Standard 6: Workforce (Version 11)

Why it matters. Skills learned at hiring fade. Checking competence against the actual job, on a schedule, finds gaps before they harm patients.

Sample. Select three roles and review the competency records for their current staff.

1. Competency is evaluated on a defined schedule.

Method. Compare the evaluation dates with the schedule in the procedure.

Evidence to show. WRK-SOP-001 Annual competency assessment procedure; WRK-REG-001 Training matrix register.

Pass when. Evaluations are recorded on the scheduled dates.

2. The evaluation covers the person's current role.

Method. Check that the competency form matches the role description.

Evidence to show. WRK-FRM-001 Competency assessment form by role.

Pass when. The form covers the current role.

3. Gaps have a defined response.

Method. Check each recorded gap for an action and a date.

Evidence to show. WRK-POL-001 Ongoing competency evaluation policy.

Pass when. Each gap has an action and a date.

Immediate fail (any one means the criterion is not met)

• A staff member with a current competency gap is kept in role with no evaluation and no response.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Pan American Health Organization (2020). Checklist for the Management of Human Resources for Health in Response to COVID-19. Used for: Workforce competence. https://news.gmj.ge/guideline/checklist-for-the-management-of-human-resources-for-health-in-response-to-covid-19-2/

Why it matters. Staff who cannot learn new skills fall behind the care they are asked to give. Giving every staff member access to ongoing education keeps the workforce able to meet the standards.

Sample. Review the training matrix for the last 12 months.

1. Every workforce member has ongoing education access.

Method. Check the training matrix for each person.

Evidence to show. WRK-REG-001 Training matrix register.

Pass when. Each person has at least one recorded entry beyond induction.

2. Development goes beyond the minimum.

Method. Check the entries for development opportunities beyond the required minimum.

Evidence to show. WRK-POL-002 Learning, training and competence policy.

Pass when. Development entries exist beyond the minimum.

3. Staff can describe a recent opportunity.

Method. Ask staff to name an education opportunity taken in the last year.

Evidence to show. WRK-REG-001 Training matrix register.

Pass when. Staff name a recorded opportunity.

Immediate fail (any one means the criterion is not met)

• A staff member has had no education beyond induction and no development route exists.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2013). Transforming and scaling up health professionals' education and training. Used for: continuing education and in-service training of health workers (6.2). https://news.gmj.ge/guideline/transforming-and-scaling-up-health-professionals-education-and-training-2013/

Why it matters. Health workers can catch infections and be hurt at work, and they can also carry infections to patients. Protecting their health, with required vaccinations and safe working conditions, protects everyone in the building.

Sample. Review the vaccination records and the exposure records for the last 12 months.

1. Protective equipment is available and used.

Method. Check stock and observe use in two clinical areas.

Evidence to show. WRK-POL-003 Occupational health, safety and wellbeing policy.

Pass when. Equipment is in stock and used.

2. Needlestick and manual handling measures are in place.

Method. Check the exposure procedure and the manual handling measures.

Evidence to show. WRK-SOP-002 Occupational exposure and needlestick response.

Pass when. Concrete measures exist and are followed.

3. Vaccinations are tracked and current.

Method. Check the vaccination record for each staff member against the required schedule.

Evidence to show. WRK-SOP-003 Staff vaccination and immunisation.

Pass when. Required vaccinations are recorded as current.

Immediate fail (any one means the criterion is not met)

• Required staff vaccinations are not tracked, or needlestick and manual handling risks have no protective measures.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Workforce Health and Safety (English).

Documents: who does each step

References

1. World Health Organization (2022). Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers. Used for: Occupational health and safety of staff. https://news.gmj.ge/guideline/caring-for-those-who-care-guide-for-the-development-and-implementation-of-occupational-health-and-safety-programmes-for-health-workers/

Why it matters. When staff raise a problem at work, such as unsafe rotas or bullying, and nothing happens, they stop raising it. A process that investigates and resolves the issue keeps problems visible and fixed.

Sample. Review the concern records for the last 12 months.

1. An accessible process exists to raise issues.

Method. Check the procedure and ask staff how they would raise a whistleblowing concern.

Evidence to show. WRK-SOP-005 Staff grievance and investigation procedure.

Pass when. The process is written and staff can describe it.

2. Raised issues are investigated and resolved.

Method. Check each recorded concern for an investigation and an outcome.

Evidence to show. WRK-FRM-002 Staff concern and investigation record.

Pass when. Each concern has an investigation and an outcome.

3. Staff are protected from adverse treatment.

Method. Check the records for any adverse action following a concern.

Evidence to show. WRK-SOP-005 Staff grievance and investigation procedure.

Pass when. No adverse action follows a raised concern without review.

Immediate fail (any one means the criterion is not met)

• A raised concern has no investigation record, or a staff member who raised one is treated adversely.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Raising and Resolving Workplace Concerns (English).

Documents: who does each step

References

1. ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector (2002). Framework guidelines for addressing workplace violence in the health sector. Used for: reporting and follow-up of workplace problems raised by staff, including bullying and harassment (6.4). https://news.gmj.ge/guideline/framework-guidelines-workplace-violence-health-sector/

Why it matters. Staff who are attacked need specific protections, not general statements. Tracking incidents shows whether the protections work.

Sample. Review the incident records for the last 12 months.

1. Specific protective measures exist.

Method. Check the prevention procedure for concrete measures.

Evidence to show. WRK-SOP-006 Violence and aggression prevention and response.

Pass when. Concrete measures are written in the procedure.

2. Incidents are recorded and reviewed.

Method. Check each recorded incident for a review.

Evidence to show. WRK-FRM-003 Violence and aggression incident record.

Pass when. Each incident is recorded and reviewed.

3. A measure has worked in practice.

Method. Ask staff to describe a case where a measure worked as intended.

Evidence to show. WRK-FRM-003 Violence and aggression incident record.

Pass when. Staff describe at least one case.

Immediate fail (any one means the criterion is not met)

• A violent or aggressive incident against staff is not recorded.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Preventing Violence and Aggression Against Staff (English).

Documents: who does each step

References

1. World Health Organization (2022). Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers. Used for: occupational health and safety programmes, including protection of health workers from workplace violence. https://news.gmj.ge/guideline/caring-for-those-who-care-guide-for-the-development-and-implementation-of-occupational-health-and-safety-programmes-for-health-workers/
2. ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector (2002). Framework guidelines for addressing workplace violence in the health sector. Used for: preventing, managing and responding to violence against health workers (6.5). https://news.gmj.ge/guideline/framework-guidelines-workplace-violence-health-sector/

Why it matters. Staff know where the service is failing better than anyone. Asking them regularly, and acting on the answers, is how the workforce's experience improves the service.

Sample. Review the feedback surveys and responses for the last 12 months.

1. Feedback is gathered on a recurring basis.

Method. Check the survey schedule and the records of exit interviews and consultations.

Evidence to show. WRK-FRM-004 Staff feedback survey template; WRK-SOP-007 Staff feedback survey and response.

Pass when. Feedback is gathered on a schedule.

2. Feedback is analysed for trends.

Method. Check the analysis of the latest survey.

Evidence to show. WRK-SOP-007 Staff feedback survey and response.

Pass when. An analysis of trends is recorded.

3. Feedback has led to a change.

Method. Ask for one implemented change that came from feedback.

Evidence to show. WRK-SOP-007 Staff feedback survey and response.

Pass when. At least one change is recorded.

Immediate fail (any one means the criterion is not met)

• No workforce feedback is gathered, or feedback is collected and never analysed.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Workforce Feedback and Action (English).

Documents: who does each step

References

1. World Health Organization (2022). Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers. Used for: involving health workers in decisions about their working conditions (6.6). https://news.gmj.ge/guideline/caring-for-those-who-care-guide-for-the-development-and-implementation-of-occupational-health-and-safety-programmes-for-health-workers/

Why it matters. Sick leave and staff leaving are early warnings. When many people are off sick or leaving one ward, the cause is often in the workload or the management, and it can be found in the data.

Sample. Review the sickness and attrition register for the last 12 months.

1. Sick leave data is monitored.

Method. Check the register for a recorded review of sick leave.

Evidence to show. WRK-REG-002 Sickness absence and turnover register.

Pass when. Reviews are recorded.

2. Reasons for leaving are captured.

Method. Check the exit records for a recorded reason for each leaver.

Evidence to show. WRK-SOP-008 Analysis of sickness and attrition data.

Pass when. A reason is recorded for each leaver.

3. The data has informed a change.

Method. Ask for one recorded change that followed the analysis.

Evidence to show. WRK-SOP-008 Analysis of sickness and attrition data.

Pass when. At least one change is recorded.

Immediate fail (any one means the criterion is not met)

• Sick leave and attrition data are recorded but never reviewed.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Sick Leave and Attrition Data for Organisational Learning (English).

Documents: who does each step

References

1. Pan American Health Organization (2020). Checklist for the Management of Human Resources for Health in Response to COVID-19. Used for: Workforce retention and attrition. https://news.gmj.ge/guideline/checklist-for-the-management-of-human-resources-for-health-in-response-to-covid-19-2/

Why it matters. Recruitment, allocation of shifts and promotion can favour some groups without anyone meaning them to. Monitoring the patterns shows where equity is missing, so it can be fixed.

Sample. Review the workforce equity register for the last 12 months.

1. Workforce data is monitored for inequity.

Method. Check the register for recruitment, allocation, scheduling and promotion data.

Evidence to show. WRK-REG-003 Workforce equity register.

Pass when. Each of the four areas is monitored.

2. A pattern has a defined response.

Method. Check for any identified pattern and its response.

Evidence to show. WRK-SOP-009 Workforce equity monitoring.

Pass when. Each identified pattern has a response.

3. Monitoring has informed a change.

Method. Ask for one recorded change in practice that followed monitoring.

Evidence to show. WRK-REG-003 Workforce equity register.

Pass when. At least one change is recorded.

Immediate fail (any one means the criterion is not met)

• Workforce data is not monitored for inequity, and no response exists to an identified pattern.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Pan American Health Organization (2020). Promoting health equity, gender and ethnic equality, and human rights in COVID-19 responses: Key considerations. Used for: Workforce equity. https://news.gmj.ge/guideline/promoting-health-equity-gender-and-ethnic-equality-and-human-rights-in-covid-19-responses-key-considerations/

Why it matters. Staff who work very long hours or without proper rest make more errors, and they are more likely to be injured. Writing down the hours, the breaks and the rotas, and checking them, keeps the workforce safe.

Sample. Review the rota and working hours log for the last month.

1. Working hours and rest are set in writing.

Method. Check the policy for stated hours and rest breaks.

Evidence to show. WRK-POL-004 Working hours and rest policy.

Pass when. The policy states hours and rest.

2. Compliance is monitored.

Method. Check the working hours log against the policy.

Evidence to show. WRK-REG-004 Rota and working hours log.

Pass when. Each excess is identified and recorded.

3. Staff take the rest they are due.

Method. Check rest breaks in the log and ask staff.

Evidence to show. WRK-REG-004 Rota and working hours log.

Pass when. Rest is taken and recorded.

Immediate fail (any one means the criterion is not met)

• Working hours and rest are not set in writing, and excessive working time is not reported.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Safe Working Hours and Rest (English).

Documents: who does each step

References

1. World Health Organization (2022). Caring for those who care: Guide for the development and implementation of occupational health and safety programmes for health workers. Used for: Working hours and rest. https://news.gmj.ge/guideline/caring-for-those-who-care-guide-for-the-development-and-implementation-of-occupational-health-and-safety-programmes-for-health-workers/

Why it matters. A staff member who sees a serious danger, or a colleague doing wrong, may not report it if the report goes through the manager who is part of the problem. A route that bypasses the line manager, and protects the person who reports, makes the service safer.

Sample. Review the speak-up reports for the last 12 months.

1. A speaking-up route exists that bypasses the line manager.

Method. Check the policy for a route that does not go through the line manager.

Evidence to show. WRK-POL-005 Speak-up policy.

Pass when. The bypass route is written in the policy.

2. Every report is answered.

Method. Check each report for an answer to the person who raised it.

Evidence to show. WRK-SOP-010 Concern handling and protection from retaliation.

Pass when. Each report is answered, with the outcome recorded.

3. Protection from retaliation is applied.

Method. Check for any recorded retaliation and its handling.

Evidence to show. WRK-POL-005 Speak-up policy.

Pass when. Protection is written and applied when tested.

Immediate fail (any one means the criterion is not met)

• No route exists to speak up that bypasses the line manager, or a report receives no answer.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: transparency, openness and a no-blame culture in which staff can report safety concerns (6.10). https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Why it matters. Falls are among the most common harms to patients in care. Staff who are trained to prevent them, and whose training is refreshed, can spot the risk before the patient falls.

Sample. Review the attendance records for all staff who care for patients.

1. All patient-care staff have received training.

Method. Compare the attendance records with the list of patient-care staff.

Evidence to show. WRK-REG-005 Falls prevention training record.

Pass when. Every patient-care staff member has an attendance record.

2. Training is refreshed at a defined interval.

Method. Check the record for the last refresher date against the interval.

Evidence to show. WRK-REG-005 Falls prevention training record.

Pass when. Each person is within the interval.

3. Training is specific to the service.

Method. Check the course content against the environment and patient groups the service serves.

Evidence to show. WRK-REG-005 Falls prevention training record.

Pass when. The content matches the service.

Immediate fail (any one means the criterion is not met)

• A staff member who cares for patients has not had falls prevention training.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

No course is required for this criterion. Optional course in the GMJ Academy: Fall Prevention (English · Georgian); Hospital Falls Prevention and Risk Assessment (English).

Documents: who does each step

References

1. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Falls prevention training. https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/