Common JCI CBAHI Survey Questions

1
JCIA, CBAHI MOST COMMON QUESTIONS AND

ANSWERS FOR ALL STAFF
DEVELOPED BY:
HOSPITAL AFFAIRS & CORPORATE QUALITY DEPARTMENT
DR. SULAIMAN AL HABIB MEDICAL GROUP
E-8
Hospital Affairs and Corporate Quality Department 16 November 2016

How to access Policies, Procedures,
Privileges, Etc.,
2

3
Facility Management & Safety

FACILITY MANAGEMENT
AND SAFETY
4
What are the FMS Plans?

 Safety of the Building
 Security
 Hazardous materials and waste disposal
 External Emergencies
 Internal Emergencies
 Fire safety
 Medical technology
 Utility systems

Who is responsible for safety?
5

Emergency Codes
6

7
Emergency Extn - ???

How to announce the Code
8
 Dial Emergency Extn
 Announce “Code xxx (Adult / Pedia if Code Blue),
Location, Floor repeat 2 times, get it confirmed by
the receiver and get the name of the receiver
Eg. Code Blue Adult, Medical Ward, 2nd Floor, Room
no - 315
Code Red, Medical Ward, 2nd Floor, Room
no - 315
 Code Orange, Code Black and Code Yellow needs
General Director / his designee approval before
announcing
Code Blue
9
 Any staff identifying the code should dial
Emergency Extn
 Announce “Code Blue (Adult / Pedia if Code Blue),

Location, Floor repeat 2 times, get it confirmed by
the receiver and get the name of the receiver
Eg. Code Blue Adult, Medical Ward, 2nd
Floor, Room no – 315
 BLS should be started immediately and ACLS

should be provided to the patient within 3 minuets
 CPR record and CPR Evaluations should be

completed and copy to be sent to quality Office

Rapid Response / Early Warning / Detoriating
10
 Criteria
 Any staff identifying the patient is detoriating should dial

Emergency Extn
 Announce “Code RRT (Adult / Pedia if Code Blue),

Location, Floor repeat 2 times, get it confirmed by the
receiver and get the name of the receiver
Eg. Code RRT Adult, Medical Ward, 2nd Floor, Room
no – 315
 BLS should be started immediately and ACLS should be

provided to the patient within 3 minuets
 CPR record and CPR Evaluations should be completed

and copy to be sent to quality Office

Fire Response
11
 Initiate RACE & PASS Protocol

FIRE RESPONSE
R – Rescue the staff or patient in danger 12
A – Alarm
 Call Emergency Extn – 111, Code Red, Location unit/ward, Floor, Room No - x 2 times with
staff name and ID
 Activate the Fire Break Station
C – Confine / Contain the smoke / fire. Close the door and place a wet
cloth to contain the smoke or fire
E - Extinguish / Evacuate
If the fire is small extinguish the fire using the appropriate Fire
Extinguisher.
If fire can not be extinguished, evacuate to the safe location.
NOTE: Never Evacuate unless CODE Orange is announced.
Gas Shut Off station
13
Only Head Nurse or team leader should shut of medical gas

after ensuring the patients are shifted to portable ozygen

How to Extinguish Fire
14

Fire Extinguisher
15
 Before Using fire Extinguisher, ensure the type of fire
and type of fire extinguisher to be used
 Ensure fire extinguisher is full / safety pin is not
removed

What are the different types
of evacuation?
16
 As per our Fire safety plan

 Horizontal Evacuation is evacuation from an area of danger to a
safe area at the greatest distance from the danger on the same floor
or level.
 Vertical Evacuation is evacuation to a safe area on another floor
(usually a lower level), or to a safe area outside the facility which is
designated as an assembly point located in the back yard parking.
Although some patients may require removal to another facility.
Vertical evacuation is only activated when there is a very serious
confirmed threat to life and safety.
 Total Evacuation is evacuation of whole hospital and all patient,
staff and visitors will proceed to the designated fire evacuation
assembly point outside of hospital.

Evacuation
17
Note: Never Evacuate unless Code Orange is

announced. Only the unit in fire needs to
evacuate to a safer location

Evacuation
18
Note: Never Evacuate unless Code Orange is announced. Only the unit in fire
needs to evacuate to a safer location

Evacuation Map
19

Assembly Points
20
 Staff should be aware how many assembly

points are there in the hospital and which is
nearest for their department
 Staff should reach the assembly points
 HOD , Head Nurse should do head count of

staff, patients of their unit
 Assess the patient, staff
 Wait for the code Clear. Should not leave until

code Clear

21
 NOTE:
Ambulatory Status in Dr. Sulaiman Al Habib,
 Ambulatory: Able to walk alone, unattended.

 Semi-ambulatory: Requires some assistance to evacuate. One staff
member usually needed to assist.
 Non-ambulatory: Requires significant assistance to evacuate. Two to
four staff members needed to assist.
 Special: Requires very special assistance for evacuation, can apply to
patients or visitors, and includes patients undergoing surgery, on life-
support systems, on dialysis or under deep anesthesia; infants and
small children; the elderly, the blind, and the mentally incapacitated.

How to Use Fire Blanket
22

23

24

25

26

27
 Seek medical assistance. Burns caused by fire should be evaluated

by a medical professional as soon as possible.
 Even if you think the burns look minor, any injury caused by fire
should be evaluated by a medical professional. Take the person to
the ER immediately
 Dispose of a fire blanket after use. Fire blankets are not designed to
be reused. It can be dangerous to use a used fire blanket again to
fight a fire. Do not touch a fire blanket untill temperature become
normal as room temperature for dispose off. It is better idea to
douse the fire blanket in water before disposal
 Replace a fire blanket as soon as possible. You should never be

without a fire blanket or extinguisher in the event of an emergency.
As soon as possible, replace any fire blankets in your home.
Code Pink
28
 S – Search the unit
 T – Telephone / activate the
Code
 O –Obtain patient
information and protect it
 R – Report and reassign
family another room
 K – Keep the staff, visitors in
the unit unless police
arrives
 If you are hearing Code Pink, Seal all the exits
including emergency exits. Search for the
infant / child or suspicious person in all areas
of your unit including emergency staircase

Code Purple
29
 Security Staff, PRO, Nursing Supervisor

should proceed to the incident site
 Calm the patient / staff
 Should take the violent patient to safe area so

patients and staff are not disturbed
 If the patient is still violent, inform the duty

manager, administration and inform the
police if needed
 Should report thru Incident report form

Code Black
30
 Obtain more information as much as possible

 Question the caller, if possible, what type of device,
its location and his motives.
 Listen for background noises during the
conversation.
 Record accents, voice characteristics.
 Use a CHECKLIST
 Report to Security Manager / Supervisor
 Security Supervisor will inform the GD or designee
 GD will authorize to announce Code Black if
necessary
 On hearing Code Black, staff should search for
suspicious objects or person and report to security
manager / supervisor
 Evacuate only if Code Orange is announced

Code Orange
31
 General Director his/ her designee only can

authorize for Code Orange announcement
 Evacuate only if Code Orange is announced
 Use Only Emergency staircase for evacuation
 Ensure all the rooms are checked before evacuation
 Ensure patient list and staff duty rota is taken
 Proceed to the assembly point
 Perform head count of the staff and patients and
report to the security in charge.
 Never leave the assembly point unless Code Clear is
announced

Assembly Points
32
 Staff should be aware how many assembly

points are there in the hospital and which is
nearest for their department
 Staff should reach the assembly points
 HOD , Head Nurse should do head count of

staff, patients of their unit
 Assess the patient, staff
 Wait for the code Clear. Should not leave until

code Clear

What are different types of firefighting
equipment’s available in the hospital?
33

Fire Triangle
34
If any one (Oxygen/Heat/Fuel) is removed,

Fire will not happen

Code Yellow (External Disaster)
35
 Mass Causalities such as bomb

exploitation, Building collapse,
Influx of patients, Major
accident, etc.,

Code Yellow
36
 Primary Triage will be set up in ER
 Zones will be created in ER
 Each Department head / incharge should act upon

the roles and responsibilities defined in the Action
Card

Command Center
37
Staff should be aware
 Location
 Members
 Action Cards

Calling External Agencies
38
 Only Security Manager /

Supervisor should contact to
police or other external
bodies after approval from
administration

Hazardous Materials (HAZMAT)
39
 HAZMAT is an abbreviation for

“hazardous materials”—
substances in quantities or forms
that may pose a reasonable risk
to health, property, or the
environment.
 HAZMATs include such
substances as toxic chemicals,
fuels, nuclear waste products,
and biological, chemical, and
radiological agents
National Fire Protection Association (NFPA)
40

Safety Data Sheet (SDS)
41
• Company Information
• Hazardous Ingredients
• Physical Data
• Fire and Explosion Data
• Health Hazard Data
• Reactivity Data
• Spill & Leak Procedures
• Special Protection Information
• Special Precautions & PPE

What you should do if there is chemical
spill?
42
 Alert people in immediate area of spill and inform

HAZMAT officer
 Locate Chemical Spill kit and wear appropriate protective
gloves, goggles, etc.,
 Avoid breathing vapors from the spill
 Confine spill to small area & absorb on absorbent pads
 Clean spill area with materials from the kit
 Collect all contaminated absorbent, gloves & residues in
plastic bag
 Label and dispose of properly

Biomedical Management
43
 PPM - Periodic Preventive Maintenance
 All the staff (physician, nurses, clinical staff) should be
trained on biomedical equipment before use and
documented
 Equipment Manuals should be available in the user
department
 Equipment Daily & Functionality checks to be done
 Demo equipments should be tagged as DEMO

What is management in case of Equipment/ machine
breakdown?
44
• The end user will send a notification regarding the breakdown of any
equipment/ machine. The details are recorded in Asset Plus in Online Software.
A service request number will be auto generated by software after entering the
details by end users and Biomedical Department will take immediate action.
• If the unit is under warranty/ contract, the supplier is informed for the same,
after the completion of a job, a service report will be generated and shall be
signed by the end user after verifying the performance of the machine/
equipment
 Shift the patient safely, report to Biomedical department. Equipment should be

labeled Not working, DO NOT USE

Clinical Equipment Alarm
45
 Should never be put off / silent

Medical Gas Outlets
46
 Ensure appropriate
outlet before connecting
 Report any new pressure

or alarm from panel to
Biomedical immediately

Oxygen Cylinders
47
 Should be stored properly in boxes or chained
 Should be checked daily for the quantity, leak or

damage
 Empty cylinders should not be kept together or close

with the new cylinders
 tag should not removed

What will you do for Utility
Management Failure?
48
 I will Dial the hospital Utility Management

 Extension Number XXXXXX

Patient Call Bell Failure
49
 Should be reported to Biomedical Immediately
 Patient and Family should be educated to use

Telephone extension
 Patient should be accompanied by staff or patients to

toilet
 Patient should be transferred to other room

50
What is the allowed fire extinguisher for MRI

fire?
 The Aluminum Co2 fire extinguisher SHOULD BE

USED for fire in MRI Room

Radiation Safety Program
51
 License from King Abdul Aziz Centre of Science &

Technology
 Appropriate PPE
 Radiation warning Signage
 Thermoluminescent Dosimeter (TLD) readings
 Room Shielding
 Radiation Safety Manual

Laser Safety Program
52
 Appropriate PPE
 Laser warning Signage
 Appropriate Environment (non reflective, etc)
 Laser Safety Manual

NO Smoking
53
 Smoking is permitted only

on designated area _____
 If patient wish to smoke,

needs physician approval,
will be escorted to smoking
area
 Any violation to the policy

leads to disciplinary actions
Safety
54
 All the staff (Full Time, Part Time, Visiting,

Contracted, visitors ) should wear ID card all the
times
 All the critical areas area controlled with access
control (should be locked always) and
continuously monitored through CCTV
 Any safety maintenance, safety issues should be
reported immediately
 Cellular phones are prohibited in critical areas such
as ICU, CCU, NICU, PICU, MRI, etc.,

Electrical Safety
55
 Only inspected and approved by Maintenance

extension boxes are allowed
 Patients should be educated not to use any electrical

devices without being inspected by the maintenance
department

Isolation Rooms
56
 Should be monitored daily on

 Temperature
 Air Changes
 Pressure
 Humidity

Use of Electrical Appliances
57
 Use of Electrical appliances by the patient and

families are prohibited in the hospital.
 If the patient and family wishes to use, should inform

the nurse who will inform the Biomedical /
Maintenance for inspection and approval

Use of Mobile Phones
58
Mobile Phones are prohibited

in critical care areas like ICU,
NICU, PICU, MRI, etc.,

Electrical Outlets
59
All critical care units / equipments

should be connected to UPS
The electrical outlet color label for

Medical Refrigerators is “Red label
outlet”-which is connected to
Generators

Things to remember
60
 Where is your nearest fire break glass point?

 Where is the oxygen shut down valve in your
area?
 Where is your nearest fire extinguisher?
 What kind of fires will it extinguish?
 How many emergency exits are there in your
floor? Which is the nearest to your
department?
 Where your fire assembly area and what is
the number assigned for it?
61
 What is the emergency number to call for all

emergency codes?
 When was the fire drill conducted in your
unit and hospital wide?
 Who is your fire safety officer?
 Who is your security officer?
 Electrical Outlets color coding

62
Patient and Family Rights

Patient Bill of Rights
63

PATIENT AND FAMILY RIGHTS
64
A copy of “Patient and Family Bill of Rights and

Responsibilities” at the earliest possible moment from
admission Office is issued to the patients
If for any reason the patients cannot understand it, they can
contact the Patient Relation Manager for help

Patients and Family Rights
65
 Right to Medical Care  Right to Refuse Treatment

 Right to Information  Right to Complaint and
 Rights of Confidentiality and Suggestions
Privacy  Child Patient Rights
 Right for Safety and Security  Elderly Patient Rights
 Right for Respect and  Special Needs Patient Rights
Appreciation  Companion’s Rights
 Right for Participation in the  Visitor’s Rights
Healthcare Plan

Right to Medical Care
66
 Receive comprehensive care, given without discrimination as to race, religion, believe,
creed, language, sex, age or disability. Receive comprehensive care by competent
personnel that reflect consideration of your personal values, beliefs with effective use of
time and as per Ministry of Health laws and regulations
 Expect emergency procedures to be carried out without delay
 Have appropriate assessment and management of pain
 Participate in decisions involving your health care
 Be provided with information upon discharge about your continuing health care
requirements and the means for meeting them
 Refuse/discontinue the treatment to the extent permitted by law, and to be informed of
the potential consequences of this action. You will be asked to sign a form
stating/confirming the above
 Sign the necessary informed consent prior to the start of any surgery, endoscopy,
anesthesia, blood transfusion and its components or any other procedures that require
consent
 Receive full and clear information about the case and health status in an understandable
language
 To receive adequate nutrition that is appropriate for his/her medical condition

Right to Information
67
 To know the Mission and Vision of the hospital

 To know the Identity of your caregiver(s).
 To receive a copy of the Patient and Family bill of rights and responsibilities
upon admission
 Receive a copy of “Patient and Family Bill of Rights and Responsibilities” at the
earliest possible moment from Admission Office and if for any reason you
cannot understand it, please contact the Patient Relation Manager for help
 To receive complete and current information from your treating doctor "once
final diagnosis is reached" regarding the diagnosis, treatment and potential
benefit and consequences of the proposed treatment, likelihood of successful
treatment and possible problems related to treatment, in language that you can
understand (interpreter is available if needed)
 When it is not medically advisable the information pertaining to your condition
shall be given on your behalf to your designated / legal representative

Right to Information
68
 To receive appropriate explanation of the cost of your treatment.

 To know all about health insurance coverage limits
 To know all about the treatment cost regardless of who will pay for it
 To know the available source of care for your condition and other alternative
treatment(s) inside or outside the hospital.
 Donate organs and tissues- although we do not provide this service. You can
contact the Saudi Center for Organs Transplantation, toll free number 800-124-
5500 and you will receive the full information that supports to your choice.
 To make patient and family bill of rights and responsibilities publically
available by ensuring posters, pamphlets or advertising banners about the Bill
in the reception and waiting area of the hospital
 To know the patient relation office number

Rights of Confidentiality and Privacy
69
 Protect your privacy while receiving services unless a medically urgent situation
arose
 To discuss the treatment with your legal guardian
 Refuse to see anyone not concerned with providing the health service, including
visitorsardian confidentiality
 Request the room transfer if another patient in the room unreasonably disturbs
you, provided a suitable room is available
 Have all information and records pertaining to your medical care treated as
confidential except as otherwise governed by the law, or third- party contractual
agreement
 Have your medical record confidential, protected from loss or misuse and read
only by individual(s) involved in your care or by individual(s) authorized by law
or regulation
 Ask for appropriate outfits and necessary personal kit
 Ask for a separated male and female waiting areas
 To request for transfer to a private examination room if the room was not
suitable for examination
Right for Safety and Security
70
 To be provided with safe care within the environment established in the
hospital.
 To be provided with safe care while transferring to other facility
 To be provided with a safety mechanism for protection of your valuables from

loss or theft when needed
 To be provided with special mechanism to protect children, people with special

needs and old people them from all forms of abuse or harm
 To be informed about no smoking policy in all the health establishment

facilities, and have designated specific smoking areas away from the places of
health services
 To be protected from physical, verbal or psychological assault

Right for Respect and Appreciation
71
 To be treated with courtesy and respect, with

appreciation of individual dignity, no matter of the time
or conditions
 To be respected by being called with your official name
 To be respected for cultural, psychosocial, spiritual and

personal values, beliefs and preferences

Right for Participation in the Healthcare Plan
72
 To be introduced to the services provided by the health facility, the proposed

healthcare plan in addition to the potentials and c
 To be provided with complete and updated information about the diagnosis and
treatment in an understandable languageapability of the health facility
 To be Introduced to the identity and professional status of the health care
providers responsible of his treatment, and be informed in case there are
licensed trainees in the medical team
 To be informed about the potential complications, risks, benefits and the
alternatives to the proposed procedures
 To be informed of the kind of interventions, medications and the radiology used
in the treatment; there efficiency and safety
 To be clarified the reasons of transferring to another department in the health
facility or to another health facility with necessary instructions
 To be able to have the possibility of obtaining a second opinion in coordination
with the Patient Relations Directorate in the health facility

Right to Refuse Treatment
73
 To be Informed of refusing the treatment or a part of it; taking into account the
adopted laws and regulations. That is in addition to the expected consequences,
where you must sign a declaration that confirms your decision
 There will be no procedures or decisions that is not related to the health

condition, taken against you as a result of refusing the treatment. The health
facility will continue provide appropriate health care to you according to
standard medical criteria
 There will be no procedures or decisions taken against you as a result of

refusing the treatment in case you want to be treated the same illness or
another one
 To be informed of other alternative treatments in case you wish to refuse for

the treatment

Right to Complaint and Suggestion
74
 To Complain about your care to the Patient Relation Manager (Extension-xxxx)
or through suggestion boxes. Our Patient Relation Manager or social worker or
will respond to you as soon as possible.
 To file a verbal or a written complaint/suggestion, whether it is signed or not, to

Patient Relations Directorate without affecting the provided service quality
 To file a complaint to different levels of the health facility
 To be dealt with your compliant as soon as possible
 To be Informed of the procedures and mechanisms adopted by the health

facility to deal with complaints and suggestions in addition to the expected
response time
 To be informed of any available information related to the complaint or

suggestion
Child Patient Rights
75
 To be examined by the specialized medical team
 To be provided with specialized equipments and tools for children
 To be protected from all kinds of harm
 To be provided appropriate environment during the treatment course in the

health facility
 To be assigned with a companion in inpatient cases except in the ICU or the

nursery according to the adopted procedures and regulations

Elderly Patient Rights
76
 To be met with the special needs in the health facility
 To be provided with nourishing meals for inpatients
 To be provided with needed health and treatment

services
 To be facilitated in making appointments and having

their medical reports in health facilities

Special Needs Patient Rights
77
 To be respect for my dignity, independency in addition to my personal

decisions
 To be provided with the health facility with specialized equipments and

tools
 To be assisted while moving around in the health facility
 To be from all kinds of harm
 To be provided with suitable aisles and bathrooms
 To be provided with Allocated parking spaces

Companion’s Rights
78
 To be provided with adequate nutrition
 To be provided mattresses or chairs that are used

according to the adopted regulations in the health facility
 To be issued a Companion Card

Visitor’s Rights
79
 To be informed about the suitable visiting hours
 To be Clarified visiting hours in addition to the

minimum age for visiting according to MOH
regulations

80
 Who adopts the “Patient and Family Bill of Rights &

responsibilities” and what does it include?
 The General Director of our hospital has adopted a clear

“Patient & Family Bill of Rights & Responsibilities”.
 This Bill of Rights includes but is not limited to:

1. Privacy for all examinations, procedures & treatment
2. Identification and respect of Patient Values and beliefs
3. Confidentiality of patient information
4. Patient’s right to access of care
81
 Patient rights and responsibilities,

 Visiting hours,
 No Smoking policy,
 Use of electrical appliances, 5. Home brought
medications,
 Safety of belongings etc.

How do you communicate the Bill of
patient rights and responsibilities to the patients?
82
 All our Out-Patient Receptionist and Admission Officer hand-

over a copy of Dr. Sulaiman Al Habib Hospital, “Bill of Patient
& Family Rights and Responsibilities” to every patient on
registration or admission respectively.
 Furthermore, it is also displayed in the designated areas of the

Hospital (and on the Hospital website).
 Patients are informed of their responsibilities by a “Patient

Information Handbook”

When do patients or relatives sign
the informed consent in your hospital?
83
Patients should sign the necessary informed consent

prior to the start of any surgery, endoscopy, anesthesia,
blood transfusion and its components or any other
procedures that require consent.

How do you manage the confidentiality
and privacy of patient’s medical records?
84
Have your medical record confidential, protected from

loss or misuse and read only by individual(s) involved
in your care or by individual(s) authorized by law or
regulation

Who identifies the Patients’
values and beliefs?
85
Patients values and beliefs are shall be identified by the

treating staff

86
What do you do when a patient or family

wishes to speak with someone related to
religious or spiritual needs?
 The staff should respond to the request by calling the

on -site / or in-house religious staff (if available),
local sources, or family- referred sources.
Note: For the complex requests related to religious or spiritual support,
the staff shall contact the Patient Service Director/Manager/Designee,
who shall be responsible for organizing such complex requests in
coordination with the embassy of that patient’s country located in
Diplomatic Headquarter
According to your hospital policy,
who is a competent person?
87
 Every adult person, 18 years and above is assumed to be

competent to consent to medical procedures, unless ruled
otherwise by the law of KSA and MOH.
 Should be fully conscious and aware about his/her
decision.
 Able to receive and understand information relevant to
their medical care, understand possible alternatives and
consequences. c. Capable to make decision.
 NOTE: A new General Consent should be taken

for each episode of admission and re-admission.
For out-patient it is an implied consent.
When you obtain an Informed
Consent and what is its validity?
88
The Informed Consent should be obtained and

documented no longer than 14 days prior to a
procedure, surgery, or treatment. After this time
period, the informed consent should be re-obtained
and re-documented by the anesthetist

What is the role of nursing staff
in obtaining consent?
89
Nurse responsibility is limited only to ensure the

availability of signed general consent form in the
patient’s file and not to obtain the consent.

How do you obtain consent for
a patient who is not competent?
90
If patient is not competent and the consent is signed by

those who make decision for the patient, and the name,
signature and relationship of the person who signs the
consent form must be mentioned on the general
consent form

91
What are the types of consent used in your hospital?

 Anesthesia / Conscious Sedation Consent
 Against Medical Advice Consent
 Blood Transfusion Consent
 Consent For Radiographs (X-Ray), Radiological Procedures and Contrast
 Consent For Temporary Out-Pass
 Epidural Consent
 General Admission Consent
 Procedure/Surgery Consent
 High Risk Consent
 NICU / Nursery Discharge Consent
 Retinopathy Of Prematurity (ROP) Information and Screening Consent

What are the types of consent
used in your hospital?
92
 A single consent is adequate for Thalassemia patient in order
to carry out repeated transfusions for one admission episode.
 For any other case requiring blood transfusion, a new

consent is mandatory for each episode of transfusion, except
wherein a procedure is still on going and there is a need for
Blood Transfusion.
 For all dialysis patients (only if included in the scope of

service of the hospital) only one signed consent will be valid
for SIX MONTHS from the date of signing the consent.
 The consent for the elective procedure shall be taken at least

one day and a maximum of fifteen (15) days prior to the
planned procedure
For how long is the consent taken
for a procedure valid?
93
 A signed consent is valid for 15 days.
 If any reason the procedure is delayed beyond fifteen

(15) days the period of consent is considered void
and a new consent form will be completed and signed
prior to the procedure. The procedure consent will
be left in the patient’s medical file and noted void
across the bottom with signature, date and stamp of
the treating clinician

94
In case of emergency or life threatening

conditions, how do you obtain consent from an
incompetent person with no relatives around?
If the patient is not competent to sign the consent and no relatives are
available, the consent is to be taken from two (2) Consultants; one (1)
from the attending clinician team and one (1) is the Coordinator of the
Department.

95
What do you do when a patient

refuses treatment or diagnosis procedure?
We take signature of patient on the AMA (Against
Medical Advice) Form.
What do you do when a patient refuses to sign an

AMA/LAMA form?
If the patient/patient’s representative refuses to sign
AMA/LAMA Form, two witnesses should sign the form
indicating hat the patient or family refusal to sign.
(One Doctor & One Nurse)

Patient Barriers
96
 Physical
 Language
 Cultural
 Emotional

How do you overcome the issues
with Language barrier?
97
In the event of language barrier, the nursing staff shall
check the list of “Translators / Interpreter List” which
should be available with “Nursing Supervisors”, in all
Nursing Units and with “Telephone Operator” staff.
The Volunteer Translator shall sign also as a witness to
the granting of consent in the designated space
(witness) on the consent form.
What if we have patient with sign language?

Staff should contact duty manager, who inturn will
contact the organization for sign language

98
When asked by the patient/family, are you

allowed to disclose the information about the
treating practitioners’ experience and length of
time with the hospital?
Yes, we should provide the following information to

our patients.

What is Patient Satisfaction?
99
The degree to which patient’s expectations, goals and

preferences are met by the health service

100
How frequently do you conduct patient

satisfaction survey in your hospital?
A patient satisfaction survey shall be conducted on a

daily basis at all sites (in-patients and outpatients),
and data should be analyzed on monthly basis.

101
Do you accept verbal/telephonic orders for

DNR?
Verbal/ Telephone orders from the treating physicians

to nurses shall not be accepted or implemented on
DNR.

When is the DNR status
considered as VALID?
102
 The DNR status is only valid once the DNR form is signed and dated by
ALL three (3) specialized physicians.
 New Orders for Do Not Resuscitate (DNR) form should be
accomplished following the same DNR documentation procedures and
guidelines. Revised Orders for Do Not Resuscitate (DNR) forms
should be marked “VOID” and kept in the patient’s medical record.
 Reversion of Do Not Resuscitate (DNR) order form should be
accomplished by the attending physician in consultation with the two
other physicians (one of whom should be a consultant and the other one
could be a specialist)
 Once agreement has been reached, the three physicians should sign the
reversion of Orders for Do Not Resuscitate (DNR) form in the
patient’s chart indicating the reasons and justification for reversion of
DNR order. The responsibility of obtaining all necessary signatures is
that of the attending or primary physician.
How do patients register their
complaints in case needed?
103
 Patients can complain about the care to the Patient

Relation Manager (Extension-XXXXXX) or
through suggestion boxes.
 Our Patient Relation Manager or social worker or

will respond to you as soon as possible.

Who oversees the patient complaint
process and outcomes in your hospital?
104
The hospital Patients’ Rights and Complaint

Committee should oversight the patient complaint
process and outcomes

Explain the patient complaint
process in your hospital?
105
 The hospital has assigned a dedicated contact number/

extension for patient complaint, which will be answered by the
concerned staff 24/7.
 Patient complaint should be received by any Patient Service/
Patient Relation staff by Telephone, Verbal, Written, or via
Feedback Box, which should be collected on daily basis at the end
of each shift by the respective staff.
 The Patient Service/ Patient Relation Staff should contact the all
complainants immediately or within 24 hours upon receiving the
complaint with the initial action and anticipated response time
frame. The concern staff should inform the patient/or family that
“We received his/her complaint and we are investigating that and
we shall get back to you once resolved or as early as possible”

106
 The Patient Service/ Relation Staff should

investigate immediately and finalize the
nonmedical case(s) not later than one week from
receiving date of the complaint and should give
feedback to the complainant.
 The Patient Service/ Relation Staff should
investigate immediately and finalize the medical
case(s) not later than one month from receiving
date of the complaint and give feedback to the
complainant

Patient Belongings
107
 Conscious Patients
All the patients should keep their values in the safety
lockers in their rooms. If the patient wish for
safekeeping by the hospital, should inform the nurse
and nurse should inform the security officer and
document in patient valuables log book
 Unconscious Patients
Nursing staff should inform the security staff. Security
staff and nursing staff should check for the valuables
and register in the valuables log book and keeps the
items safe till the next of kin arrives
Lost & Found Items
108
 Any item found should be immediately reported to

security department
 Security staff should make efforts to locate the owner
 If no one identified, should register in the log book

and store in the locker
 If not claimed more than 90 days, the items will

discarded after approval from the executive manager
109
Quality Improvement & Patient Safety

QUALITY IMPROVEMENT AND
PATIENT SAFETY
110
Define Quality?
The degree to which health services for individuals and

population increases the likelihood of desired outcome
and are consistent with current professional
knowledge.

QUALITY IMPROVEMENT
111
An approach to the continuous study and

improvement of the processes of providing health care
services to meet the needs of patients and others.
Synonyms include continuous quality improvement,
continuous improvement, organization wide
performance improvement, and total quality
management

WHAT IS ACCREDITATION
112
Accreditation is a process in which an entity, separate

and distinct from the health care organization, usually
nongovernmental, assesses the health care organization
to determine if it meets a set of requirements (standards)
designed to improve the safety and quality of care.
Accreditation is usually voluntary. Accreditation
standards are usually regarded as optimal and
achievable..

113
Accreditation provides a visible commitment by an

organization to improve the safety and quality of patient
care, to ensure a safe care environment, and to
continually work to reduce risks to patients and staff.
Accreditation has gained worldwide attention as an
effective quality evaluation and management tool
A survey is a process by which an external body assesses

the performance of an organization

WHAT ARE THE BENEFITS
OF ACCREDITATION?
114
1. Improve public trust that the organization is concerned for patient safety
and the quality of care;
2. Provide a safe and efficient work environment that contributes to worker
satisfaction;
3. Negotiate with sources of payment for care with data on the quality of
care;
4. Listen to patients and their families, respect their rights, and involve them
in the care process as partners;
5. Create a culture that is open to learning from the timely reporting of
adverse events and safety concerns; and
6. Establish collaborative leadership that sets priorities for and continuous
leadership for quality and
7. Patient safety at all levels.
Different Accreditations
115

116
Joint Commission International (JCI)

Patient – Centered Standards
117
1. International Patient Safety Goals (IPSG)

2. Access to Care and Continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
Health Care Organization
Management Standards
118
1. Quality Improvement and Patient Safety (QPS)

2. Prevention and Control of Infections (PCI)
3. Governance, Leadership, and Direction (GLD)
4. Facility Management and Safety (FMS)
5. Staff Qualifications and Education (SQE)
6. Management of Information (MOI)

Saudi Central Board of Accreditation of
Healthcare Institute
119
1. Leadership (LD)
2. Human Resources (HR)
3. Medical Staff (MS)
4. Provision of Care (PC)
5. Nursing Care (NR)
6. Quality Management and Patient Safety (QM)
7. Patient & Family Education (PFE)
8. Patient & Family Rights (PFR)
9. Anesthesia Care (AN)
10. Operating Room (OR)
120
11.Adult Intensive Care Unit (ICU)

12. Pediatric Intensive Care Unit (PICU)
13. Neonatal Intensive Care Unit (NICU)
14. Coronary Care Unit (CCU)
15. Labor & Delivery (L&D)
16. Hemodialysis (HM)
17. Emergency Care (ER)
18. Radiology Services (RD)
19. Burn Care (BC)
20. Oncology & Radiotherapy (ORT)
121
21. Respiratory Care Services (RS)

22. Dietary Services (DT)
23. Social Care Services (SC)
24. Physiotherapy Services (PT)
25. Dental Care (DN)
26. Management of Information (MOI)
27. Medical Records (MR)
28. Infection Prevention and Control (IPC)
29. Medication Management (MM)
30. Laboratory (LB)
31. Facility Management and Safety (FMS)
INTERNATIONAL PATIENT SAFETY GOALS (IPSG)
122
 How many International Patient Safety Goals are there?

Name them?
SIX (6) Goals
 PATIENT IDENTIFICATION
 IMPROVE EFFECTIVE COMMUNICATION
 IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS
 ASSURANCE OF CORRECT PATIENT, CORRECT SITE AND CORRECT
PROCEDURE
 REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS
 REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS

GOAL 1:
IDENTIFY PATIENTS CORRECTLY
123
How do you identify your patients?
All patients’ will have standard an identity band placed

on their wrist at the time of admission which will
remain on during the entire period of hospitalization

124
Adult:
Patient Identification is done from the wrist
band, based on two (02) identifiers:
 Patient’s full name (minimum of three (03) names)
 Patient’s medical record/ Patient ID number.

How do you identify newborns
in your hospital?
125
For newborn we apply infant ID bracelet, one on ankle

and one on wrist, with the following information.
 Mother’s Name (minimum three names) and Medical

Record Number/ ID Number
 Sex/ Gender of the Baby
 Date and Time of Birth
 Birth Order if multiple birth.

How do you identify comatose patient/
patient with no identification?
126
If the information regarding patient is not available,

our HISGNEX system will generate the temporary
name as Unknown Patient Number 1, Unknown
Patient Number 2 etc. with the temporary File/
Medical Record Number. Once the identification is
confirmed, the concern staff shall modify the patient
identifiers.

Do you ever use room number or
bed number to identify your patients?
127
As per our hospital policy, we are NOT supposed to

use patient room number or bed number to identify
them.
When do you identify patients?
 Before giving Medications
 Before giving blood and blood products
 Before Specimen collection
 Before taking blood samples and other specimens for clinical
testing.
 Before providing any other Treatments / Procedures/
Surgery/Investigation etc.
 Before giving Food
 At the time of discharge (NICU and Nursery)
When do you remove the wrist bands
from patients and who does it?
128
 The nurse shall remove the wrist band prior to the patient leaving his/ her
rooms after the discharge procedure are completed.
 Note: ID bands must not be removed if a patient is transfer to another

hospital, into social service.
 How do you ensure the identity of patients with similar names?
 We use Alert stickers stating “Alert, Patient with Similar Name” which will
be placed on all relevant documentation, including the medication record
and all forms.

How do you discharge newborn
in your hospital?
129
 The staff nurse shall discharges the baby to the

parents after verifying the following that includes
but is not limited to:
 Matching baby's name bracelet with mother's name, bracelet and the
Medical Record/ File Number.
 Reviewing education provided to mother about the baby's care.
 Documenting in the medical record (in the form of a Discharge
Consent), with the signature of the qualified Nurse and Doctor.
 Keeping the patient covered when attending to his/her physical
needs.

How do you verify the identity of
patient’s prior to drawing blood?
130
 Two (2) clinical staff should verify the patient’s

identity prior to blood drawing for cross match.

How do you verify the identity of patient’s
prior to administration of blood?
131
Two (2) nurses or (1) nurse and two (2) staff

members should verify the patient’s identity, prior to
the administration of blood.

What do you do if a patient refuses
to wear an ID band?
132
Patients must be informed of the importance of

wearing an ID band and the risks involved if they do
not comply so that they can make an informed
decision. The decision of a patient not to wear a name
band must be clearly documented in the healthcare
records.

GOAL 2 : IMPROVE EFFECTIVE
COMMUNICATION
133
Who can give telephone/verbal order?
As per our hospital policy, Only Doctors may give a

Telephone Order
Verbal orders are accepted only on emergencies

Who can receive Telephone orders and what is
the process of receiving and documenting it?
134
 Registered Nurse/Pharmacist/ Respiratory Therapists can receive a
telephone order.
 The receiver of the information will write down (or enter into the computer)
the complete order, then the order is confirmed by the individual who gave
the order. The rule: WRITE DOWN, READ BACK, and CONFIRM
 The telephone order shall be countersigned and stamped by the ordering

physician within 24 hours of giving one order or in case of electronic
medical records to be acknowledged.

Under what circumstances are telephone
orders NOT accepted?
135
Telephone orders NOT accepted under the following

circumstances:
 Orders for repeated or recurring medication dosages (a
telephone order for a single dose of medication is acceptable);
 Telephone orders for narcotic or controlled drug administration
are not acceptable (except for one oral dose).
 Restraints
 Orders for initial ventilator settings
 For all Out-Patients/Discharge medications
 High Alert Medications (except in emergency or CPR)
 Restarting medications which are already stopped by automatic
stop order.
How do you accept verbal orders?
136
Use the REPEAT-BACK verification process (verbal

order repeated and the person giving the order verbally
confirms)

What is the timeline for physicians to
acknowledge the verbal orders given
137
 The verbal order should be immediately signed by

the ordering physician after the emergency is over
and before the physician leaves the unit.
 Nursing staff who check and administer the

medication shall sign in the Verbal Order Form.

To whom should critical results of diagnostic
tests be reported to?
138
 Any investigation with critical results received from

the laboratory or radiology shall be reported
immediately to the attending physician.
 When receiving such critical test results, the same

methodology should be followed: WRITE DOWN,
READ BACK, and CONFIRM

How do we define critical
test results?
139
 Results that are significantly outside the normal

range that may indicate a high-risk or life-
threatening condition
 Reference for critical values and handling critical test

results can be found in: Hospital Policies and
Procedures/Laboratory/Laboratory General and
Hospital Policies and Procedures/Radiology

140
What is the standard communication tool we use

especially during handover of patient care within
the hospital (ex: shift endorsements, patient
transfers, sending patients to diagnostic or
treatment departments like radiology or physical
therapy)?
SBAR
(Situation, Background, Assessment,
Recommendation)

GOAL 3: IMPROVE THE SAFETY OF
HIGH ALERT MEDICATION
141
What are high-alert

medications?
 Medications that have a

heightened risk of causing
significant patient harm
when used in error.
Examples: insulin, heparin,
concentrated electrolytes (pls.
see High Alert, Look-Alike and
Sound-Alike Medication List
posters)
What are the hospital’s strategies to improve
the safety of high alert medications?
142
 Labeled with high alert stickers as “High-Alert Medication-

Double Check”
 Kept in locked cabinets/trolleys
 Stored separately from regular medications and look-alike
medications
 Concentrated electrolytes are not stocked up in the wards, only
in critical areas as needed.
 Independent double check should be done prior to
administration.
 Only in Emergency or CPR telephonic orders can be accepted.
Note: Concentrated electrolytes – RED Label
All remaining high alerts - YELLOW Label
High Alert Medication List
143

How to reduce the risk of
High Alert Medications?
144
 High alert Medication and Concentrate Electrolytes

should be stored in locked cabinets, should be stored
separately from the normal medications
 Stored only in critical care areas and crash carts
 Independent Double check
 Using color code labels

How is independent double
check being done?
145
 An independent double check requires two people to

separately check each component of the work
process.
 For example, a pharmacist or nurse compare the

product to the order, calculates the dose, prepares
the syringe of medication; then, a nurse
independently checks the order, calculates the dose,
and compares the results with the dispensed product
or the prepared syringe for verification.

146
Key Points on Concentrated electrolytes:

Areas to place concentrated electrolytes to be identified by pharmacist.
List to be approved by P&T committee.
 To be placed in RED BIN in pharmacy with Label and must be diluted.
 To be dispensed from pharmacy in a diluted ready to administer state.
 SHOULD NOT be stored in outpatient pharmacy.
 SHOULD have “High Risk Warning Label” before issuance from
Pharmacy.
 Unused stock to be returned back to Pharmacy by nurses with a return
note to avoid stock piling.

GOAL 4: ASSURANCE OF CORRECT PATIENT,
CORRECT SITE and PROCEDURE
147
How does the hospital ensure the correct site,

correct procedure, and correct patient surgery?
We adhere to our policy:
 Ensure correct patient – by using the 2 patient identifiers

 Ensure correct site - the surgeon marks the site with an ARROW
mark using a surgical marker; we involve the patient during marking
(as much as possible); the surgical site is marked in all cases involving
laterality, multiple structures (fingers, toes, lesions), or multiple levels
(spine).

148
 Ensure correct procedure – Check the signed informed consent;
imaging studies are reviewed A preoperative verification process
is performed and for inpatients, it is done at the following
times:
 In the ward/clinic by the operating surgeon
 Just before sending the patient to OR, by the ward nurse · In the
receiving area, by the receiving OR nurse.
 Timeout done in the operating theatre immediately prior to the start of
surgery.
 Components of the verification process:
 Verify the correct site, procedure, and patient
 Ensure that all relevant documents, images, and studies are available,
properly labeled, and displayed
 Verify that any required special medical technology and/or implants are
present
What is timeout?
149
It is a final pause and final verification process to be

done on a patient before the performance of a
procedure/s in the presence of all clinical team
members and in the location where the procedure is to
be conducted to assure right patient, right site and
right procedure.

What is checked during the
timeout process?
150
 Confirm the correct Patient Identify

 Confirm the correct Side and Site
 Check the Agreement / Consent on the procedure to be performed
 Confirm the correct Procedure and Patient Position
 Check the availability of Correct Blood and Blood Products (if
applicable)
 Check the availability of Correct implants (if applicable)
 Check the availability of all relevant documents, images, and studies
which are properly labeled, and displayed (if applicable)
 Check the availability of special equipment, implants, or requirements
and are functional (if applicable).

What is checked during the
timeout process?
151
 NOTE: The procedure should not start until

the final time out is completed and any
questions or concerns are resolved.
 Time of time-out must be documented in the

timeout form.

GOAL 5: REDUCE THE RISK OF HEALTH CARE
-ASSOCIATED INFECTIONS
152
What are the common infections associated to

health care?
As mentioned in our hospital policy, following are the

infections commonly associated with healthcare:
1. Catheter Associated Urinary Tract Infection

2. Central Line Associated Blood Stream Infection
3. Ventilator Associated Pneumonia
4. Surgical Site Infections

Standard Precautions
153

How do you prevent your patient from getting
an infection during hospitalization?
154
We adhere to our standard precautions `hand hygiene

guidelines and PCI (Prevention and Control of
Infection) Program – see last entry on PCI Program

What is the duration of hand rub?
155
20-30 seconds

156

What is the duration of hand
wash technique?
157
40-60 seconds

158
What is the rate of hand hygiene compliance in

your unit? ________
XX. XX %

How do you dispose different types
of waste (color coding)?
159
 General Waste
e.g. administrative, food Waste etc. - (Black / Blue plastic bag)
 Bio hazardous (Infectious Waste)

e.g. gloves, masks, dressings etc.
(Yellow thick plastic bag with Bio hazardous sign)
 Human Tissue Waste -(red thick plastic bag with label).

How does the hospital practice
Linen Management?
160
 Proper handling of soiled linen (soiled with blood or other body fluids)
use of personal protective equipment.
 Transport from departments to laundry in closed carts.
 No mixing of clean and soiled linen.
 Use of PPE’s:
 Contact Precautions – gowns, gloves (e.g. MRSA infected patients)
 Droplet Precautions – surgical mask, gowns, gloves, (e.g. German
Measles, Meningitis, Mumps)
 Airborne Precautions – N95 mask, gowns, gloves, and negative
pressure room (e.g.
 Pulmonary Tuberculosis, Measles, Chicken Pox).

161

GOAL 6 : REDUCE THE RISK
OF FALLS
162
What does our policy state regarding fall risk

assessment?
All in-patients will be assessed for the risk of fall upon

admission, post surgery / procedure, after
administration of any medication that can result in fall.
Outpatients shall be assessed for fall risk upon initial
screening.

How do you protect your
patient from falls?
163
 We perform risk assessment and reassessment (Risk

assessment tools used are: Morse Fall Scale for adult
and Humpty Dumpty Scale for children)
 We apply standard fall prevention precautions and
extra precautions for high risk patients
 We conduct patient and family education on fall
prevention
 We have a FALL PREVENTION PROGRAM

What are the components of our
fall prevention program?
164
 Fall Risk Assessment and Prevention to the Patient

 Environment and Equipment Safety Checking
 Reporting of near fall or actual falls
 Post Fall Protocol of Care
 Program Evaluation
 Education

What are the Key performance measures used
to prevent fall in your hospital?
165
We Conduct a monthly environmental assessment

using the Environmental Safety Checklist and
Equipment Safety Checklist and submit to Quality
Department Office.

Within what time do you report the
incident of falls to quality office?
166
 When a fall occurs, inform physician and Head

Nurse/Charge Nurse.
 Report all near fall and identification of hazards by
submitting the Fall Hazard / Near Fall Report Form to
the Quality Department within 24 hours.
 Complete the Post Fall Assessment Form and attach in
the patient’s medical record.
Note: Post fall assessment shall be done immediately after

stabilizing the patient AND 24 hours after the fall incident.
In which conditions/situations do we
reassess our patients for the fall risk?
167
 Following a change in the patient’s condition .

 After a fall.
 Immediate post-operative period.
 Following procedural sedation.
 After administration of medication (see Attachment A), procedure or
change in condition that may alter patient’s level of consciousness or
mental status 6. Changes in ambulatory status and/or elimination
status
 Transfer between nursing units/clinics.
 When in locations that poses a high risk for falls (physiotherapy
department)
 When in situations that poses a high risk for falls (patients arriving by
ambulance, patient transfers from wheelchairs or carts, or the use of
patient-lifting devices)
Is the incidence of falls monitored
in your unit/hospital?
168
Yes. It is one of our clinical indicators and also

considered a nursing sensitive care measure.

What is the falls rate in your unit?
169
XX. XX %

DEFINE BENCHMARKING?
170
A continuous process of measuring products, services,

and/or practices against the competition in order to
find and implement best practices

DEFINE INDICATOR?
171
Performance measurement tool which is used as a

guide to monitor, evaluate and improve the quality of
patient care and service.

DEFINE STANDARD?
172
Statement of structure and process expectations

necessary to enhance quality care.

DEFINE TRENDING?
173
The evaluation of data collected over a period of time

for the purpose of identifying patterns or changes

What are the Goals of your
Quality Improvement and Patient
Safety Plan?
174
 Goal: 1- Leadership support and involvement

 Goal: 2- Continuous Monitoring and Quality
Improvement
 Goal: 3- Community Benefit
 Goal: 4- Employee Satisfaction (Service Quality)
 Goal: 5- Customer (Patient) Satisfaction (Service
Quality)
 Goal: 6- Education and Training
 Goal: 7- Financial Improvement/Operational Quality
 Goal: 8- Communication
What Quality Improvement Methodology
you adopted for improvement?
175
We have adopted the FOCUS-PDSA Quality

Improvement Methodology

FOCUS?
176
 Find - An improvement
opportunity.
 Organize - A team who
understands the process.
 Clarify – Current knowledge of
the process.
 Understand – The causes of
variation in the process.
 Select – The improvement that
needs to take place
PDSA (PDCA)?
177
 Plan
 Do
 Study/ Check
 Act

How you prioritize
quality improvement?
178
 Quality Improvement Committee is responsible to

establish priority areas for quality improvement.
 Quality Improvement priorities are based on the
following:
 Customers’ Feedback
 Variations in Operation
 Strategic Plan (Strategic Priorities)

What is the selection Criteria for process
improvement or Quality Indicator?
179
 High Volume
 High Cost
 High Risk
 Problem Prone
 CBAHI
 JCIA

What Statistical Tools/Processes are used
for Data Analysis (Seven Basic Tools of Quality)?
180
 Cause and Effect Diagram (Fish Bone Diagram)

 Check Sheet
 Control Charts
 Histogram / Bar Charts
 Pareto Chart
 Scatter Diagram
 Stratification

Define Risk Assessment?
181
A Risk Assessment is a calculation of the likely impact

of a hazard should it come to fruition

What is Proactive Risk Assessment?
182
 The Dr. Sulaiman al Habib Hospital adopted a proactive

approach to risk management, for which the hospital has a risk
management program which include risk identification, risk
prioritization, risk reporting, risk management, investigation of
adverse events, and management of related claims.
 An important element of risk management is risk analysis, such

as a process to evaluate near misses and other high-risk
processes for which a failure would result in a sentinel event. One
tool that provides such a proactive analysis of the consequences
of an event that could occur in a critical, high-risk process is
Failure Mode and Effects Analysis (FMEA) and Hazard
Vulnerability Analysis (HVA).

Define Sample?
183
In statistics and quantitative research methodology, a

sample is a set of data collected and/or selected from a
statistical population by a defined procedure

How you determine your sample
size for Data Validation?
184
Sample Size Required Sample Size

(Actual Collected for
Data) “Data Validation”
Less than 50 100% of the actual Collected
Data
More than 51 but less 50% of the actual Collected
than 100 Data
More than 101 10% of the actual Collected
Data

Define Data?
185
 Factual information (as measurements or statistics)

used as a basis for reasoning, discussion, research, or
calculation. — H. A. Gleason.
Or
 Raw facts and figures from which information can be

generated. (CBAHI)

Define Data Validation?
186
 Data Validation is a process that is used to compare a body of

data to the requirements in a set of documented acceptance
criteria. It checks that the data is sensible before it is processed.
Or
 The comparison of data against a set of documented acceptable

criteria is known as data validation. It determines to what extent
analytical and other forms of data are reliable, accurate and
usable in various contexts. Validation is done to ensure that
programs and processes operate on correct and accurate data and
is used by various organizations and government agencies

When you do Data Validation?
187
 Data Validation would be done during the following:

 Implementation of a new measure, especially the clinical measures that intend
to help a hospital in evaluating and improving the clinical process or outcome;
 When data will be made public on the hospital’s website or in other ways;
 Whenever changes have been made to an existing measure; such as the data
collection tools have changed or the data abstraction process or abstractor has
changed;
 Whenever the data resulting from an existing measure has changed in an
unexplainable way;
 The data source has changed, such as when part of the patient record has been
turned into an electronic format and thus the data source is now both electronic
and paper; or
 The subject of the data collection has changed, such as changes in average age
of patients, comorbidities, new practice guidelines implemented, or new
technologies and treatment methodologies introduced.

MEASURES CATEGORY
188
 Clinical
 Managerial
 International Library of Measures
 International Patient Safety Goals
 Outsourced Services

CLINICAL MEASURES
189
 Patient assessments;
 Laboratory services;
 Radiology and diagnostic imaging services;
 Surgical procedures;
 Antibiotic and other medication use;
 Medication errors and near misses;
 Anesthesia and sedation use;
 Use of blood and blood products;
 Availability, content, and use of patient records;
 Infection prevention and control, surveillance, and reporting;

MANAGERIAL MEASURES
190
 The procurement of routinely required supplies and medication

essential to meet patient needs;
 Reporting of activities as required by laws and regulations;
 Risk management;
 Utilization management;
 Patient and family expectations and satisfaction;
 Staff expectations and satisfaction;
 Patient demographics and clinical diagnoses;
 Financial management; and
 Prevention and control of events that jeopardize the safety of patients,
families, and staff

INTERNATIONAL LIBRARY
OF MEASURES
191
 Acute Myocardial Infarction (AMI)

 Children’s Asthma Care (CAC)
 Nursing-Sensitive Care (NSC)
 Perinatal Care (PC)

What is FEMA?
192
Failure Modes and Effects Analysis (FMEA) is a

systematic, proactive method for evaluating a process
to identify where and how it might fail and to assess
the relative impact of different failures, in order to
identify the parts of the process that are most in need
of change. FMEA includes review of the following:
Steps in the process
 Failure modes (What could go wrong?)
 Failure causes (Why would the failure happen?)
 Failure effects (What would be the consequences of
each failure?)
Define Incident Report (IR) or
Occurrence Variance Report (OVR)?
193
Incident/Events that are unusual, unexpected, may

have an element of risk, or that may have a negative
effect on patients, staff, or the hospital (CBAHI).
Any incident relating to patients, should be educated

to patient and family and documented in medical
records

Incident Report / OVR Form
194
Staff should be aware the location of the incident reporting

form

Define an Event?
195
Something that happens or is regarded as happening;

an occurrence, especially one of some importance

Define an Event?
196
Something that happens or is regarded as happening;

an occurrence, especially one of some importance

Define Sentinel Event?
197
An unanticipated death, including, but not limited to, death that is related to the natural
course of the patient's illness or underlying condition (for example, death from operative
infection or a hospital acquired pulmonary embolism);
 Death of a full term infant
 Suicide
 Major permanent loss of function or limb unrelated to the patient natural course of
illness
 Transmission of a chronic or fatal disease or transplanting contaminated tissues or organ
 Infant abduction or an infant sent home with wrong patient
 Rape, workplace violence such as assault (leading to death or permanent loss of
function);; homicide (willful killing)of patient, staff member, visitors, et
 Retained instrument or sponge
 Serious medical error leading to death or major morbidity
 Maternal death
 Hemolytic blood transfusion reaction
 Air Embolism

Define Near Miss?
198
Any process variation that did not affect an outcome,

but for which a recurrence carries a significant chance
of a serious adverse outcome.
Such a “near miss” falls within the scope of the

definition of an adverse event (JCI).

Define Root Cause Analysis (RCA)?
199
A process for identifying the basic or causal factor(s)

that underlies variation in performance, including the
occurrence or possible occurrence of a sentinel event.
(JCI)
In how many hours an incidents/accident must
be acted upon of its occurrence?
All incidents/accidents must be acted upon within 24
hours of its occurrence.

Which kind of Incidents and
Events should be reported?
200
 Any incident, accident, near miss or serious untoward incident (sentinel

event) that occurs in the workplace, or whilst at work must be reported.
 A single reporting system is used which incorporates the reporting of both
clinical and non clinical events.
 An analysis shall be conducted for the following:
 All confirmed transfusion reactions, if applicable, to the hospital
 All serious adverse drug events, if applicable and as defined by the hospital
 All significant medication errors, if applicable and as defined by the
hospital
 All major discrepancies between preoperative and postoperative diagnoses
 Adverse events or patterns of adverse events during moderate or deep
sedation and anesthesia use
 Other adverse events; for example, health care–associated infections and
infectious disease outbreaks

When and whom one should
report Sentinel Events?
201
All the Sentinel Events should be reported immediately

to the Quality Staff or designated staff and on-call
Medical Administrator.

How Sentinel Events are investigated?
202
 All sentinel events require immediate investigation

and appropriate response. All events shall have an
Incident Report or Occurrence Variance Report
(OVR) generated; as per the directives of the
Ministry of Health (MOH), all sentinel events have to
be reported through an online portal
http://app.moh.gov.sa. Medical coordinator has
been assigned the responsibility to notify the MOH
through the above mentioned portal within a
stipulated time frame.

203
In how many days the Root Cause Analysis

(RCA) and action plan must be completed
after the event or becoming aware of the
event?
The Root Cause Analysis (RCA) and action plan must

be completed within 10 days of the event or becoming
aware of the event

204
What are the different Sentinel Events you know?

An unanticipated death, including, but not limited to:
 Death that is unrelated to the natural course of the patient’s illness or underlying
condition (for example, death from a postoperative infection or a hospital-acquired
pulmonary embolism);
 Death of a full-term infant
 Suicide
 Major permanent loss of function , loss of limb unrelated to the patient’s natural
course of illness or underlying condition;
 Wrong-site, wrong-procedure, wrong-patient surgery
 Transmission of a chronic or fatal disease or illness as a result of infusing blood or
blood products or transplanting contaminated organs or tissues;
 Infant abduction or an infant sent home with the wrong parents; and
 Rape, workplace violence such as assault (leading to death or permanent loss of
function); or homicide (willful killing) of a patient (if applicable, only), staff
member, practitioner, visitor, or a vendor while on hospital property

Things to remember
205
 Incident reported in your unit
 Hospital QIPS Plan
 Indicators hospital wide and your department / unit
 Performance Improvement Projects for your department

and hospital wide
 Clinical Guidelines, Pathways, Protocols
IPSG Implementation
 Affairs and Corporate Quality Department
Hospital 16 November 2016
206
GOVERNANCE LEADERSHIP AND

DIRECTION (GLD/LD)

Vision & Mission
207
Vision:
To be the most trusted healthcare provider in
medical excellence and patient experience
globally
Mission:
To develop and operate state of the art medical
facilities and provide innovative healthcare
services to create value for people.

What are the Values of your
organization/hospital?
208
1. Superior Services
2. Care
3. Respect
4. Teamwork
5. Innovation and
6. Dignity

Board of Governance
(BOG) Structure
209
1. Chairman
2. President and CEO
3. All VP’s
a) Board of Governance (BOG) Bylaws

b) Valid for TWO YEARS
c) BOG Committee- Operation Committee

Organization Chart
210

Hospital Scope of Service
211
1. Range of services offered

2. The targeted age groups
3. The number of patients seen annually
4. The principal diagnostics and therapeutic
modalities used in the hospital
5. Approved by the governing body

Department Scope of Service
212
 Vision, Mission
 Description of the hospital
 Description of the services offered
 Age group of patients being served
 Annual Census
 Staffing Plan
 Organization Chart
 Most common diagnosis and procedures performed
 Hours of Operation
 Internal and External Customers
 List of Staff Competencies
 Budget
 Communication with other departments

What is the Code of Conduct
of your Hospital?
213
1. Every employee shall conduct business fairly in an ethical manner.

2. All personnel are required to abide by the Hospital Dress code
Policy.
3. Follow and respect the local rules and regulations while interacting
with female employee.
4. Maintain the Patient and Family Bill of Rights at all times.
5. All employees shall abide by the Conflict of Interest Policy.
6. All employees shall follow all restrictions on use and disclosure of
information.
7. No staff member shall accept any gift, favors, services or other
things of value under the circumstances from which it might be
inferred that these were offered for the purpose of influencing them
in the discharge of their duties.

of your Hospital?
214
8. Every employee shall promote relationships based on mutual trust

and respect and shall provide an environment in which individuals
may question a practice without fear of adverse consequences.
9. Visitors are allowed in the hospital inpatient areas as per the
approved hospital visiting hour’s policy
10. To access the hospital building the employee has to have his/ her ID
visible to the security guard.
11. Drug abuse is a serious offence; hence avoid getting involved with
drugs.
12. The staff shall not offer or accept payment (money, goods, services,
or anything of value) for referring a patient to a physician or any
other health care provider

of your Hospital?
215
13. Dr. Sulaiman Al-Habib Hospital Employees will be

courteous to the management, managers, officers,
employees, professional staff and contractors
14. Practitioners in positions that require professional
licenses, certifications, or other credentials shall be
responsible for maintaining the current status of their
credentials and shall comply at all times with MOH Saudi
Arabia requirements applicable to their respective
disciplines.
15. Staff must comply with all applicable environmental,
safety, and health laws and policies to provide a safe
environment for employees, patients, and others
What are the Hospital Wide
Committees in your hospital
216
1. Hospital Executive Committee
2. Quality Improvement & Patient Safety Committee
3. Infection Control Committee
4. Credentialing & Privileging Committee
5. Pharmacy Therapeutic Committee
6. Environment of Care Committee
7. Blood Utilization Committee
8. Tissue Review Committee
9. Medical Records Committee
10. Cardiopulmonary Resuscitation Committee
11. Operating Room Committee
 12. Mortality & Morbidity Committee
13. Patient Rights and Complaints Committee
14. Utilization Committee
15. Ethic Committee
16. Medical Executive Committee
17. Nursing Executive Committee
Departmental Meetings
217
 Monthly department meetings should be conducted

 all the department issues, recommendations should
be discussed
 Should be multidisciplinary (Physicians, Nurses and
other related staff)
 Mortality and morbidity cases should be discussed
 Staff should be aware what are the points discussed
in the meetings and location of the meeting minutes

Delegation of Authority
218
 Letter of appointment
 Responsibilities of Managers, Department Heads
 Hand over of responsibilities during absence

Hospital Strategic Plan
219
1. Validity of Strategic Plan- 3 Years (2016-2019)

2. Approved by BOG
3. Strategic Goals and Objectives with timeframe and
responsible staff

220
STRATEGIC GOALS AND OBJECTIVES:

 Goal 1 – To Develop And Operate New Services
 Goal 2 – To Provide State Of Art Medical Facilities
 Goal 3 – To Create Value For People
 Goal 4 – To Provide Ideal Patient Experience
 Goal 5 – To Be Regarded As Organization Of Choice
 Goal 6 – To Enhance Quality Improvement And
Patient Safety

221
STRATEGIC GOALS AND OBJECTIVES:

Goal 7 – To Involve, Provide And Promote Healthcare
Awareness And Education In The Community
Goal 8 – To Ensure Effective And Efficient Human
Resource Management System
Goal 9 – To Ensure Effective Financial Management
System
Goal 10 – To Ensure Effective And Efficient
Information And Technology Management System

Ethical Management Framework
and Ethical Behavior
222
1. Disclose ownership and any conflicts of interest;

2. Honestly portray its services to patients;
3. Protect confidentiality of patient information;
4. Provide clear admission, transfer, and discharge
policies;

223
5. Bill accurately for its services and ensure that

financial incentives and payment arrangements do
not compromise patient care;
6. Encourage transparency in reporting organizational
and clinical performance measures;

224
7. Establish a mechanism by which health care

providers and other staff may report clinical errors
and raise ethical concerns with impunity, including
disruptive staff behavior related to clinical and/or
operational issues;
8. Support an environment that allows free discussion
of ethical concerns without fear of retribution;

225
9. Provide an effective and timely resolution to ethical

conflicts that arise;
10. Ensure nondiscrimination in employment practices
and provision of patient care in the context of the
cultural and regulatory norms of the country; and
11. Reduce disparities in health care access and clinical
outcomes.

Clinical Care Pathways
226
1. To provide the standardized patient care as per the

approved clinical care pathways/ Clinical Practice
Guidelines in order to achieve the best outcome with
patient safety.
2. To describe appropriate care based on the best available
scientific evidence and broad consensus;
3. To reduce inappropriate variation in practice;
4. To provide a focus for continuing education;
5. To promote efficient use of resources;
6. To act as focus for quality control, including audit;

227
1. selected from among those applicable to the

services and patients of the hospital (mandatory
national guidelines are included in this process, if
present);
2. evaluated for their relevance to identified patient
populations;
3. adapted when needed to the technology, drugs, and
other resources of the hospital or to accepted
national professional norms;

228
4. assessed for their scientific evidence and

endorsement by an authoritative source;
5. formally approved or adopted by the hospital;
6. implemented and measured for consistent use and
effectiveness;
7. supported by staff trained to apply the guidelines or
pathways; and
8. periodically updated based on changes in the
evidence and evaluation of processes and outcomes

Outsourced Contract Monitoring
229
The hospital leaders are responsible (including

but not limited to):
1. Should ensure that the contracts clearly state the
services to be provided by the contracted entity.
2. Hospital leaders and other heads of departments
should participate in the selection, monitoring, and
management of contracted services.
3. Should ensure that contracted services and
providers both meet applicable laws and
regulations.

Outsourced Contract Monitoring
230
4. Should ensure the services provided are consistent

with the hospital’s quality and safety standards.
5. Should consider the quality of services provided by
the contractor for contract renewal.
6. Should monitor and document the quality
indicator on each contracted services/providers.

Hospital Manual
231
1. A brief general description of the hospital

2. Vision, Mission and Values
3. Organizational Chart
4. Scope and organization of services
5. Standing meeting and committees
6. Staff code of conduct and ethics
7. Conflict of interest
8. Admission and discharge referrals
9. Visiting times
10. Smoking policy
11. Parking policy
Vertical and Horizontal
Communication 232
 Please follow hospital and department organization

Structures/ Charts for Vertical and Horizontal
Communications.

Safe Management of Medical
Supplies & Devices
233
1. Selection
2. Storage
3. Protection from theft, loss, damage, contamination
4. Report any adverse events
5. Safe disposal
6. Recall
7. Evaluation of suppliers

Leadership Rounds
234
 General Director, Executive Director, Medical

Director, Nursing Director, Quality Manager, Facility
Manager, Safety Officer, Infection Control Nurse and
others (if required)
 Rounds should be conducted on monthly basis and

cover all the areas of the hospital.

IMPORTANT QUESTIONS ON LEADERSHIP
EVERYONE MUST KNOW –
HOSPITAL LEADERSHIP
235
1. Who is the General Manager/General Director?

2. Who is the Executive Director?
3. Who is the Medical Director?
4. Who is the Nursing Director?
5. Who is the Patient Service Director?
6. Who is the HR Manager?
7. Who is the Facility and Engineering Manager?
8. Who is the Quality Manager / Coordinator?
9. Who is the Safety Officer?
10.Who is the Radiation Safety Officer?
11. Who is the Security Officer?
12.Who is the Infection Control Head Nurse?
13.Who is HAZMAT officer?
14.Who is your safety coordinator in the unit?

236
Assessment of Patients, Access to Care

& continuity of Care, Care of Patients,
Provision of Care

Assessment of Patients
237
 Initial Assessment & Care Plan should be completed

as per the time frames
 Admission & Discharge Plan should be completed

within 24 hrs of admission

What are the parameters that you
will assess for your patients?
238
Following are the parameters which we assess for our patients:
 Chief / Presenting complaints;
 History of present illness;
 Past Medical and Surgical History
 Current Medication and Durations
 Family History (Including Social / Psychological Factors)
 Allergies
 Physical Examination
 Pain Screening
 General Examination
 Systemic Examination
 Local / Systemic Specific Examinations
 Special Needs Assessment (Functional, Nutritional, Psychological, and Social Economic )
 Individualized Initial Assessments for Special Populations
 Risk for fall
 Diagnostic tests indicated by patient condition
 Initial Care Plan
 Discharge Planning
 Provision Diagnosis
Special Needs Screening
239
 All the patients should be screened for

 Nutritional
 Function
 Socio Economic
 Psychological
 If the screen is positive should be referred to

concerned specialty

What are the types of Care Plan?
240
The following three are the types of care plans:

 Initial Care Plan
 Modified Care Plan
 Post-Operative Care Plan
 Multi Disciplinary Care Plan

Define Discharge Planning?
241
 Discharge Plan shall be completed by the treating

physician preferably at pre-admission for all elective
cases (or at the time of admission) and within 24 hours of
admissions for unplanned admissions.
 Patient care discharge needs are assessed and reviewed at

least once every 24 hours or as needed by the
multidisciplinary team members working together for the
patient. Patient and family discharge needs are
documented in the specific
 “Discharge Plan” forms of each health care provider

The Discharge Plan includes
(but not limited to):
242
 Expected Discharge Date

 Follow Up
 Physiotherapy
 Sick Leave
 Physical Activity Modification
 Diet & Fluid Modification
 Transport & Driving
 Education needs

Consultant Validation
243
Initial Assessment, Care Plans

should be validated in the progress
by the Primary Consultant if it is
done by specialist or residents.

Daily Reassessment
244
 Patient should be reassessed by the specialist /

resident at least once and documented in the patients
progress notes
 Consultant should document in the patient progress

notes at least once daily

What is the criterion for Revalidation
of assessment?
245
 If at the time of admission as an inpatient the medical assessment is

greater than 30 days old, the medical history must be updated and the
physical examination repeated.
 For medical assessments performed and documented 30 days or less

prior to admission, any significant changes in the patient’s condition
since the assessment are noted at admission. This updating and/or
reexamination can be accomplished by any qualified individual.

For which patients you are conducting Individualized
assessments
246
 Children
 Adolescents
 Frail elderly
 Terminally ill/dying patient
 Patients with intense or chronic pain
 Women in labor
 Women experiencing terminations in pregnancy
 Patients with emotional or psychiatric disorders
 Patients suspected of drug and/or alcohol dependency
 Victims of abuse, domestic violence and neglect
 Patients with infectious or communicable diseases
 Patients receiving chemotherapy or radiation therapy
 Patients whose immune systems are compromised
 Patients with dental, hearing, eye or speech defects
How frequently you reassess
your patients?
247
 Reassessments shall be conducted and results must be entered in the

patient’s record:
 at regular intervals during care (for example, nursing staff periodically
record vital signs and pain assessment as needed based on the patient’s
condition or as per hospital policy);
 daily by a physician;
 in response to a significant change in the patient’s condition;
 if the patient’s diagnosis has changed and the care needs require revised
planning; and
 to determine if medications and other treatments have been successful
and the patient can be transferred or discharged.
 When the level of care changes

Screening of Patients
248
 Out Patient Department

- Visual Screening
 Emergency Department
- Triaging System

Admission of Patients
249
 Admission of Patients from OPD
 Admission of Patients from Emergency Room
 Admission of Patients from Other Healthcare

Facilities

ACCESS TO CARE AND CONINUITY OF CARE,
ASSESSMENT OF PATIENT , PROVISION OF CARE
250
What standard screening and diagnostic tests

are done on admission?
There is no standard screening and diagnostic tests are

done on admission, as these are based on the patient’s
health needs and doctor’s order.

What will be your action if there is delay in
the service to your patient?
251
If there is delay in service, the concerned nurse keeps

the patient informed about any delay in the service and
the cause of delay, also the nurse will document the
delay in the medical record.

What will be your action when the bed is not
available in the relevant admitting ward?
252
When the bed is not available in the relevant admitting

ward, the shift in-charge nurse in the Emergency
Department will inform the nursing supervisor for
temporary arrangement of bed in another ward, the
Nursing supervisor will be responsible for this

What will be your action when the bed is not
available throughout the hospital?
253
When the bed is not available throughout the hospital

or the patient is in need of a specific medical service,
admitting physician will transfer the patient to other
hospital in coordination with the nursing supervisor as
per- transfer policy, the Nursing Supervisor and
Admitting Physician are responsible for this

How many hours a patient can stay in ER/
what is your observation time in ER?
254
In ER the patient can stay up to four hours. If

condition requires more than FOUR (04) hours, a
Manager on duty or his/ her designee should be
informed to facilitate patient’s admission.

255
What if the patient who doesn’t speaks

English Language get admitted in your ward
midnight and if you don’t speak his/her
language?
For Language Barriers we have list of staff with names

and contact numbers and also list of List of Embassies
with address and contact numbers to contact.

What if the patient who understands only
sign language?
256
 The staff should contact Duty Manager who will in

turn contact the agency for interpreter for sign
language

How do you maintain the continuity of care for
patients those who went on Against Medical
Advice (AMA)?
257
To maintain the continuity of care, our PRO’s calls all

the patient went on AMA/LAMA/DAMA and
documents it in the log-book.

Age of Pediatrics
258
 14 years or less

Define Temporary Out Pass?
259
It is defined as a formal authorization for an inpatient

to be absent from the hospital for a specific period of
time.

What is High Risk Group for
Temporary Out Pass?
260
 Patient whose ambulation outside the hospital may endanger his/ her
health.
 Patient whose ambulation outside the hospital may interfere with other
lines of management.
 Patient who conceals risk factors to him/ herself or the society like
suicidal intentions, psychopathic personality.
 Patient with communicable disease during his/her isolation period, i.e.,
infectivity stage.
 Notifiable accidents to local security authorities, e.g. Motor Vehicle or
Road Traffic Accidents, Suicide, Assault, food & chemical poisoning
 Unknown patient.
 Patient with no valid identity.
 Expatriate with no valid residency permit (IQAMA) or passport.
 Patient under custody of local authorities.
What is the validity of
Temporary Out Pass?
261
For cash patients- The period of a pass shall not exceed

forty eight (48) hours, for credit patients- Credit
patient can be allowed up to three hours. However,
Credit patient needs company approval- if the pass
period is more than three hour

Temporary Out on Pass
262
 Temporary Out on Pass form should be filled

 Patient should be assessed before leaving the
hospital and after arrival to the hospital
 Medication should be given to the patient to cover
the temporary out on pass
 Patient should be educated on instructions,
medications, wound care, etc.,

What will be your action, if the patient failed to
return back after the Temporary
Out-Pass Period?
263
Failure to return to the hospital after the allowed

period will be considered as Left Against Medical
Advice (LAMA), the discharge procedure shall be
initiated immediately, the period is accountable and
readmission could be considered depending on bed
availability and completion of the necessary medical &
payment formalities applicable to the standard
admission procedure

What education shall the attending physician
and nurse provide to his /
her patient at discharge?
264
The attending physician shall educate his / her patient on the

following issues prior to discharge (including but not limited to):
 The patient’s illness and how to provide self-care.
 Times to take the medication and any special instructions
 Any equipment that the patient will use at home.
 When to call the physician and how to obtain “urgent” care.
 Why the patient needs to see any sub specialist. (If applicable).
 The reason the patient needs to be transferred to another
institution (if applicable).
 Involving the family members whenever patients cannot fully
understand the information provided to them (if applicable).
 Documenting all education and information provided to the
patient and/or family in the medical record.

How the attending physician and nurse
ensures that continuity of care occurs after
discharge or referral?
265
 The attending physician ensures that continuity of care

occurs after discharge or referral by (including but not
limited to):
 Assigning the follow up appointment for the patient

 Arranging any referral services for the patient.
 Follow-up instructions in an understandable manner.
 information on how and when re-access services

What are the components of the
discharge summary?
266
The discharge summary should include but not limited to

the following information:
 Reason for admission, diagnoses, and comorbidities
 Significant physical and other findings
 Diagnostic and therapeutic procedures performed
 Consultation / referral
 Significant medications, including discharge medications
 The patient’s condition/status at the time of discharge
 Follow-up instructions
 Any special care the patient requires after discharge

What are the components of your
Shift Endorsement?
267
 Below are the components of shift endorsement (including but not
limited to):
 Patient Name, ID Number, Age

 Medical Diagnosis and Treating Physician
 Medication list, Medication Added or Discontinued or any stat
Medication, IV fluids, blood transfusion etc.
 Any lab investigation done or for follow up
 Type of diet
 Any specific procedure done or to be done
 Any x-ray or ultrasound done or to be done
 Any change in the patient condition and the action taken
 If patient has companion with food and bed according to the contract.
 If patient for discharge or transfer to other facilities.
Day Surgery / Day Care Policies
268
All day care surgery / procedure patients follow the

same admission & discharge policies of inpatients

Define Patient Flow?
269
Patient Flow represents the ability of the healthcare

system to serve patients quickly and efficiently as they
move through stages of care. When the system works
well, patients flow like a river, meaning that each stage
is completed with minimal delay. When the system is
broken, patients accumulate like a reservoir, as in the
chronic delays experienced in many big city emergency
departments.

Please elaborate Internal
Transfer of Patient?
270
 Transfers of patients shall be based on the patient’s needs for

continuing care.
 To ensure patient safety during the transfer by given consideration to
issues such as risk assessment, planning, monitoring, transport,
escorting personnel and communication.
 The referring unit/ ward/ departments remain responsible for the
provision of care until the patient arrives and is accepted by the
receiving unit/ward/departments.
 Before transport is ordered the Consultant’s team transferring the
patient should have made arrangements for transfer and acceptance
with the receiving Consultant’s team (only applicable if there is a
change in the primary or treating consultant).

271
 Discussion of transfer with patient/ family by the

treating physician should be documented.
 In emergency situations when a patient is unable to
be consulted, where possible, the next of kin should
be informed of the decision to transfer.
 The responsibility for transfer rests with the
Consultant in charge of the patient’s care.
 All patient records and information transferred
should be treated confidentially.

Please elaborate External Transfer?
272
 When referring a patient to another hospital, the referring hospital

must determine if the receiving hospital provides services to meet the
patient’s needs and has the capacity to receive the patient.
 Before transport is ordered the Consultant’s team transferring the

patient should have made arrangements for transfer and acceptance
with the receiving Consultant’s team.
 Discussion of transfer with patient/ parent by the treating physician

should be documented.
 Discussion of transfer with patient/ parent by the treating physician

should be documented.

What are the components of
External Transfer?
273
 Patient and Family Education

 Acceptance Letter
 Communication
 Written Summary of The Patient’s Clinical Condition
 Escort Team and Escorts Criteria
 Supplies and Equipment during Transfer
 Monitoring During Transfer
 Ambulance Conduction
 Transfer of Responsibilities between practitioners and settings
 Transfer of patient with specific Isolation Precautions
 Continuity of care
 Documentation (Ambulance Request Form, External Transfer Form
and Ambulance Monitoring form etc.)
Who can escort the patient on
External Transfer?
274
 The treating doctor should assess the patient to arrange the Escort
Team.
 The qualifications of the staff member shall be appropriate for the
patient’s condition.
 Any staff escorting a patient on External hospital transfer must be
competent to provide at least the same level of care provided on the
referring unit/ ward/ department.
 All patients for transfer should be accompanied and monitored by a
Registered Nurse with BCLS, preferably ACLS certified.
 A qualified physician or paramedic (as appropriate) shall be assigned
to accompany the patient and handle any emergency that might
happen during transfer.
 A Physician certified in BCLS (preferably ACLS) should be assigned
to accompany all critically ill patients or intubated patients.
 Staff accompany patient are chosen according to patient condition.
Define Triage?
275
Triage is the process by which patients are prioritized

according to the type and urgency of their condition,
ensuring that patients are treated in order of medical
priority.

276
What kind of triage you are using in your

Emergency Room (ER)?
We are using a XXXXXXX Triage in our ER.

277
What is the response time of a Consultant for

Routine and Emergency (Urgent and Very
Urgent) cases after receiving proper
notification?
The Consultants should respond within 24 hours for

Routine Cases and 30 minutes for Emergency (Urgent
and Very Urgent) cases after receiving proper
notification
PATIENT AND FAMILY EDUCATION
278
Define Patient And Family Education?

Patient And Family Education is the process of preparing
patient/family to meet self-care needs and assume responsibility
for care provided during hospitalization and/ or outpatient
visits. It promotes healthy behaviors, supports recovery and a
progressive return to function, and enables patients and/or
family members to be involved in decisions about their own
care.
Patients and Family needs for education will be assessed and
accordingly the education will be provided by the
multidisciplinary team of healthcare practitioners. (Please refer
to the policy for details).
279
Education Need Assessment

 Needs of the patient education should be assessed
and documented
Content of PFE
 Diagnosis & Care Plan
 Medications
 Diet
 Equipments
 Infection Control
 When to seek emergency care, etc.,
CARE OF PATIENTS
280
What do you know about Uniform Care for All Patients?
 The patients with the same health problems and care needs shall receive the same quality of
care throughout the hospitalization duration.
 All services provided to all our patients in multiple departments or units/ settings shall be
provided as per our hospital policies and procedures to maintain the uniform delivery.
 The concern leaders should ensure that the same level of care is available each day of the week,
and all work shifts each day.
 The uniform patient care should be reflected in the following:
 Access to and appropriateness of care and treatment shall not depend on the patient’s ability to
pay or the source of payment.
 Access to appropriate care and treatment by qualified practitioners shall not depend on the day
of the week or time of day.
 Acuity of the patient’s condition shall determine the resources allocated to meet the patient’s
needs.
 The level of care provided to patients shall be the same throughout the hospital.
 Patients with the same nursing care needs shall receive comparable levels of nursing care
throughout the hospital.

What is Plan of Care?
281
 A plan that identifies the patient’s care needs, lists the strategy to meet
those needs, documents treatment goals and objectives, outlines the
criteria for ending interventions, and documents the individual’s
progress in meeting specified goals and objectives. It is based on data
gathered during patient assessment. The format of the plan in some
organizations may be guided by specific policies and procedures,
protocols, practice guidelines, clinical paths, or a combination of these.
The plan of care may include prevention, care, treatment, habilitation,
and rehabilitation.

In how many hours a Plan of Care
should be completed?
282
A Plan of Care must be completed within 24 hours of

admission as an in-patient.

What is the arrival Time of
Code Blue Team?
283
The arrival Time of Code Blue Team should be within

maximum three (3) minutes from the activation time

Orders
284
 Only Physician are allowed to give orders

 Verbal Orders are accepted only in emergency
situation and should be documented as early as
possible
 Telephone orders should be documented in the
telephone orders records and should be signed by the
ordering physician within 24 hours
 Results of investigations given as telephone orders
should be viewed or verified by the physician

Define Abuse?
285
 Abuse is defined as any action that intentionally harms or injures

another person. Abuse also encompasses inappropriate use of any
substance, especially those that alter consciousness (e.g., alcohol,
cocaine, methamphetamines).
 Any willful, negligent, or reckless mental, physical, sexual, or verbal

mistreatment or maltreatment or misappropriation of personal
property of any person receiving treatment in a mental health facility
that insults the psychosocial, physical, or sexual integrity of any person
receiving treatment in a mental health facility.

How do you Care of Dying Patients?
286
 It is the policy of Dr. Sulaiman Al- Habib Hospital to ensure that the
unique needs of terminally ill patients in a culturally and age-
appropriate manner are meeting by:
 Assessing and respecting the unique needs of dying patients, including

spiritual and cultural needs.
 Response to the psychological, social, emotional, spiritual needs.
 Effective management of pain and other distressing symptoms.
 Involvement of the family members in care decisions and teaching them
how to care for their patient.
 Referral to outside sources for support is made when indicated

Assessments and reassessments will include as
indicated by the patient’s condition
(Care of Dying Patients),
287
 Such symptoms as nausea and respiratory distress;

 Factors that alleviate or exacerbate physical symptoms;
 Current symptom management and the patient’s response;
 Patient and family spiritual orientation and, as appropriate, any involvement in a
religious group;
 Patient and family spiritual concerns or needs, such as despair, suffering, guilt, or
forgiveness;
 Patient and family psychosocial status, such as family relationships, the adequacy of
the home environment
 If care is provided there, coping mechanisms, and the patient’s and family’s
reactions to
 illness;
 The need for support or respite services for the patient, family, or other caregivers;
 The need for an alternative setting or level of care; and
 Survivor risk factors, such as family coping mechanisms and the potential for
pathological grief reactions.
How a patient can revoke or
cancel consent?
288
A patient may revoke/ cancel consent verbally or in writing

at any time. This should be communicated to the
anesthetist and documented in the medical record.

Pre-Operative / procedure Checklist
289
A verification process to ensure all the essential documents, screening are

performed before surgery or procedure. Checklist should have Yes / No
/NA. A pre – operative Check list includes but not limited to,
 Relevant and complete Consents
 Assessments by Physician and nursing staff
 Evidence of site marking
 Availability of results of investigations requested
 Availability of requested blood and blood products
 Evidence of removal of dentures and loose objects such as eye lenses,
eye glasses, removable nails, etc.,
 Evidence of removal of Jewelry

What is the time-line for the documentation
of surgical report, or a brief operative note?
290
The written surgical report, or a brief operative note in

the patient’s record, must be available before the
patient leaves the post- anesthesia recovery area.

291
What education should be provided to the patient if an

Outpatient procedure is planned to be done under Local
Anesthesia in Out Patient Department?
 If an Outpatient procedure is planned to be done, then the treating

doctor should:
 Explain the procedure to be done to the patient/ family,

 Consent should explain in detail and signatures should be taken prior to
starting procedure.
 Upon completion of the procedure- clear follow-up instructions should
be given
 Follow-up appointment must be given (based on the procedure
performed and need of the same).
Handling, Use, Administration of Blood & Blood
Products
292
 Physician Order and cross request is required for blood & blood product requisition
 Two witness should witness and document in the blood cross-match form while
withdrawing blood from the patient for cross match
 Vital signs should be taken
 Pre Transfusion
 During transfusion –
 Every 15 min for 1 hour,
 Every 30 min for 1 hour
 Hourly till blood transfusion completes
 Time of transfusion completed
 Staff should be aware of the symptoms of Blood transfusion reactions

 Any blood transfusion reaction noted, the transfusion should be stopped immediately and
reported to the duty physician, primary physician and blood bank
 Blood Transfusion reaction report, with the blood & blood product component bag,
samples should be completed and sent to the laboratory with samples.

Venous Thrombo Embolism (VTE)
293
 All the patients should be assessed for Venous

Thrombo Embolism (VTE) on admission and
whenever the condition of the patient changes
 Prophylaxis should be ordered to the patients if the

patient is above low risk
 Staff should be aware about the clinical guidelines of

VTE
Consultation / Referral
294
 Very Urgent :
Patient should be seen within 30 minutes and
documented by the required physician
immediately
 Urgent :
Patient should be seen within 4 hours and
documented by the required physician
 Routine:
Patient should be seen and documented within
24 hours from the referral

Describe about Pain Management?
295
 The hierarchy of pain assessment shall be considered in choosing the suitable pain assessment
tool to be used.
 Interdisciplinary approach to pain management should be encouraged.
 The need for effective management of pain and other distressing symptoms by terminally ill
patients should be provided and dealt in a culturally and age -appropriate manner.
 For patients following surgery adequate pain relief should be provided and adjustments to pain
medications should be in accordance to the patient's response.
 Pethidine is not recommended for the treatment of chronic pain especially in sickle cell patients.
 Placebo should not be used to treat pain neither therapeutic nor diagnostic even with written
order for it is considered unethical and violating the patient's right for optimal pain relief.
 Patient's response to pain medication should be assessed and side effects from pain medications
should be dealt and documented.
 Patients and family should be educated about pain assessment, other symptoms, the
management plan, side effects of pain medications and how to deal with chronic pain.
 Patients should be discharged from the hospital with optimal pain management plan including
medications, teaching and referral if indicated.
 Each registered nurse shall undergo education and training regarding pain assessment and
management.
 Staff should be aware pain assessment, reassessment time frames and management
What are the assessment tools
are used in your hospital for pain?
296
 Below are the assessment tools used in our hospital

for pain:
 Numeric Pain Rating Scale
 Wong-Baker Face Pain Rating Scale
 FLACC Scale
 NIPS Pain Scale
 CRIES Pain Scale
 Critical Care Pain Observation Tool or CPOT
 Comfort Pain Scale

Admission & Discharge Criteria for Critical Care Areas
297
 ICU
 CCU
 PICU
 NICU
 Labor & Delivery

Organ Donation
298
 Adopted from Saudi Center for Organ Donation and
Transplantation (SCOT)
 Policy defines criteria for inclusion and exclusion for organ donation
 Two consultant (one should be neurologist / neurosurgeon along
with the critical care consultant) are required to evaluate the patient
 Medical Director should be notified
 Family should be informed about the condition and potential case
for organ donation
 If the patient agrees, Critical Care Physician should Contact the
SCOT
 Staff should be aware of the guidelines, FATWA, Rules and
regulations, Patient educational brochures

Restrains
299
 Physician Order with Indication, type of restrain,

duration, location
 Restraint order should be renewed every 24 hrs
 Educate the Family
 Visibly check all restrained patients at least every
fifteen (15) minutes
 Conduct reassessment every one hour

Describe the hospital program to prevent pressure
ulcers
300
 Skin integrity is assessed on admission as part of

nursing initial assessment. Risk for impaired skin
integrity is assessed on admission and every shift
using braden scale. If the braden score is <19, the
patient is considered at risk and initiate management
in prevention of Pressure Ulcer

Medical Staff Bylaws
301
Medical Staff Bylaws include

 Purpose & Responsibilities
 Medical Department Organization Chart
 Functions of the department
 Medical Executive Committee Members
 List of committees
 Clinical Department & Units
 Rules & regulations of medical staff
 Category of medical staff
 Credentialing, Privileging, Appointment, Reappointment, Evaluation,
promotion, Transfer of Medical staff

Clinical Guidelines, Pathways, Protocols
302
 Top 5 diagnosis of your department
 What are the clinical pathways, guidelines, protocols

approved and used in your department
 Audit of the clinical pathways, guidelines, protocols

and where the results of the auditing discussed

303
Medication Management & Use

Medication Profile
304
Initial Physician assessment and care plan should be completed for the
pharmacist to do medication profile which includes,
 Patient’s age and sex
 Current medications
 Diagnoses, co-morbidities
 Laboratory values
 Allergies
 Body weight and height
 Pregnancy and lactation status
`
Medication review should include the following but not limited to,
 the appropriateness of the drug, dose, frequency, and route of administration;
 Therapeutic duplication;
 real or potential allergies or sensitivities;
 Real or potential interactions between the medication and other medications or food;
 variation from hospital criteria for use;
 patient’s weight and other physiological information; and
 other contraindications.
Patient own medications
305
 Patients are not allowed to take medication on their

own
 Patients own medications should be collected by the

nurse, document in the form and send the
medications to the pharmacy
 Patient own medication should be labeled

Content of Medication order
306
 Patient’s Full Name

 Patient Medical Record Number
 Age and Gender
 Weight for Paediatric Patients
 Generic Name of Medications (no abbreviations are allowed)
 Strength
 Dose (metric system),
 Frequency
 Route of administration
 Duration of treatment
 Diagnosis
 Name, Signature and Stamp of the Prescriber,
 Whether or when indications for use are required on a PRN (pro re nata, or “as needed”)
or other medication order, the types of orders that are weight based or otherwise
adjusted, such as for children, frail elderly, and other similar populations

307
Hospital prohibits blanket orders

(e.g., resume pre-op medications).

High Alert Medication
308
Medications which cause an

immediate life threatening condition
for the patient if an error in
preparation / administration occurs.
These medications carry a higher risk
for adverse outcomes.

High Alert Medication List
309

High Alert Medications?
310
 High alert Medication and Concentrate Electrolytes

should be stored in locked cabinets, should be stored
separately from the normal medications
 Stored only in critical care areas and crash carts
 Independent Double check

Look Alike Sound Alike (LASA) Medications
311
Medications that are visually similar in

physical appearance or packaging and
names of medications that have
spelling similarities and or similar
phonetics

LASA List
312

LASA Medications?
313
 Indications for use should be documented in
prescription. Using Generic and Brand name
 Minimizing telephone / verbal orders
 Changing the appearance of look alike products
 Placing LASA medications in locations separate from

each other or in non-alphabetical order
 Independent Double check . Reading carefully each time

the medication is accessed.

What are hazardous pharmaceutical
chemicals?
314
Any substance posing a physical or health hazard

Examples: Hydrogen peroxide, ethyl alcohol, etc

315

Where can you access the drug information
316
 Drug Formulary
 Lexicom System
 IV Preparation Guidelines
 Medication Management & Use Policies

Rights of Medication
317
 Right Patient
 Right Medication
 Right Dose
 Right Route
 Right Time
 Right Frequency
 Right Documentation
Verify (expiry, discoloration, particulate, or other clues of
loss of integrity or instability, other contraindications

Prohibited Abbreviations
318

Prohibited Abbreviations
319

Approved Abbreviations
320
 Ensure all the abbreviations used by the department

are in approved abbreviations list. If you use
abbreviations not listed in the document, please
contact the quality department for addition to the
list.

What do you know about
medication errors?
321
 Medication Error: It is a preventable event that may

cause or lead to inappropriate medication use or
patient harm while the medication is in the control of
the health care professional, patient or consumer.
 Types of Medication Error:

 Prescribing Errors
 Dispensing Errors
 Administering Errors

What is Adverse Drug Reaction (ADR)?
322
 An unintended physical reaction to a drug when it is

used in the approved manner. (e.g. Allergic
reactions).
 All ADRs should be reported immediately to

physician and pharmacy dept, by filling the ADR
form within 24 hours of the event

Medication Error
323
 Patient should be assessed

 Report the medication error or Adverse Drug
Reactions to physician, Pharmacy staff
 Inform the Patient & Family by the physician
 Documentation of medication error, near miss or
adverse drug reaction in Medical Records by
physician, nurse, pharmacist
 What is the medication error rate in your department
???

What is Automatic Stop Order (ASO)?
324
Is a form of standing order to discontinue the use of

medication after a number of specified doses, or days
of therapy unless the physician renews the order. The P
& T committee will determine the ASO duration. This
policy ensures that: - Orders for potent drugs are
reviewed in a timely fashion.

How long is the validity of physicians order for antibiotics,
controlled drugs, ordinary drugs, anticoagulants and
continuous I.V. drips?
325
 For Antibiotics:
 Prophylactic Antibiotics: 24 hours (or only one dose).
 Empiric Antibiotics: 72 hours
 Therapeutic Antibiotics: 7 days
 Heparin IV: 24 hours
 Continuous IV infusion: 24 hours
 Anticoagulants: 72 hours
 Blood derivatives (e.g. Albumin): 24 hours
 For Anticoagulants – Continuous I.V. drips: 1 Day (Unless a new
order is written)

What are "Restricted Medications"?
326
 Medications for which the P & T committee has

imposed certain limitations for prescription & use.
 * Restricted medications should be signed by the ID

(Infectious Disease) doctor. e.g: -Vancomycin -
Tazocin-Colistin Meropenem -Imipenem -
Amphotericin -Tigecycline -Teicoplanin -
Linezolid -Ecalta -Caspofungin -Micamin

When is crash cart checked?
327
 Daily, or when opened/used by the nurse.

 Monthly by pharmacy

How is crash cart restocked
after use?
328
Crash cart is restocked immediately after each use

What would you do if you found that
the crash cart was unlocked?
329
 Crash cart should be locked all the times.

 Inform the head or in-charge of the department.
 Check if there is any missing item.
 Lock the cart.

Medication Samples
330
 Medication samples are not allowed in the hospital

Drug Formulary
331
 Location
 containing medication and its indication
 Also contains approved and prohibited abbreviation
 Prophylactic Antibiotics
 Appendix contains therapeutic guidelines, drug
safety in pregnancy and lactation, etc

Preparing sterile preparation
332
 IV Guidelines
 Clean the area with spirit (tray/table surface)
 Wash Hands
 Wear gloves
 Verify the medication order
 Prepare medication as per the IV guidelines

Medication Label content
333
 Patient name
 Medical record number
 Patient location
 Medication name, dosage form, strength and amount
 Direction for use
 Relevant cautionary instruction (e.g., refrigerate,
shake before use, may cause drowsiness).
 Date of preparation, beyond use date, and time
(when beyond use date occurs in less than twenty
four hours).
What would you do if you found that
the crash cart was unlocked?
334
 All staff should know where these items are kept:

Patients'Own Medications
 Expired Medications
 Hospital Formulary
 Manuals:
Department Policies - Compounding (Extemporaneous preparations)
IV Guidelines-Compatibility & Stability Guidelines
MSDS
Aseptic Techniques
Infection Control

Medication rooms, storage
335
 Medication Refrigerators should be connected to

emergency power
 All medication room including the crash cart location
should be monitored and documented for
temperature and humidity
 All the medication rooms, refrigerators, carts should
be locked

Medication Expiry
336

What is the importance of monitoring the
Par Level?
337
• Important for keeping inventory numbers stable as well as

determining and controlling the levels of stock needed for
optimal profit. Good inventory management involves having
enough inventory on hand to meet customer demand, yet not
too much to exceed inventory turnover goals.

338
Staff Qualification Education (SQE)

Job Description
339
 Signed by the employee on joining
 JD Includes
 Knowledge
 Skills
 Attitude
 Duties and Responsibilities
 Reporting relationships
 Job Description helps in evaluation, internal

promotion, transferring or hiring an employee
Credentialing & Privileging Process
340
Credentialing / Primary Source Verification;

 Process of verification of Education, Experience,
Training / Certification, License (country of Origin),
References from the primary source for all clinical
staff who requires license from Saudi Council
 Copy of the results of credentialing are kept in the
employee file

Privileging
341
 Process by which a licensed practitioner is permitted by the

hospital to practice independently, to provide medical or other
patient care services within the scope of their license, based on
the individual’s clinical competence as determined by peer
references, professional experience, health status, education,
training and licensure
 All the clinical staff should be aware how to access the

privileging of the physicians (self and other physician in the
department)
 Conscious sedation physician requires Conscious sedation

Privileges
Conscious Sedation
342
 Staff performing / monitoring the patient during the

conscious sedation should have valid conscious
sedation privileges
 Should be ACLS / PALS Certified based on the age

group of the patients
 Adhere to the Conscious sedation policy

Privileging Process
343
 Privileging Application form should be completed by the

physician, signed by the department head, sent to medical
admin for review in Credentialing and Privileging Committee
 HR department will present the results of credentialing /
primary source verification in the committee
 Committee which includes the heads of the department
reviews the privilege application and approves / disapproves
the request
 Privileges are valid for every 2 years
 Approved privileges are placed in hospital shared folder
 Physicians are not allowed to practice outside the approved
privileges

What kind of Orientation did you receive upon
joining this hospital?
344
The hospital conducts New Hire Orientation for all new hires,
re-hired and transferred employees within 15 days of
joining the hospital which includes but not limited to
 Hospital Vision, Mission, Values
 Quality Management & Patient Safety (including Quality plan,
Quality & Patient Safety Programme, Risk Programme, incident
reporting, safety culture, adverse, sentinel events, safety culture)
 Patient bill of rights & responsibilities, compliant process
 Facility Management Plans and programme
 Infection Control
 Human Resource Department Policies (including evaluation process,
staff complaints, credentialing & Privileging Process, staff health
program, local cultural & social themes, Code of Conduct, etc.,)
 Abuse, neglect of child and adult
What kind of orientation did you
receive in your department?
345
 The head of the department/coordinator gave the

Departmental/Unit Orientation before starting the
job in my department/unit

Staffing Plan
346
 Developed by department head in collaboration with

human resource department that includes
 Number
 Type
 Qualification of the staff required
 Reviewed every year

What kind of evaluations does
your hospital have?
347
 Out hospital have three kinds of Evaluations as

follows:
 Early Evaluation-Ten (10) days following

commencement of employment.
 Probationary Evaluation-Ninety (90) days
following employee probation.
 Annual Evaluation-One (1) year following
commencement of employment i.e. Anniversary Date

Does your hospital have an Orientation
Programme for Nursing Staff?
348
 Yes, our hospital has a General Nursing Orientation

Programme for all new nurses, which is conducted by
the Nursing Education Department.

Training & Education Needs
349
 Identify Training and education needs for the

department by
 Collaboration with quality, HR department
 Staff education & training history
 Staff evaluations
 Peer reviews
 Incident reports
 Needs generated by advancements made in the medical and
healthcare management fields
 hospital’s technology and safety management programs
 Infection control activities

How do you allocate cross trained staff in
the department?
350
Check the staff qualification, competencies and job

description of the staff before allocating any patient to cross
trained staff in the unit.
Hospital
HMG-AlAffairs
QassimandHospital
Corporate Quality Department 16 November 2016
Staff / Employee Health Program
351
 All the staff are screened before joining
 All staff are screened yearly
 After needle stick injury, exposure to blood or body

fluids

Staff Satisfaction Survey
352
 Conducted regularly
 What is the results of the survey? Satisfaction rates?

Staff Complaints & Grievances
353
 Written Complaint or grievance should be submitted

 Investigation to be completed within 5 days by HOD
 If not resolved or employee wish to appeal, request
should be submitted to HR within 5 days to HR
department
 Complaints / Grievance should be settled within 10
days

Work Place Violence
354
Any physical assault, threatening behavior or verbally

abusive remarks that are made in the workplace and or
affect the workplace behavior of an employee
 All the employees should behave professionally
 Any incident should be report immediately
 Employee will be assessed and referred for
counselling if required
 Disciplinary actions will be taken on the employee
after the investigations

355
MANAGEMENT OF INFORMATION

Management of Information (MOI)Plan
356
MOI Plan includes

 Information Need Assessment
 Access, Confidentiality, Security
 Retention of records (Medical Records, audio visual
records, employee files, etc.,)
 Communication Systems
 System down Time process
 Back Up
 Data request process

Information Needs Assessment
357
 To analyze the information requirement of the

customers
 Information Need assessment are done from

 Internal Customers (departments)
 External Customers (Government organization, Insurance

Companies, Regulatory agencies, etc.,)

Down Time
358
 Manual Records should be used during system

(VIDA, Lynx, LIS, PACS,ETC) downtime
 Manual records should be available during the
downtime
 Records should be verified before entering the data
back to the system
 Staff should be trained and down time preparedness
should be tested regularly

Release of Medical Records Information
359
 Medical records information are confidential
 Medical records information are released only to the

patient or to the relatives on written request /
authorization from the patient
 Any request for medical records information not

relating to direct patient care, should be approved by
the HOD and submitted to medical director for
review and approval
How do you define Policy, Procedures
360
 Policies are rules that govern, guide and direct the

operations in the organization. Policies are the basic
principles by which an organization is guided
 It is a process that is carried out to achieve the rules,

regulations and work process. They assign, prioritize
and order responsibilities.

What do the following represent in as
mentioned in the header of all policies in your hospital?
361
 Policy Number: for numbering, tracking purposes
 Date of Issue: The date on which Policy is issued.
 Effective Date: the date on which policy takes effect. The policy is
effective only after the final approval of the Hospital Leader or concern
Head of the Department/Coordinator for Departmental Policies.
 Review /Revision Date:

A re-examination or reconsideration of the policy based on
recommendations or new edition of standards.

Policies , Plans Revision time frames
362
 All Policies and Procedures (including but not

limited to all plans of the hospital, protocols,
manuals, Job Descriptions, Clinical Pathways) shall
be revised on every two (02) yearly basis or as per the
requirements
 Plans (FMS, QIPS, Risk Assessment Plan, Etc.,)are

revised on yearly basis or as per the requirement
 Strategic Plan – every three (3) years

When does the quality improvement office
contact the policy owners for revision?
363
 Minimum two (02) months prior to the review date

of the policy, the quality improvement office should
contact the Policy owner to remind them about the
revision and if any amendments.
 The policy owners should revise the policy as per the

practice and if any amendments done should inform
and complete the Revision History part in the policy
and forward it to the quality for final approval.

Policy on Policy, Document Management
364
 Any document (policies, plans, checklist, forms, etc.,)

should be reviewed by quality and approved by the Medical
Records Committee for forms and policies, plans, by the
General Director
 All the policies should be in standardized format
 Forms, checklist should have control number
 Only approved policies will be placed in the hospital shared
folder
 Hard copies of the policies should not be kept in the unit
 Any document / information coming from outside the
hospital should be circulated to hospital staff after review
and approval of General Director or his designee
Departmental / Unit Policies
365
 All the staff in the unit should be aware about their

department / unit specific policies

Common Questions to HOD
366
 How do you establish or create committee, members, how do you monitor

 How do u select indicators, who collects the indicators, where are the results
discussed and how frequently, how indicators are used to improve process,
staff
 How do you develop clinical pathways, guidelines, protocols, do you audit
and where are the results of the audit discussed and how frequently
 Who are your internal and external customers
 How do you identify customer needs
 How do you ensure the patient and family rights are executed in your
department
 Any new process was implemented or existing process was modified
 How does the recommendation of medical executive committee is passed to
the department level staff
 How patient are informed about the diagnosis and plan of care and where is
it documented

Common Questions to HOD
367
 Continuous medical education plan, staff evaluation, staff

development
 What is the process for requesting new service, new
equipments, additional staff
 Staffing plan
 Scope of service

Department Head / Head Nurse Check List
368

Check List
369

Check List
370

371
PLEASE READ ALL THE POLICIES

THAT ARE APPLICABLE TO YOUR
SCOPE OF WORK.
THANK YOU…

Common JCI CBAHI Survey Questions

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Common JCI CBAHI Survey Questions

Uploaded by

Copyright:

Available Formats

1

JCIA, CBAHI MOST COMMON QUESTIONS AND

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Facility Management & Safety

Hospital Affairs and Corporate Quality Department 16 November 2016

What are the FMS Plans?

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Emergency Extn - ???

Hospital Affairs and Corporate Quality Department 16 November 2016

 Announce “Code Blue (Adult / Pedia if Code Blue),

 BLS should be started immediately and ACLS

 CPR record and CPR Evaluations should be

Hospital Affairs and Corporate Quality Department 16 November 2016

 Any staff identifying the patient is detoriating should dial

 Announce “Code RRT (Adult / Pedia if Code Blue),

 BLS should be started immediately and ACLS should be

 CPR record and CPR Evaluations should be completed

 Initiate RACE & PASS Protocol

Hospital Affairs and Corporate Quality Department 16 November 2016

Only Head Nurse or team leader should shut of medical gas

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

 As per our Fire safety plan

Hospital Affairs and Corporate Quality Department 16 November 2016

Note: Never Evacuate unless Code Orange is

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

 Staff should be aware how many assembly

 Staff should reach the assembly points

 HOD , Head Nurse should do head count of

 Assess the patient, staff

 Wait for the code Clear. Should not leave until

Hospital Affairs and Corporate Quality Department 16 November 2016

 Ambulatory: Able to walk alone, unattended.

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

Hospital Affairs and Corporate Quality Department 16 November 2016

 Seek medical assistance. Burns caused by fire should be evaluated

 Replace a fire blanket as soon as possible. You should never be

Hospital Affairs and Corporate Quality Department 16 November 2016

 Security Staff, PRO, Nursing Supervisor

 Calm the patient / staff

 Should take the violent patient to safe area so

 If the patient is still violent, inform the duty

 Should report thru Incident report form

Hospital Affairs and Corporate Quality Department 16 November 2016

 Obtain more information as much as possible

Hospital Affairs and Corporate Quality Department 16 November 2016

 General Director his/ her designee only can

Hospital Affairs and Corporate Quality Department 16 November 2016

 Staff should be aware how many assembly

 Staff should reach the assembly points

 HOD , Head Nurse should do head count of

 Assess the patient, staff