patient.
26. Do not abuse or exploit your patient.

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27. Having accepted professional care for a patient, continue until the service in no longer need or the care
of the patient has been transferred to another suitable physician.

28. Respect the patient’s right to obtain a medical report.
29. Respect your patient’s right to a second opinion or request for transfer of care to another healthcare

provider.

Confidentiality:
30. Avoid public discussion about patients that could potentially lead to breach of their confidentiality and

identification by others.
31. Always maintain patients’ confidentiality except in cases permitted by the laws of the Kingdom of

Bahrain.
32. Ensure that confidential patient information is only disclosed to other parties with the patient’s consent

or in otherwise exceptional circumstances to comply with local laws.
33. Access information, whether electronically or in written form, relevant to your own patients only or

when requested by the treating colleague.
34. In dealing with relatives, only share medical confidential information with the patient’s consent.

Patient’s Consent:
35. All relevant information must be provided to the patient prior to any decision being made regarding

treatment.
36. Ensure that informed voluntary consent has been given by the patient before any medical treatment is

carried out.
37. Respect a competent patient’s right to accept or refuse treatment.
38. The refusal of treatment should be fully informed.
39. Give the patients enough information about the nature of their illness, alternative options of treatment

available, risks and benefits of each alternative, risk of refusal of treatment, and your recommendation
as a physician in order to allow them to make an informed decision (please refer to consent policy
(RPP/ MED/ 01) for further details).
40. It is the responsibility of the treating physician to provide the relevant information to the patient. The
responsibility may be delegated to another physician if he/she is suitably qualified to undertake it and
has sufficient knowledge and understanding of the treatment and the risks involved.
41. Always assess the patient’s level of understanding of the information provided.

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42. Communicate with your patient in a way that the information being given is understood by them.
43. Provide information about beneficial diagnostic and therapeutic options available.
44. Consent should not be sought when the patient is stressed or in pain as they will be less likely to make

a reasoned decision at such a time.

Beginning of life:
45. Termination of pregnancy in illegal in the Kingdom of Bahrain except where there is a direct threat to

the mother’s life, and even then abortion should not be undertaken except in a licensed hospital after
the approval of three obstetrics gynecology consultants, one of whom must be from a governmental
hospital, and the approval of the mother’s guardian if she is below 21 years old.
46. Embryos created for reproductive purposes must be treated with respect.
47. Cloning for the creation of an embryo is not permitted.
48. Respect the local laws and regulations related to IVF in the Kingdom of Bahrain and all relevant
guidelines.

End of life care:
49. Respect the dignity of dying patients.
50. Ensure that decisions made in the care of a dying patient are in accordance with the patient’s wishes

as far as possible.
51. Communicate effectively and compassionately with patients and their families when breaking bad

news and try to ensure their understanding of the expected outcome.
52. Provide access to palliative care where available even if a cure is not possible.
53. After the death of the patient, a team member should be available to explain to the family members,

as best as possible, the circumstances of the patient’s death.

Care for patients with infectious disease:
54. All patients must be treated with compassion and equal respect for their dignity irrespective of their

medical condition.
55. A patient with an infectious disease deserves and needs competent treatment and should receive

treatment unless care is outside the healthcare provider’s competence. In such cases, a referral should
be made to another practitioner or facility equipped to provide competent care for the patient.
56. Ensure that you protect yourself, your patients, and colleagues by adhering to universal precautions.

Transfer of patients:
57. Transfer of patients may be in the form of:

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a. Delegation: where another healthcare provider provides care on your behalf while you retain the
overall responsibility for patient care.

b. Referral: When a patient is sent to another healthcare provider to obtain an opinion or treatment from
another healthcare provider for example in areas outside your area of expertise.

c. Handover: where all the responsibilities for the patient is transferred to another.
58. Upon patient transfer, you have to ensure that the person to whom the patient is transferred has the

appropriate knowledge, skills and expertise to provide the required care.
59. Patient transfer should be made where it is in the best interest of the patient and not to serve the interest

of a colleague or institution.
60. Sufficient information should be communicated to the receiving healthcare provider about the patient

through a detailed medical report to enable continuity of care.
61. When delegation takes place, the primary healthcare provider will remain responsible and accountable

for the overall management of the patient and must ensure adequate supervision takes place.
62. The transferring physician should contact the receiving physician to provide details about the patient’s

condition.

9.1.3 Duties to colleagues:

63. Respect all members of the health care team.
64. Deal honestly with colleagues.
65. Work as a member of a team rather than individually.
66. Treat your colleagues in a manner that you would like to be treated.
67. Do not undermine other colleagues in order to attract patients.
68. Do not make derogatory comments about your colleagues or the services they provide.
69. Communicate efficiently with colleagues involved in the care of the same patient.
70. Never engage in bullying, discriminatory, or harassment behaviors.
71. Recognize the value of a team approach to patient care.

Concerns about colleagues:
72. Report colleagues who have difficulties in relation to their health or are performing poorly.
73. Report inappropriate, unprofessional, or unethical behavior to NHRA.

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9.1.4 Duties to the profession:

74. Recognize that self-regulation of the profession in a privilege which places the responsibility of
maintaining it on each and every health care provider.

75. Be willing to teach and learn.
76. Be willing to participate in peer review and undergo peer review.
77. Do not withhold information from colleagues about proven therapeutic agents or procedures that you

provide.
78. Collaborate with other colleagues for the improvement of health care services.
79. Do not receive financial benefits or other incentives solely for referring patients or prescribing a

specific product.
80. Testify only to what you have personally verified.
81. Seek appropriate care when suffering from mental or physical illness.

Use of social media:
82. Be aware about the limitation of privacy online as it can be difficult to control access to it to remove

it.
83. Keep your privacy settings under regular review.
84. Never use social media to discuss individual patients or their care including radiological images,

photos, or surgical procedures.
85. Social medical may be used to educate the public, however, do not venture into specialties or areas of

practice outside the scope of your specialty.
86. Do not misrepresent yourself in social media.

Advertisement:
87. Comply with NHRA guidelines regarding advertisements.
88. Ensure factual, accurate, and verifiable information is used only.
89. Avoid using photographs to promote cosmetic procedures.
90. Do not make false claims or exploit patients’ lack of knowledge.
91. Do not use patient’s information or photographs in any advertisement
92. Advertisements should ensure the maintenance of the dignity of the profession.

Prescribing:
93. Prescribe pharmaceutical agents only when the drug or treatment serves the patient’s needs.

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94. Ensure that the prescribed treatment, medication, or therapy is safe, evidence-based, registered in the
kingdom of Bahrain, and clinically necessary for the patient.

95. Be aware of the danger of drug dependence when prescribing benzodiazepines, opiates, and other
drugs with addictive potential.

96. Have appropriate training, facilities, and support before treating patients with drug dependency or
abuse problems.

97. Refer patient to other facilities where needed.

9.1.5 Duties to society:
98. Remember the profession’s responsibility to society through public education.
99. Promote equitable access to health care resources.
100. Use health care resources responsibly.

9.1.6 Duties to oneself:
101. Seek help from appropriately qualified colleagues for personal problems that might affect your

duties to your patients and the profession.
102. Practice within the limits of your knowledge and specialty.
103. Do not overwhelm yourself with responsibilities that exceed your level of expertise.
104. Seek advice of more experienced colleague when faced with a difficult situation.
105. Escalate the matter to the consultant or even chief of staff if necessary when the proper assistance,

guidance, or supervision is not provided by other members of the team.
106. Refuse to perform procedures without supervision even if requested to do so by more senior

members of the team if you are not competent to perform them.

9.1.7 Duties in Clinical Trials:
107. Ensure your participation in research approved by the NHRA and other appropriate research ethics

committees only.
108. Inform the patients clearly that they are participating in research and not receiving the standard of

care or an unapproved modality of treatment.
109. Provide the potential participants with enough information about the trial to aid them in making an

informed decision about their acceptance or refusal to being enrolled into the given trial.
110. Ensure all participants sign an informed consent form prior to being enrolled into the trial.

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111. Inform trial participants about their right to withdraw from the trial at any time without prejudice to
their ongoing health care services.

112. Inform trial participants about unanticipated risks that occur during the trial and access their
willingness to continue in the trial.

113. The participant’s best interest and well-being always precedes the interest of the trial and the gaining
of knowledge.

9.1.8 Duties to NHRA:

114. Clinical practice should not be started except after the issuing of NHRA license
115. Licenses must be renewed within the periods specified within the Laws
116. Full cooperation must be extended to NHRA staff and inspectors to ease the performance of their

responsibilities
117. Comply with all regulations, standards, and resolutions issued by NHRA
118. Practice must be limited to the license categorization only
119. Accumulate the required continuous professional development (CPD) hours required for the renewal

of the license and continue to be knowledgeable of new advancements in your field
120. The practice of sub-specialties should be initiated after the approval of NHRA only
121. Inform NHRA about your transfer to another healthcare facility
122. Inform NHRA about your cessation of practice or any other changes in your personal information.

9.2 EMPLOYEES RIGHTS AND RESPONSIBILITIES

9.2.1 Employees’ Rights:
Every Employee, during the course of his tenure with the organization, shall be privileged to the following
right:

 To be aware of the hospital wide policies
 To avail the benefits being extended by the organization
 If any one believes that he/she has been the victim of harassment he /she has the right

to report it to the grievance committee
 To be treated considerately and respectfully, and not discriminated on the basis of

caste, religion, sex or socio-economic background
 To be aware of the terms and conditions of his/her employment before joining the

organization
 To be entitled to the terms and conditions as specified in the appointment letter
 To seek clarity on the targets to be achieved/job to be performed, and the

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roles/responsibilities associated with the task to be performed
 To be aware of all the rights being conferred on an employee during the course of

employment including the leave policy, staff welfare measures etc.
9.2.2 Employees Responsibilities:

 It shall be the endeavour of all employees of Royal Bahrain Hospital to contribute to
the highest standards of medical and service excellence. To do so, every employee
shall follow a certain Code of Conduct during his commitment with the organization.

 Royal Bahrain Hospital functions round the clock and employees are expected to
work on shifts or normal duty hours to support the Hospital’s 24 X 7 operations.
Employees may be required to work overtime when the workload so necessitates.

 In order to ensure that the duty roster is maintained, leave should be planned well in
advance and prior sanction taken before proceeding on leave. If for whatever reason
an employee is unable to report to work on schedule, he/she must inform his/her
Manager, in writing.

 Employees are expected to use email and internet access that is provided in a manner
that is ethical and lawful

 All employees are responsible for ensuring that the equipment allocated to them or
in use in their work is used and maintained in accordance with the standard operating
guidelines.

 All employees are expected to maintain proper discipline, professional ethics and
complete integrity in the performance of work. They are expected to maintain proper
discipline in the Hospital/office and to conduct themselves with the highest degree of
professionalism.

 An employee is expected to maintain complete integrity in his/her action and work.
If any declaration given or furnished by him/her proves to be false or if he/she is
found to have willfully suppressed any material information, he/she may be liable to
be removed from the services of the Company and to such other action, as the
Company may deem necessary & fit.

 All employees are expected to maintain complete confidentiality in respect of their
documents and patient information they handle. They shall not during the term of
employment with the Company or at any time thereafter disclose any patient related
information or any business or affairs of the Company that they are not authorized to
divulge.

 Employees are not expected to have any contact with the Press or make any public
statements without the prior approval of the Company.

 The company has adopted an open office plan. Employees are therefore encouraged
to be sensitive to those around them by conversing in soft tones & quiet behavior.

 Employees shall be discrete in their personal conversations while in the presence of
customers and patients.

 Employees are encouraged to adopt a clean desk policy and clear up their
workstations on completion of each workday. They shall ensure that all personal and

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confidential papers are kept securely.
 Employees working in patient contact areas, such as nurses, front office executives,

who are issued company uniforms, are expected to be in uniform while at work.
Employees who are not provided uniforms shall follow a business dress code.
 It is the responsibility of each employee to promptly notify their supervisor and HR
department of any changes in their personnel data.

9.3 EMPLOYEE GRIEVANCE HANDING

The Head of Human Resources is responsible for overall coordination of the grievances handling

procedure and making necessary interventions to address / solve these grievances.

The Staff Grievances & Complaint Management Committee is responsible for ensuring long term

preventive measures are taken to eliminate recurring grievances in coordination with Manager – Human

Resources.

9.3.1 Description:
 Any grievance should be in writing by the individual employee.
 Grievance should be submitted through proper channels like e-mail or letters dropped
in the grievance box available at the premises.
 The Human Resources Manager is the nodal representative of the Management for
receiving all employee grievances. The employees are encouraged to take up the
grievances with their immediate supervisors.
 In case the employee is not satisfied with the decision of the immediate supervisor or
Functional manager or fails to receive an answer from them within 3 days, he/she
may refer the grievance to the Departmental Head.
 On receipt of a written employee grievance the Head of Department shall have a
closed-door discussion with the concerned employee. After verifying the various
aspects of the grievance he/she shall have a separate or joint meeting with the all
employees involved.
 All grievances received by the HR Department shall be filed and maintained for a
period of at least three years. (F-HR-11)
 In case a grievance cannot be addressed in the normal handling mechanism at
Departmental level, these may be forwarded to Head HR. The HR department shall
analyze the grievances to identify recurring grievances and patterns. These shall be
forwarded for the attention of Staff grievances & Complaint Management committee
the decision of the committee in the matter shall be given within 30 days & will be
final and binding on the employee
 The committee shall provide the guidance to the HR Department for actions to be
taken to eliminate the root causes of such grievances and prevent their re-occurrence.
 Staff can also send email to [email protected] which can be

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viewed by Chief Operating Officer, Executive Director and Chief Executive Officer.
 The key members will investigate the complaints and actions will be taken

accordingly
 Following are the members of Staff Grievances & Complaint Management

Committee.

9.3.2 Disciplinary Activities
To establish a system for handling disciplinary actions against errant employees with appropriate levels
of enquiry and opportunity for the concerned employee to present his case.

This procedure is applicable to disciplinary actions initiated by management.
9.3.3 Definitions
A. Patient / Staff Relations – Any patient / staff relationships which could lead to
unprofessional conduct or the possibility of a staff member’s job performance being affected
is strongly discouraged.
B. Gratitude – Gifts, gratitude and other forms of favors from patients, patient families, vendors
and others are discouraged. No monetary gratitude should be accepted.
C. Misconduct– Conduct by any staff member, whether by act or by omission which fails to
meet the Hospital’s expectations, violates rules and regulations, causes unsatisfactory job
performance or adversely affects the employment relationship is considered as a misconduct.
D. Wrongful act – Wrongful act means any act, misstatement, or omission in violation of the
law, especially the civil law. A wrongful act infringes the rights of another to his/her damage,
unless it be done in the exercise of an equal or superior right. Wrongful acts includes illegal
acts, acts that are immoral, anti-social, or libel to result in a civil suit, error, misstatement, or
breach of duty by any staff.

9.3.4 Responsibility:
The Human Resources Management staff is responsible for overall coordination of the disciplinary
activities. A preliminary enquiry is initiated on receipt of a complaint against a particular employee who
has done any misconduct / wrongful act in the course of his/her employment. The purpose of holding a
preliminary enquiry is to examine the facts and to see whether a prima facie case exists there by calling
for a detailed enquiry. The preliminary enquiry is conducted to the satisfaction of the disciplinary authority
as to whether the matter to be further proceeded or dropped.

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The H.R Director / COO are responsible for the final confirmation of disciplinary actions taken against
all non-medical staff.

The C.E.O is responsible for the final confirmation of disciplinary actions taken against all medical staff.

Work Conditions and Employee Conduct: We strive to provide the highest standard of care and
service to our patients. Our employees represent the company and are expected to conduct
themselves in a safe, professional and courteous manner. General Conduct and working rules
include:

Patient / Staff Relations, Gratitude, Misconduct, and Wrongful act :

 Any form of insubordination.
 Theft or unauthorized removal of company property or property of others.
 Refusal to perform or follow reasonable directions.
 Reporting to work under the influence or possession of intoxicants, drugs, not prescribed

for medical reasons.
 Illegal or unauthorized possession of weapons or firearms.
 Defacing, damaging or destroying hospital property.
 Abuse or discourteous treatment of patients, public, medical staff or coworkers.
 Behavior that creates intimidating, hostile or offensive work.
 Leaving assigned work without required authorization or job abandonment (2 days or more

without proper notification or approval).
 Disregard of confidentiality.
 Smoking in non-smoking areas.
 Falsification of records including, but not limited to employment information, information

pertaining to patients, records of time worked.
 Violating the dress code policy of the institution.
 Irregular attendance, habitual absenteeism, late entry/early exit beyond the permissible

time limit.

Disciplinary Procedure: An employee suspected with having committed a misconduct /
wrongful act warranting any of the major penalties shall be schedules to have a hearing served as a
notice stating briefly the facts of the charge and the nature of misconduct / wrongful act.

 If the hearing is finalized with a decision that the employee didn’t commit any major
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penalties the case will be withdrawn and no further actions will be taken.

 If the hearing is finalized with a decision that the employee did commit a major penalties,
a warning letter will be issued. The employee will be given e period within which he shall
give a written explanation if he wishes. If the period is not specifically mentioned in the
written warning, the employee shall submit the explanation within 24 Hours of receipt of
the Show Cause Notice.

 In case an employee refuses to receive Written warning, the management may consider it
expedient to send it by registered post to the last known address of the employee; registered
post charges will be recovered from the employee.

 Management may also intimate the employee in the presence of witness the substance of
the written Warning.

Suspension of the Employee: An employee against whom any misconduct / wrongful act is
alleged may be suspended or placed on Garden Leave pending enquiry, and final decision
thereupon by the management.

 The suspension pending enquiry shall be intimated to the employee in writing.

 When an employee submits his explanation and the explanation is found satisfactory,
suspension pending enquiry shall be withdrawn and the case shall be closes.

 The period of suspension will be treated as if the employee was on duty and he/ she shall
be entitled to his salary for the period deducting the subsistence allowance is any.

 If the explanation is not found satisfactory or if no reply is received within 24 Hours.

 Management may proceed on the basis that the employee has no explanation to offer and
take further necessary steps, as it deems proper and necessary.

Enquiry Process In case the explanation given by the employee is found to be unsatisfactory and
it is considered necessary to take further proceedings under these rules, the management may order
an enquiry into the charge to be held by an officer of the company or any person including an
external counsel, the period of suspension may also be extended.

1. In case the errant employee fails to attend the enquiry without any reasonable cause, enquiry
may be conducted in his/her absence.

2. Written explanation and record of enquiry shall be submitted for consideration by the
management or the authorized officer of authority or the punitive authority for the purpose
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of taking a final decision.
3. An employee, found guilty of misconduct/wrongful act may be punished in any of the

following manner:

 Employee counselling or Verbal reprimand with suggestions for improvement
 Written Warning
 Recovery from his pay the whole or part of any loss of income caused by the

misconduct/wrongful act.

 Imposition of fine up to 3 % of his salary in a month
 Suspension for any period that may be decided by the management without salary or on

such reduced salary as may be ordered.

 Withholding of increments, with or without cumulative effect or postponing of any
increment to any future date with or without cumulative effect.

 Reversion or demotion to a lower grade or post or pay scale or to a lower stage in the same
pay scale either permanently or for a specified duration.

 Treating the absence as break in service.
 Barring of promotion.
 Discharge from service without compensation or notice.
 Dismissal
*The Management should involve RBH Legal advisor in any Disciplinary meeting/ Investigations related to
any violation.
9.4 ANTI-CORRUPTION POLICY

KIMS is committed to high ethical standards in our business dealings.

The purpose of this policy is to ensure that managers and employees have a detailed understanding of the
KIMS group’s Anti-Corruption policy

9.4.1 Standards of Business Practice

A. Bribery Offering, giving or promising (or authorizing someone to offer, give, or promise) an
 -40-

improper benefit, directly or indirectly, with the intention of influencing or rewarding
the behaviour of someone to obtain or retain a commercial advantage.

 Offering or giving money or anything else of value. Receive, agree to receive, request
or accept a financial benefit or anything else of value are regulated by the Conflicts
of Interest Policy.

B. Gifts, Hospitality & Entertainment
 Gifts or entertainment may only be offered to a third party if they are consistent with
customary business practice in the relevant territory, are modest in value and cannot
be interpreted as inducements to trade. Guidance should be sought from the
Entertainment Policy. Where there is any doubt, guidance should be sought from the
relevant Regional or Group General Counsel.

 Sales of the Group’s services and products and purchases of services and products
from suppliers will be made solely on the basis of quality, performance, price, value
and/or for the benefit of the Group, and never on the basis of giving or receiving
inducements in the form of payments, gifts, entertainment or favors or in any other
form. The Commercial Sponsorship Policy provides additional guidance to managers
on this subject.

 Employees should not accept gifts, money or entertainment from third party
organizations or individuals where these might reasonably be considered likely to
influence business transactions. Gifts, other than trivial ones with a low value, should
be returned. This becomes even more important when a procurement decision is
pending. In a culture where such an action might cause offence, the gift should be
declared to the company and, if practical, donated to an appropriate charity.

C. Political contributions
 KIMS does not make contributions to political parties, political candidates or
organizations which are politically active and this policy should be followed across
KIMS. The only exceptions to this might be in countries where there is a legal
requirement to do so. Any payment must be approved in advance by the Chief
Executive Officer.

D. Treatment of Patients
 Mutual trust and confidence with our patients is vital. All employees should strive to
consistently deliver care with compaction and excellence, meeting patients’
expectations and anticipating their changing requirements.

 Accurate understanding of both the Patients’ expectations and the company’s
obligations are vital and depend on open and clear communication.

E. Treatment of suppliers

 Our suppliers are entitled to fair treatment. It is our policy to pay suppliers in
accordance with agreed terms of trade. We set high standards for our suppliers in the
context of our own ethical policy.

F. Competition
 KIMS will always compete vigorously and in a fair and ethical way. Competitive
success is built on providing good value and service excellence. When in contact with

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competitors, employees will avoid discussing confidential information and no
attempt will be made to improperly acquire competitors’ trade secrets or any other
confidential information.
 Employees must not publicize, discuss or share with competitors (even indirectly)
pricing information or engage in any conduct or practices which would conflict with
the laws applicable to the business concerned.

G. Approach to Corporate Governance
 KIMS is committed to protecting the interests of our shareholders and our
organization through compliance with the relevant legal and regulatory environments
and careful management of business risks.
 KIMS comply fully with all relevant national and international laws and regulations.
 It is the responsibility of all managers to ensure, by taking legal or other expert advice
where appropriate, that they are aware of all local laws and regulations which may
affect the area of the business in which they are engaged.
 All accounting documentation must clearly identify the true nature of business
transactions, assets and liabilities in conformity with relevant regulatory, accounting
and legal requirements. No record or entry may be false, incomplete or suppressed.
 All Group reporting must be accurate and complete and in compliance in all material
respects with accounting standards, policies and procedures, as outlined in the Group
Finance Manual. Employees must not materially mis-state or knowingly misrepresent
management information for personal gain or for any other reason. Concerns that this
may have or will occur should be reported via the whistleblowing facilities available.

H. Conflicts of Interest
 Every employee has a duty to avoid business, financial or other direct or indirect
interests or relationships which conflict with the interests of the Company, or
which divides his or her loyalty to the Company. Any activity which even appears
to present such a conflict must be avoided or terminated unless, after disclosure to
the appropriate level of management, it is confirmed in writing that the activity
does not constitute a conflict of interest and is not detrimental to the reputation and
standing of the Company.

9.5 SEXUAL HARASSMENT

All concerned should take cognizance of the fact that RBH strongly opposes sexual harassment and have
zero-tolerance for it.

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RBH is committed to creating and maintaining a secure work environment where it’s Employees, Patients,
Vendors and Partners can work and pursue business together in an atmosphere free of harassment,
exploitation and intimidation caused by acts of Sexual Harassment within but not limited to the office
premises and other locations directly related to the Company’s business.
The objective of this policy is to provide prevention and protection against sexual harassment at the
workplace and for the complaints management of sexual harassment.
This policy applies to all members of staff, patients and visitors working or present on the hospital
premise.
This policy is aimed at securing the dignity and personal development of all members of staff within RBH.

9.5.1 Forms of Sexual Harassment
Physical conduct

 Unwelcome physical included but not limited to patting, pinching, stroking, kissing,
hugging, fondling, or inappropriate touching

 Physical violence, including sexual assault
 The use of job-related threats or rewards to solicit sexual favors
 Indecent exposure

Verbal conduct

 Comments on a worker’s appearance, age, private life, etc.
 Sexual comments, jokes or Tales of sexual exploits
 Showing any Material that is sexual in nature
 Sexual advances
 Repeated and unwanted social invitations for dates or physical intimacy
 Insults based on the sex of the worker
 Condescending or paternalistic remarks.

9.5.2 Employer’s Responsibility

 Prevent and prohibit all and any acts of harassment, in order to ensure a safe and
healthy work environment.

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 Resolve grievances pertaining to sexual harassment.
 Take the following proactive steps:
 Conduct regular workshops and employee awareness programs for gender

sensitization.
 Monitor timely submission of the reports including Annual Report by the Staff

Grievance & Complaint Management Committee
 Timely and efficiently enforce the recommendations received from the Staff

Grievance & Complaint Management Committee
 To assist the aggrieved employee.

9.5.3 Employees Responsibility:

 All employees are mandated to read and acquaint themselves with the company
policy with respect to any instances of sexual harassment reported at the workplace.
Pleading ignorance about the policy or the following consequences shall not stand a
valid ground in any case whatsoever.

 Employees of KIMS must conduct themselves so as to ensure a work environment
that promotes respects and upholds the dignity of every individual at the workplace
and does not become the cause of any physical and mental harassment.

 Employees must report every incident of perceived harassment that they are aware of
through the official channels mentioned here.

 Employees are expected to cooperate with the company in investigations and in
preventing and curtailing unlawful discrimination and harassment at the workplace.

9.5.4 The Internal Complaints Committee:

 No sexual harassment complaint should be dealt with at the Unit level.
 Every complaint received shall be forwarded to internal complaint committee formed

under this policy. The investigation shall be carried out by the Internal Complaints
Committee constituted for this purpose.
 For any grievances, employees must report harassment to a supervisor or HR
representative or members of the Internal Complaints Committee
 On receipt of the complaint, the Internal Complaints Committee shall proceed to
commence enquiry as per service rules/rules in that regard.

9.5.5 Process

Any aggrieved person may make, in writing, a complaint of sexual harassment at workplace to their
immediate supervisor, Head of Department or Human Resources Department or to directly to the Internal
Complaints Committee as follows:

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 The report should be sent within a period of one (1) week from the date of incident.
In case of a series of incidents, within a period of two (2) weeks from the date of first
incident.

 Providing ample details about the date , the time, the place and the series of actions
taken and words spoken that happened before, during and after the sexual harassment
was meted out to her/him

 On receipt of complaint, the Internal Complaints Committee shall decide the place
and time for hearing the complaint and shall intimate the date, time and place of
hearing to the Complainant and ask her/him if require to furnish additional
information about the alleged harassment.

 Where the aggrieved person is unable to make a complaint or attend a hearing on
account of their incapacity, a complaint may be filed by a third parties they explicitly
give power of proxy to as below:
- A relative or friend; or

- A co-worker; or
- Any person who has knowledge of the incident, with the written Consent of

the aggrieved person.

 Once the hearing of the complainant is completed. The receipt of such complaint,
the Committee shall provide a copy along with supporting documents of such
complaints to the Respondent within 3 working days

 Respondent shall file reply within 7 working days of receipt of the complaint along
with list of documents, witnesses…etc. if any.

 The Committee shall investigate in detail into the matter of the complaint. They shall
have the right to call the person against whom the complaint is made or any other
witnesses when necessary.
- The Committee shall have the right to terminate the enquiry or give ex-parte
decision on the complaint, if the Respondent or complainant remains absent for
3 consecutive hearings, without sufficient cause.
- During such enquiry, upon written request by the aggrieved person, the
committee may at its discretion recommend to transfer the aggrieved person or
the respondent to another location or grant the aggrieved employee Garden
Leave
- The Committee must complete its investigation within a period of 30 days from
the day of receiving the complaint.

9.5.6 Actions:

 The Committee shall on completion of the enquiry provide a report of its findings
within 2 days from the date of completion of the enquiry and such report shall be
made available to the concerned parties and the Chief Executive Officer.

 If the allegation against the respondent has not been proved, the Committee may

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recommend that no action needs to be taken in the matter.
 If the allegation against the respondent has been proven to be made in bad faith the

Committee may recommend deduct from salary of the complainant/ issue a written
warning or even terminate.
 If the Internal Complaints Committee arrives at the conclusion that the allegation
against the respondent has been proved, it shall recommend to:

- Written apology to the complainant,
- Issue warning,
- Withholding of promotions, increments of the Respondent,
- Terminating the Respondent
-
9.5.7 Members of the Internal Complaints Committee:

Name Title

Dr. S. Sahadulla Chief Executive Officer
Hasna Zavrak Human Resources Head- Middle East
NA Administrator/ Head of Unit/ COO of Unit
NA Nursing Manager/ Nursing Head

9.7 WHISTLE BLOWER POLICY

This Policy is intended to assist employees to report, in good faith, any act of malpractice or impropriety
without having any fear. Employees are provided utmost protection against any possible retaliation or
reprisals, whether actual or threatened, as a result of their whistleblowing.

A whistleblower as defined by this policy is an employee of KIMS who reports an activity that they
consider to be illegal or dishonest to one or more of the parties specified in this Policy. The whistleblower
is not responsible for investigating the activity or for determining fault or corrective measures; appropriate
management officials are charged with these responsibilities.

9.7.1 What to report:

Employees are to report any but not limited to the below wrong doings:

 Significant violation of a law, rule, regulation or policy
 Gross mismanagement; financial malpractice, corruption, fraud, or any attempt to

conceal information
 Abuse of authority
 Substantial and specific danger to Patient health

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 A substantial and specific danger to public safety
 Criminal activity
 Breach of legal obligations,
 Harassment or discrimination of anyone receiving healthcare services, working or

visiting the Hospital
 Intentional negligence or non-compliance with the patients protocols

9.7.2 Protection:
Reasonable steps should be taken for the protection of a person who reports alleged improper conduct in

good faith should entitle:

 Keeping the anonymity of the whistle blower to others except for the committee
tasked for the investigation

 The Whistle blower shall receive no retaliation or retribution for a report that was
provided in good faith – that was not done primarily with malice to damage another
or the organization

 The employee against whom a report was made shall receive no retaliation or
retribution until the investigation is complete and the wrong doing is proven.

 Organization Details of the nature of the wrongdoing and or misconduct should be
kept confidential throughout and even after the decision by the committee is made.

9.7.3 Guiding Principles:
 Reports shall be made in good faith, without any intension to do harm to neither of
the organization and the person allegedly committing the wrongdoing.
 A whistleblower must have more than just a suspicion, he/she must have an evidence
of the wrong doing.
 Where it is established that a Whistleblower who is a member of staff is not acting in
good faith, or he/she has knowingly made a false disclosure of Improper Conduct,
then he/she will be subjected to disciplinary proceedings, which may include
summary dismissal.

9.7.4 Process:

Reports

 If an employee of KIMS or any of its Units has a proof about possible malpractice
falling within the scope of this Whistleblower Process, he/she should raise it in the
first instance directly to the Audit Committee.

 The receiver of the report shall immediately notify the Chief Executive Officer.

 The Company Secretary will promptly inform any employee who is alleged to be
involved in the issue of the facts alleged against him/her, as well as how to exercise
his/her rights of access and correction. Such notice may be deferred for a very limited
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time period in order to secure any potential evidence.

Investigation

 The Audit Committee shall task the relevant department to investigate depending of
the nature of the alleged wrong doing. The unit may even require external counsel on
the matter.

 The Audit Committee will decide on the next step based on the result of the
investigation and may decide either to make further investigations or to make
recommendations.

Feedback

 The employee who submitted the report will receive feedback about how the report
has been dealt with, whether any corrective measures or process improvements have
been recommended and if any further steps will be taken.

 No details will be released relating to specific individuals and the feedback might be
of a general nature, taking into account the interest of the unit and KIMS to keep its
information confidential and the rights of any third parties.

 The reports will be disclosed only to the employees who have a “need to know” for
the purpose of the investigations. All employees involved in the Whistleblower
Process will maintain strict secrecy about the content of any reports.

No Retaliation

 KIMS will take the necessary measures to protect employees who have, in good faith,
Actions made reports through the Whistleblower Process, against any retaliation from
managers or other involved parties.

 Necessary punitive actions will be taken against the employee and or employees
reported in case the wrong doing was identified and proven.

 Necessary punitive actions will be taken against the whistle blower in the event that
the whistle blower didn’t report in good faith.

 No action will be taken in case the wrong doing was not proven or proof of honest
mistake was found.

9.7.5 Audit Committee Members

Name Designation
Dr. Sheriff M. Sahadulla Chief Executive Officer- Middle East
Mr. Jacob Thomas Executive Director – Operations & Projects (GCC)

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