Amhara Public Health Institute Dessie

Branch Regional Reference Laboratory

Standard Operating Procedure for

Personnel Management
Compiled by : Abebe Eyasu Signature:

Approved by: Aynalem Mohammed Signature:

Effective date: December 15/ 2019 Version No. 01

Document No: APHIDBL -ALS- SOP5.1-01 Copy No. _____

Date of Discontinuation: _____________________________________

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 1 of 7 Effective date: December 15/ 2019

A. Annual Review of Document

Reviewed by: Approved by:
Revision No. Review Date
Name Signature Name Signature

B. Version Change History/Description

Version. Effective Description of Version Change Name & Name &

No. Date Signature of Signature of

Reviewer approval

C. Amendment
Rev. Page Description of Amendment Amendment Effective Name &

No. No Date Date Signature

of approval

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 2 of 7 Effective date: December 15/ 2019

1. Purpose
This procedure describes managing of personnel from the time they join APHIDBL up to
the time of retirement.
2. Scope
This procedure applies to all laboratory staffs in APHIDB Laboratory.
3. Responsibilities
The Laboratory Director and Quality manager share the responsible of ensuring effective
implementation and maintenance of this procedure.
4. Definitions
 Personnel Management: An administrative function to provide the personnel needed
and to manage the general employee-employee relationship.
5. Abbreviations:
ALS All Laboratory Section
APHIDBL Amhara Public Health Institute Dessie Branch Laboratory
EQA External Quality Assessment
ISO International Standard for Organization
SOP Standard Operating Procedure
6. Activity Description
6.1. Recruitment and Hiring
 APHIDBL uses the government of Ethiopia procedures for the recruitment of
laboratory personnel.
 All personnel are recruited through the APHIDBL human resource management
and are forwarded to the laboratory.
 All personnel are recruited on the basis of their qualification as a medical
laboratory technologist/technician and MSc/PHD
 All personnel are registered with professional licencing body if applicable.
6.2. Job Descriptions

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 3 of 7 Effective date: December 15/ 2019

 Upon reporting for work, the laboratory director prepares the Job description for
the personnel, which will detail the responsibility of the position.
 Job descriptions also contain the qualifications required for each position.
 The respective member of staff is given the job description to sign
 A copy of the signed job description is kept in the personnel file.
6.3. Orientation
 All new members of staff are oriented to the laboratory by laboratory director or
Quality manager. Students and other temporary staff not staying more than three
months do not undergo a full scope of the orientation but will required to sign
confidentiality and visitor form.
 Orientation of new staff covers the following:
 Introduction to each of the sections of the laboratory,
 the terms and conditions of employment,
 staff facilities i.e. washrooms, tea rooms, changing rooms,
 health and safety requirements (including fire and emergency), and
 occupational health services
 Orientation for the new member of staff is conducted during the first month of
reporting to work.
 The laboratory director orients staff and completes the orientation checklist.
 The laboratory director introduces new staff to the rest of the staff, gives
orientation on ethics, terms and conditions of work.
 The Quality manager orients staff to the quality management system.
 The laboratory director /quality manager orients staff to the respective sections,
equipment and the technical procedures in use.
 Safety officer orients staff to the safety requirements.
 New member of staff acknowledges on the orientation checklist as proof of having
completed the orientation

6.4. Training and continuing education

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 4 of 7 Effective date: December 15/ 2019

 The Quality manager develops a training plan which gives details of various
topics to be presented.
 Training sessions are conducted twice a year.
 All members of staff are required to undergo training on the following topics:

 quality management system;

 assigned work processes and procedures;
 laboratory information system;
 health and safety, including the prevention or containment of the effects
of adverse incidents;
 ethics;
 Confidentiality of patient information.
 After receiving training on each of the topics, officers are responsible of evaluating
effectiveness of the training.
 Continuing education is provided to staff according to their service year, need,
performance (BSC) and resource availability.
6.5. Competency Assessment

 All members of staff undergo competency assessment at least once years for the
activities they perform.
 Competence assessment is done after training.
 Competence assessment is done using a combination of the following means:

a. Objective Observation of Procedure, Process or activity. This involves

observation of the trainee conducting the procedure by the trainer. The trainee
will be required to conduct the procedure as is documented. During the
assessment, the trainer may be asking questions to the trainee to verify
whether the trainee really understands the procedure/activity using
competence assessment form (APHIDBL-ALS-F5.1-01). Trainee is expected
to follow procedure as documented in order to be deemed competent.

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 5 of 7 Effective date: December 15/ 2019

b. Testing of Known Samples: Trainee is given samples with known results like
EQA samples /quality control samples or previously analyzed samples.
Trainee is expected to produce expected results in order to be deemed
competent.
c. Theory test: Trainee will be given some theory questions to assess their
understanding of the procedure. Pass mark for theory test will be indicated on
the question paper.
 Trainee will be competent upon fulfilling all the three criteria above, thereafter the
laboratory director gives authority to perform work independently.

6.6. Performance Appraisals

 All members of staff undergo a performance appraisal once yearly using

Government staff performance evaluation tool.
 All laboratory staffs are appraised by the laboratory head.
 Records of performance appraisal are kept in personnel files.
a. Code of Ethics and Professional Conduct
 New staff are given orientation on ethical conduct by laboratory
director and made to declare on (APHIDBL-ALS-CL5.1-01).
 Students and visitors are given orientation on safety and ethical
conduct issues and signed on the prepared form.
6.7. Personnel Files
 The Laboratory Director maintains personnel files for all staff.
 Personnel files contain the following records:
 Educational and professional qualifications;
 Professional License
 Curriculum vitae
 Job descriptions;
 Orientation records
 Training
 Competency assessments records;

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 6 of 7 Effective date: December 15/ 2019

 Records of continuing education and continuous professional development

 Staff performance appraisal;
 Reports of accidents and exposure to occupational hazards;
 Vaccination to hepatitis B

7. Supporting Documents

Document name Document number

SOP for Competency Assessment APHIDBL-ALS-SOP5.1-03
Employee orientation checklist APHIDBL-ALS-CL5.1-01
Duty roster APHIDBL-ALS-F5.1-01

8. Reference

1. Federal civil servants proclamation (Proclamation No. 515/2007)

2. WHO laboratory quality management system
3. ISO 15189: 2012 medical laboratory requirements for quality and competence.

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 7 of 7 Effective date: December 15/ 2019

9. Declaration

I, the undersigned laboratory personnel, certify that I am conducting every steps of the procedures
incorporated in this SOP after a prior reading.
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Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory

Title: Standard Operating Procedure for Document No: APHIDBL-ALS-SOP5.1-01

Personnel Managment Version No: 01
Section: All Laboratory Sections Page No: 8 of 7 Effective date: December 15/ 2019

Authority for Issue: APHIDBL Authorized Date: November 15/2019

This is a controlled document for internal use only