AMAN HANBOOK

A Hospital guide to understanding

the Essential Safety Requirement Standards
1st Draft April 9, 2017

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 Appendix
Topics Page NO
Part 1: ESR standards intent 3
- HR. 5
- MS.7
- PC.26
- PC.25
- QM.17
- QM.18
- AN.2
- AN.15
- IPC.4
- IPC.15
- MM.5
- MM.6
- MM.41
- LB.51
- FMS.9
- FMS.21
- FMS.24
- FMS.22
- FMS.23
- FMS.32
Part 2: Frequent asked questions 16
Part 3: Do & Don’t 24

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 PART 1: ESR standards intents
The hospital has a process for proper credentialing of staff members licensed to provide
HR.5
patient care.

Standard definition:
Staff credentials include licensing, certification, education, training, competencies, and
experience. Staff in this standard includes all staff who provide direct (independent)
patient care including diagnostic, therapeutic, rehabilitative, palliative, and preventive
care.
Why it is an ESR:
This standard aims to improve the safety of the services provided to patients by holding
the hospital accountable for ensuring that all staff members who provide patient care have
the required qualifications that enable them to provide safe and effective patient care. Staff
qualifications are believed to influence personal, professional, and practice characteristics,
and consequently, can significantly impact the provision of high-quality patient care.
Methods to comply with :
Those who independently provide patient care and the required credentials including
licensing, certification, education, training, competencies, and experience are identified in a
policy or another document.
Current and updated required staff credentials (as per hospital policy) are kept in staff
personnel files.
All credentials are verified from original source.

MS.7 Medical staff members have current delineated clinical privileges.

Methods to comply with :

• Availability of a criteria for delineated clinical privileges to medical staff.
• Every medical staff must have a valid delineated clinical privileges (standards and
special privileges.)
• A comprehensive list of all privileged medical staff must be made accessible in all
clinical units.

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 Policies and procedures guide the handling, use, and administration of blood and
PC.25
blood products.
The use of blood in the organization is supervised and closely monitored by the
blood utilization committee. Blood must be handled and used in accordance with
standards of practice and in a consistent manner in order to ensure the safety of the
recipient. Policies and procedures are developed and approved by the blood
utilization committee covering the administration of blood (including patient’s
identification, accepted practices, monitoring during and after the transfusion and
reporting of transfusion errors) and when to administer blood without a consent.
Only physicians can order blood for transfusion. Patients are informed for the reason
for transfusion and sign an informed consent for blood transfusion that must include
the elements in the substandard PC.25.3.1 through PC.25.3.5.
All transfusion reactions are immediately reported to the blood bank and
investigated by the appropriate blood bank staff in order to avoid its recurrence. A
report is given to the blood utilization committee to ensure the implementation of
corrective actions.

PC.26 Patients at risk for developing venous thromboembolism are identified and managed.
PC.26.1 Patients are screened for the risk of developing venous thromboembolism.
PC.26.2 Patients at risk receive prophylaxis according to current evidence-based practice.
Methods to comply with :
• Availability of Policy for Deep venous thrombosis (DVT) prophylaxis.
• All patient are screened for the risk of DVT.
• Patients at risk for deep venous thrombosis must receive prophylaxis before
surgery.

QM.17 The hospital has a process to ensure correct identification of patients.

Standard definition:
The correct patient identification ensures that a correct match is made between the
service and the patient.
Why it is an ESR:
Identifying patients correctly is vital for patient safety. The healthcare services are of
a multidisciplinary nature, wherein many professionals provide care to each patient.
Therefore, there is increased chance for hand-over and communication problems.
Misidentifying patient can result in harm to patient throughout the healthcare
organization including medication errors, blood transfusion errors, testing errors,
wrong person procedures, and the discharge of infants to the wrong families.
Misidentifying patients is identified as a common root cause of many incidents and
near misses.
Methods to comply with :

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 Hospitals are required to establish and maintain a uniform process to correct patient
identification. The process should include but not limited to, patient sample
identities throughout pre-analytical, analytical, and post-analytical processes,
identifying patients who lack identification, identifying comatose or confused
patients, staff training on procedures for checking/ verifying a patient’s identity, and
the technologies used to support and improve patient identification (for example:
bar coding).
Use of at least two identifiers to verify a patient’s identity prior to the administration
of care and upon transfer to another hospital or other care setting.
Encourage patients and their families to be active participants in all stages of the
process of identification, to express concerns about safety and potential errors, and
to ask questions about the correctness of their care

The hospital has a process to prevent wrong patient, wrong site, and wrong
QM.18
surgery/procedure.
Standard definition:
This standard encompasses surgeries performed on the wrong body part, incorrect
surgical procedure performed, and surgery performed on the wrong patient.

Why it is an ESR:
Surgeries on the wrong patient or body part such as removing a kidney from the
wrong patient or amputating the wrong limb are rare but extremely unacceptable.
Such errors are classified as “never events” because they should never occur.
However, such mishaps can be prevented by adopting certain strategies and
procedures that improve communication among staff and between staff and the
patient, support patient involvement, improve patient assessment, and improve
legibility of information in medical records.
Methods to comply with :
The hospital is expected to develop and implement a multidisciplinary process to
prevent wrong patient, wrong site, and wrong surgery/procedure. The process
should include a preoperative verification of patient information, consistent
method of marking the surgical site, and a timeout that is conducted immediately
before starting the procedure.
The verification process should include verifying the correct patient, procedure and
site. All patient information including identity, consent, full details of the procedure,
laboratory tests, radiology images, and any implants or prosthesis should be
available, labeled and displayed.
The surgical/procedural site is marked before conducting the surgery especially in
bilateral organs and multiple structures (e.g. fingers, toes, and spine). The mark is
done by the individual who will perform the surgery/procedure. The mark is done
while the patient is awake. The mark is visible after the patient is prepped and
draped

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 Before starting the procedure and in the location where the procedure will be done,
a time out must be conducted. The time out is initiated by a designated member
and involves all team members. During the time out, and using active
communication, the team members agree on the correct patient, correct procedure
and correct site, and on the availability of the required implants or equipments.

AN.2 Anesthesia staff members have the appropriate qualifications.

Methods to comply with :

 Every anesthesia staff members must have appropriate qualifications,
approved and updated privileges and all required mandatory competencies
(e.g. BLS,ACLS,etc,,).

AN.15 Qualified staff perform moderate and deep sedation/analgesia.

Methods to comply with :

 Availability of written policy on conscious sedation approved by the head of
anesthesia, the nurse manager, and the appropriate department heads.
 Availability of list of all conscious sedation privileged physicians
 Availability of list of all conscious sedation privileged units/sites.
 Availability of continuous monitoring of patient level of consciousness, vital
signs, oxygen saturation, skin color and ECG findings and this is documented
by the physician and nurse during conscious sedation.

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 There is a designated multidisciplinary committee that provides oversight of the
IPC.4 infection prevention and control program.

Standard Infection control committee is a designated coordination mechanism for all infection
definition: prevention and control activities involving a group of hospital health professionals
Why it is composed of infection control personnel, with medical, nursing, administrative, and
an ESR: occasionally dietary and housekeeping department representatives, who plan and
Methods supervise infection control activities .
to comply Everyone knows that infection control is the responsibility of all healthcare workers.
with The purpose of the Infection Control Committee is not to reduce the individual
responsibility that each healthcare provider has, but to provide leadership for all
employees throughout the facility .
Every healthcare facility uses interdisciplinary task forces such as the Infection
Control Committee to minimize patient and employee risk. The Infection Control
Committee plays an integral part in the care of every patient. Coordination involves
communicating with all parts of the organization to ensure that the program is
continuous proactive and infection prevention and control activities reach into every
part of health care organization and involve individual in multiple department and
services .
The role of the Infection Control Committee is very multi-faceted. It should be
involved in planning, monitoring, evaluating, updating, and educating. That is
accomplished in a variety of ways that assessed by the surveyor during the survey
process which include: surveillance of Healthcare Associated infections, tracking of
infection rate, compare it with other organization though comparative database and
regularly communicate the results to organization leaders and staff (PCI. 9&10),
establishment a defined process for investigation of infection outbreaks and
infection clusters (PCI. 11), proper monitoring of antimicrobial uses within the
organization via preparation of anti-biogram and regularly discussed in the
committee (PCI. 37), the active role of committee in staff education; the committee
must set direction for staff continuous education and validation of that education
(PCI. 8), Safe medical waste disposal and management (PCI. 26), proper mechanism
ensure that the infection control team review and supervise reconstruction project
within the organization (PCI. 31) and finally allocation of adequate infection control
resources that support the Implementation of effective infection prevention and
control program (PCI. 1& 32.)
The organization should comply with these seven areas and meet the standard
requirements related to these areas; any non-compliance with those areas will affect
the functions of infection control committee and reflected on its score.

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IPC.15 Facility design and available supplies support isolation practices.
Methods to comply with :
The goal of an organization’s prevention and control program is to identify and to
reduce the risks of acquiring and transmitting infection among patients, staff,
healthcare professional, contract workers, volunteers, students, and visitors.
Isolation precautions create barriers between people and germs. These types of
precautions help prevent the spread of germs in the hospital. Different types of
isolation precautions protect against different types of germs.
The organization should have strategy to protect patient, staff and visitor from
communicable diseases and protect the immunocompromised patient from
acquiring infections to which they are uniquely prone.
The organization establish the isolation procedures based on the method of
transmission and address the individual patient who may be infectious as well as
influx of large number of patient with contagious infection. Airborne precautions
are necessary to prevent the transmission of infectious that remain suspended in the
air for long period.
The preferred placement for a patient with airborne infection is in a negative
pressure. The organization should comply with the standard requirements by
availability of negative pressure isolation room for isolating airborne infectious
patient that meet the substandard criteria, availability of required supply that
support implementation of isolation precautions ( different types and sizes of PPE,
including N95 mask) and staff education in management of infectious patient.

MM.5 The hospital has a system for the safety of high-alert medications.
Why it is an ESR:
High alert medications are drugs that bear a heightened risk of causing significant
patient harm when they are used in error. Although errors may not be more
common with these than with other medications, but the consequences of errors
may be devastating. Known safe practices can reduce the potential for harm. This
may include strategies like:
 Identification of a list of high-alert medications and hazardous
pharmaceutical chemicals available in the hospital.
 Development and implementation of a plan for managing high-alert
medications and hazardous pharmaceutical chemicals.
 Improvement of access to information about high-alert medications
 Limiting access to high-alert medications
 Using auxiliary labels or computerized alerts if available

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  Standardization of ordering, transcribing, preparation, dispensing,
administration, and monitoring of high-alert medications
 Employment of independent double checks
 Development and implementation of standard concentrations for all
medications administered by intravenous infusion

The hospital has a system for the safety of look-alike and sound-alike (LASA)
MM.6
medications.
Why it is an ESR:
Look-alike, Sound-alike (LASA) medications account for an estimated 25- 30% of
medication errors. With tens of thousands of medications currently on the market,
the potential for serious error due to confusing medication names is significant. The
definition of the term "look-alike/sound-alike drugs" refers to medications having
drug names that look similar in print or sound similar to other drugs when their
names are spoken.
• Look-alike medications: Names of medications, which due to their spelling,
may look similar to other medications’ names, and the
distribution/administration of these medications may be prone to errors. Also
refer to product labeling/packaging. Example: Prozac® and Proscar®
• Sound-alike medications: Names of medications, which due to their
pronunciation, may sound similar to other medications’ names, and the
distribution/administration of these medications may be prone to errors.
Example: Ceftazidime and Ceftizoxime.
Hospitals can greatly reduce the risk for LASA medication errors and enhance patient
safety by incorporating measures such as these:
• Reviewing and revising annually the list of confusing drug names, which
include LASA medication name pairs that the hospital stores, dispenses, and
administers.
• Providing education on LASA medications to healthcare professionals at
orientation and as part of continuing education.
• Using both the brand and generic names for prescribing LASA medication.
• Writing the diagnosis/indication of the LASA medication on the prescription.
• Changing the appearance of look-alike product package.
• Reading carefully the label each time a medication is accessed, and/or prior to
administration.
• Minimizing the use of verbal and telephone orders.
• Checking the purpose/indication of the medication on the prescription prior
to dispensing and administering.
• Placing LASA medications in locations separate from each other or in non-
alphabetical order.

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 The hospital has a process for monitoring, identifying, and reporting significant
MM.41 medication errors, including near misses, hazardous conditions, and at-risk behaviors
that have the potential to cause patient harm.
Why it is an ESR:
Medication errors compromise patient confidence in the health-care system and
increase health-care costs. Many medication errors are probably undetected. The
outcome(s) or clinical significance of many medication errors may be minimal,
with few or no consequences that adversely affect a patient. Tragically, however,
some medication errors result in serious patient morbidity or mortality. A
medication error is defined as any 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. Such events may
be related to professional practice, health care products, procedures, and
systems, including prescribing, order communication, product labeling,
packaging, and nomenclature, compounding, dispensing, distribution,
administration, education, monitoring, and use. Key organization strategies to
reduce medication errors and improve patient safety may include:
 Adoption of the internationally accepted (NCCMERP) definition for
medication errors, near misses, and hazardous situations.
 Development of a simple and user-friendly reporting system for
medication errors.
 Education of healthcare providers on the importance and the process of
reporting errors.
 Conduction of intensive root-cause analysis for all significant or
potentially significant medication errors.
 Documentation of medication errors, near misses, and hazardous
situations in the patient’s medical record.
 Utilization of reported data to improve the medication use process,
prevent medication errors, and improve patient safety.
 Provision of feedback to healthcare professionals on reported medication
errors, near misses, and hazardous situations.
 Reporting of sentinel events related to serious medication errors to the
relevant authorities.

The blood bank develops a process to prevent disease transmission by blood/platelet

LB.51
transfusion.

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Methods to comply with :
Transfusion of blood and blood components is usually a safe and effective method to
correct hematological deficits, but untoward results may occur, some can be
prevented, but not all can be completely avoided. Thus, health care providers should
be aware of the risks of blood transfusion and weigh these risks against the potential
therapeutic benefits. Without doubt, the biggest impact on transfusion medicine
during the last two decades was transfusion transmitted diseases and contamination,
although their incidence is much lower than all other adverse effects of transfusion.

Concerns about transfusion-transmitted diseases have driven a growing number of

safety and quality measures employed at each stage of the blood collection,
processing and blood transfusion processes. Employing these safety measures will
not make blood transfusion risk-free. Nevertheless, it will reduce the residual risk of
blood transfusion considerably. The recent introduction of NAT testing is expected to
reduce the residual risk of HIV, HCV and HBV by half (56%) and the pursuit of
further reduction in the risks of post transfusion infection will continue.

Bacterial contamination of blood components (mainly platelets) is another major

cause of transfusion-related fatalities. To limit blood component contamination by
bacteria from donor skin, two elements of the blood collection process are critical;
before venipuncture, the donor skin must be carefully disinfected using a method
with demonstrated efficacy. Second, diversion of the first 10 to 40 mL of donor blood
away from the collection container. Furthermore, the blood bank needs to use a
method sensitive enough to detect significant bacterial contamination in platelet
components. Insensitive methods including pH, glucose and microscopy are no
longer acceptable.

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FMS.9 The hospital ensures that all its occupants are safe from radiation hazards.
Standard definition:
This standard aims to improve radiation safety in medical settings by developing
and facilitating the implementation of scientific evidence-based policies and
recommendations covering diagnostic radiology, interventional radiology, nuclear
medicine and radiotherapy; focusing in the public health aspects and considering
the risks and benefits of the use of radiation in healthcare. Hospitals should by
engaging and collaborating with stakeholders from the healthcare sector and
relevant non-health sectors. The initiative’s activities will be outcome-driven rather
than process-driven. This will be achieved by providing policy recommendations to
health
Authorities and decision makers; and by delivering practical tools to radiation safety
to protect patients and workers.
Why it is an ESR:
Radiological protection, is the science and practice of protecting people and the
environment from the harmful effects of ionizing radiation.
Ionizing radiation is widely used in industry and healthcare, and can present a
significant health hazard. It causes microscopic damage to living tissue, which can
result in skin burns and radiation sickness at high exposures (known as "tissue
effects"), and statistically elevated risks of cancer at low exposures ("stochastic
effects").
Methods to comply with :
1. The hospital should has a radiation safety policy and procedure.
2. The radiation safety policy needs to be implemented.
3. All radio-active materials are clearly labeled.
4. All radioactive materials should be safely and securely stored.
5. The hospital has the relevant valid license(s) from King Abdul-Aziz City for
Science and Technology that guarantee the proper shielding of radiation areas such
as X-ray, C.T, and MRI etc.
6. Lead aprons and gonad/thyroid shields are available to cover patients and staff
needs and are annually tested according to a hospital-wide inventory.
7. Personal radiation dosimeters (TLD cards) are available, tested every 3 months,
and actions taken when test results exceed permissible levels.

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FMS.21 The hospital has an effective fire alarm system.
To ensure functionality of hospital’s fire detection and alarm system a record of all
inspections, testing, and maintenance shall be provided that includes the following
information regarding tests and all the applicable information requested in :
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination
thereof, and affiliation.
(6) Designation of the detector(s) tested.
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (e.g., owner notified, problem
corrected/successfully retested, device abandoned in place)

Testing Frequency. Testing shall be performed in accordance with an approved

schedule.

FMS.22 The hospital has a fire suppression system available in the required area(s).
In a wide range of applications where human lives and material assets need to be
protected against the effects of fires, reliable fire extinguishing systems need to be
properly installed and maintained.
Hospitals need to endure that such systems (sprinklers , clean agent suppression,
wet chemical ,stand pipes and hose systems) are properly installed (depending on
room functions) , that their functions are by any means not interrupted due
surrounding practices (improper storage , adjacent construction activities ,and
that their functions are regularly inspected and maintained.

FMS.23 There are fire exits that are properly located in the hospital.
To ensure safe evacuation during emergencies , hospitals must maintain the
integrity of its fire exits (including exit routes , exit doors , exit stares and landing
to a safe outside public area) through the following:
1. Fire exits are available and are properly located in the hospital.
2. Fire exits are not locked.
3. Fire exits are not obstructed.
4. Fire exits have panic hard ware.

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 5. Fire exits are fire resistant.
6. Fire exits are clearly marked with illuminated exit sign.

FMS.24 The hospital and its occupants are safe from fire and smoke.
To ensure that hospitals and its occupants are safe from fire hazards , number of
measures need to be implemented. This includes:
1. Adopting a strict No-Smoking policy that clearly defines smoking , states the
hospital’s policy , specify smoking designated areas and any exceptions.
2. Ensure free access to exits, fire extinguishers, fire alarm boxes, emergency
blankets, safety showers, and eye wash stations.
3. Provision of necessary emergency evacuation lighting.
4. Follow safe storage practices all-over the organization.
5. Installing necessary Fire rated doors.

FMS.32 The hospital ensures proper maintenance of the medical gas system.
Standard definition:
Medical piped gas systems in hospitals, and most other healthcare facilities, are
essential for supplying piped oxygen, nitrous oxide, nitrogen, carbon dioxide and
medical air to various parts of the hospital. These systems are usually highly
monitored by various computerized alarm systems that needs regular maintenance
considering the safe practices. Also, hospitals needs to ensure the qualification and
training needed for those individuals who maintaining the medical gas system using
proper calibrated test equipment.
Why it is an ESR:
Hazards in handling and storing cylinders are divided into four categories:
Fire: Some cylinders contain flammable gases. Others, like oxygen, support a fire.
Missile: Mishandling can separate the valve stem from the cylinder. The cylinder
becomes a torpedo.
Incorrect Usage: Human error can result in incorrect labeling, installation, or user
errors that creates a potential hazards to patients.
Chemical Reaction: Results of mixing gases.
Since the gases are contained in heavy, highly pressurized metal containers, the
large amount of potential energy resulting from compression of the gas makes the
cylinder a potential rocket or fragmentation bomb
Methods to comply with :
The hospital needs to ensure the safety of MGS depending on four basic principles:
A. identity;
B. adequacy;
C. continuity;

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D. quality of supply.

1) Identity is assured by the use of gas-specific connections throughout the pipeline

system, including terminal units, connectors etc, and by the adherence to strict
testing and commissioning procedures of the system.
2) Adequacy of supply depends on an accurate
Assessment of demands and the selection of plant appropriate to the
clinical/medical demands on the system.
3) Continuity of supply is achieved by:
• The specification of a system that (with the exception of liquid oxygen systems
which may include a secondary vessel) has duplicate components;
• The provision of a third means of supply for all systems except vacuum;
• The provision of alarm systems; and
• Connection to the emergency power supply system.
4) Quality of supply is achieved by the use of gases purchased to the appropriate Ph.
Eur. requirements or produced by plant performing to specific standards, by the
maintenance of cleanliness throughout the installation of the system, and by the
implementation of the various testing and commissioning procedures.

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PART 2: FREQUENT ASKED QUESTIONS
 Difference between HR 5.5 and 5.6?
HR.5.5 is to be checked by presence of SCHS registration in the personnel files
HR.5.6 Is to be checked by matching the provided license against the current
position or actual job of the employee in the hospital. As an example, for the nurse
working in OR as anesthesia technician will take FM in 5.5 but NM in 5.6 because her
position is different from her current license.

 If Primary source verification is done by data flow in UAE, Is this accepted?

Yes, an official certificate including the required elements

 If the hospital showed track record of emails to communicate with primary

source, but no response! Do you consider it met?
This can be accepted for some cases not 100% of the files, two trials of contact with
I month in between using two different means.

 In remote area hospitals, there is special scenario. Some residents working as

specialists. In this case, what is the score of 5.6?
HR.5.6 is talking about the profession, in your case still the resident is working in his
field but with upgraded privileges and this will be scored under another standard
MS.7.1

 Does verification through data flow enough?

If you show the data flow certificate it’s enough for education and experience.

 Question: HR.5.8 when verification is conducted through 3rd party, the hospital
must request for a confirmatory documentation. Can we consider it NA, as stated
in the instruction "if applicable"?
It depends on the hospital ' policy on credential verification as per the standards 5.1
5.2 and 5.3
If this is the case and the hospital has a competent HR department and a clear
verification document from the granting universities and organizations for a
representative sample it is OK.
5.8 can be considered NA
5.8 could be NA if the hospital doesn't use third party for the verification of any of
the credentials (education, experience, license, and training)

 Data flow now conducted verification for both education and experience, did the
payment receipt considered as confirmatory document?
Not meeting the standard HR.5.8 requirement

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 May I confirm that the local graduates (Saudi universities) also requires primary
source verification?
Yes, they do need to be verified from Saudi universities.

 SCFHS license will not be issued without verification, does it still need to check on
it?
Yes, no registration or classification from SCFHS without the qualifications are being
verified and the new form of verification is including experience and training but
you need to see the confirmation documents and not the payment slip.

 Recorded voice conversation as an evidence for verification?

No just documentation in personnel files in any format

 How could we approve that anesthesiologist is present inside OR throughout

operation (AN. 2.2). Some surveyor use recovery room discharge form signed by
Anesthetist. Is there any other method of evaluation?
In ESR visit the surveyor may review some of medical records, recovery room sheet
can be in full compliance if signed by a nurse based on approved criteria as in
AN.12.4,
If he is not satisfied, he can compare the number of anesthesiologists against the
number of working operation rooms as per the daily OR list
It will show us the actual work schedule in ORs
If the number of available anesthesiologists is enough to cover the working rooms
this will indicate that they can satisfy the standards.

 The hospital had 3 procedures per week and one Anesthesiologist. How to
confirm that anesthesiologist will stay the whole procedure inside OR?
First, the surveyor will check the anesthesia sheet and the signature as we agreed
before and to stick to the standard activity. Then if they have one working
Anesthesiologist with this very low number of procedure so he has no doubt that he
can be present inside the OR the whole procedure, he has nothing else to do they
need to look at OR anesthesia form filled from the beginning tell the end of
procedure and signed by Anesthesiologist, that will be more than enough.

 How the surveyor will evaluate qualifications of Anesthesia staff?

Anesthesia staff files will be checked for their qualifications and ACLS and must be
consultants for major operations

 What constitutes MAJOR surgery? Is liposuction major? Needs Anesthesia cons?

• Pediatric surgery
• Transplant
• Neuro
• Cardiopulmonary

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 It said includes But not limited?
Liposuction is high risk if very obese patient is involved
we must stick to surgeries mentioned in the standard until CBAHI provide other
guidelines because this will be endless list.

 Standard is also talking about High Risk patients not surgery only?
Standard AN.2.3. Listed 4 Major/specialized group of surgeries that require
consultant anesthesiologist to supervise. These are:
Pediatric surgery
Cardio-pulmonary surgery
Neurosurgery
Transplant surgery
Surveyors are requested to utilize this generic list as the minimum examples to
satisfy the standard, unless the hospital administration and or head of surgery
added in their policy other types of surgery that is considered major/specialized
according to the hospital scope of service.

 Does Clinical Staff refer to the anesthesia/medical, or does it refer to all

clinical staff participating .. ie. Nurses (or technicians)?
Yes, this refers to all staff participating in sedation procedures. Including anesthesia,
other physicians, nurses giving medications

 How the surveyor will evaluate competency-based privileges?

Conscious sedation staff (physicians and nurses) files will be checked for formal
training and ACLS to provide sedation.

 Does the CBAHI define what medications are considered under the standards for
moderate or deep sedation?
The CBAHI standards do not specify specific medications that moderate or deep
sedation standards apply. If the medication is used for inducing moderate or deep
sedation the standards apply.

 Does the person administering sedation must be qualified to monitor the patient
if other staff who are present are qualified?
Both should be qualified.

 Patients are screened for the risk of developing VTE at ER or WARD?

According to the hospital policy.

 In open health record activity, is there an agreement on minimum/maximum

number of files to be reviewed?
Yes, in each unit you visit review a patient record to cover screening for DVT, blood
transfusion, time out, site marking and medication error documentation

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 Is it necessary to mention 2 patient identifiers on each drawer of unit dose
trolley?
It is necessary to identify anything related to patients with the 2 identifiers.

 One of the hospital used room number on each drawer. Is it allowed to use
physical location?
No it's not
The 2 acceptable identifiers are normally patient full name and medical record
number. Location is a big NO.

 There are no IV meds given in the hospital. Mainly IM, assume that MM.5.4 is
NA?
Any critical care management (ER, ICU, OR) depend on the use of IV infusion of
medications such as Dopamine, Noradrenaline, etc. Serious medication errors are
common with non-standard concentration infusions. It can't be NA in any hospital
setting.

 Is it allowed to store calcium chloride in the patient care unit?

It is preferred to stock calcium gluconate since it is much safer to use (calcium
content is one third that of calcium chloride). Calcium chloride is not considered
high risk by medication safety authorities.

 What is the content of high alert label?

Shelves should be labeled with red auxiliary as “High Alert” or “High Alert
Medication”
Medications should be labelled with red auxiliary labels “High Alert” or “High Alert
Medication”

 Is this considered as standard concentration for KCL or we have to see the

table format with rate calculation?
Surveyor need to see standard concentration guidelines of KCL infusions (e.g. 80
mmol per liter Dextrose 5%) and standard rate of infusion (peripheral e.g. 10
mmol/hour and central line e.g. 20 mmol/hour).

 Is it allowed to keep high alert medications in regular wards or only critical

areas?
High alert medications can be available where ever there is a need with evidence of
clinical necessity as far as its clearly indicated in the hospital documents.

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 Standard MM.5.3.2 Said only limiting access, so is it enough just to keep in locked
cabinet in all wards?
Patient needs vary from hospital to another. Our standard does not prohibit having high
alert medications on the ward but asks for safe and secure storage and handling.

 Regarding high alerts medication; can hospitals store them in double looked
cabinets only, does this fulfill the requirement?
The standards enumerate some safety practices and we expect to have them all
implemented as much as possible

 If hospital has time out list and pre-procedural verification But No policy, what do
u think of score?
If it is medical record review and all the files contain the pre-procedural verification,
this will be fully met.
This standard QM 18 is not asking for policy

 What about old staff who has No Primary Source Verification? Do we apply
standard from 2016 and above?
PSV should be completed for new hires after January 2016 until hospitals go for 2nd
cycle on the 2016 edition.

 I would to confirm from CBAHI Experts; if the hospital has No Radiation Therapy,
is the ESR related to "Hot Lab" scored as N/A?
Yes, the substandard addressing radio-active materials will be not applicable.

 The facility has Radiation monitoring for shielding and walls last 2008. How
frequent they should do it?
Annual testing for walls. But can be done by their radiation safety officer if qualified
and having the right testing equipment.

 Can lead aprons be tested by the hospital itself?

Yes.

 X ray films were supposedly indicated no fractures in the apron. Even if plastic
layer is torn, is that acceptable.? does it have to be by an authorized company.?
Yes. previously we accept testing of aprons by the hospital ER and OR

 What tool can be used by the hospital to test the aprons internally
It can be tested by X-Ray for cracks within the aprons.

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 KACST only issues a license to physics but nothing for technologists. Both handle
radioactive materials. How do the surveyors score this?
Usually one staff handling radioactive and certified by KACST is enough. In each
hospital, there should be min. one safety radiation officer.
And the certified officer will train hospital staff

 Staff handling nuclear materials - Responsible to Radiologists only, or

including the technicians?
Usually the staff deal with radioactive material is a medical physics who should be
certified by King Abdullah City, (KACST) are certifying the medical physics

 Did the surveyors accept license of King Abdullah City for atomic & renewable
energy? Because KACST didn’t written in ESR-documents?
 King Abdulaziz city for science and technology or King Abdullah City for
atomic & renewable energy?
Yes, we agree however any valid license from KACST or King abdullah city should be
accepted.

 The license for nuclear materials now come from King Abdullah City for
Atomic and Renewable energy. Is this ok?
Yes.

 Regarding the colour code of the precaution cards, should we stick to the same
color code mentioned in the IPC.25.6.1 standard?
Because some hospitals follow MOH standard colours:
Airborne: Red
Contact : Yellow
Droplet: Blue
Colour is not a must provide that all other sub standards requirements are fulfilled.
As long as the colour code is consistent all over the organization and mentioned in
the policy.

 IPC.15.1: At least 1 isolation in ER and 1 in patient care areas. Does this mean
50% of score for ER, and 50% for the other areas regardless of the total
number of hospital isolation rooms?
It is mandatory to have at least one negative pressure room in ER, in addition to one
for 25-30 beds in clinical areas.

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 If the hospital has 4 isolation rooms, all with negative pressure except the one
in ER, shall I score it as 1 or 2?
• ER isolation room is very important especially with MERS-CoV. If the ER had
no negative pressure room the score is zero.
• Score two or one in case the ER had negative pressure room and the
inpatient one forth or less from the bed capacity.

 If there is no anteroom in ER isolation room, what is the score for both

IPC.15.1 & IPC.15.4? Even if there is negative pressure or HEPA filter.?
Score 0

 Is it acceptable that the toilet outside isolation room?

Toilet should be inside isolation room.

 What do you think about an isolation room with 2 unsecured windows

opposite to each other that could jeopardize the negative pressure system,
especially when a patient opens them?
Not accepted.

 Air exchange/hr, does it need to be done daily?

Monitoring daily if there is patient and weekly if isolation room is vacant.

 I visited a hospital today has different colours?

It is not a must to have the same colours mentioned in the standard provided that
the color code is standardized all over the organization and mentioned in the policy
and all other sub standards are fulfilled.

 If a hospital has restricted isolation area with multiple rooms, beside each
room all required PPEs are available following clear guidelines, work station
in the middle, and all rooms have toilets. Question: is ante-room still a
requirement?
Anteroom still required.

 Entry of isolation room is through ante-room. What are the specifications of

the ante room?
Ante room is a physical location adjacent to the negative pressure room. It works as
a buffer zone and is stocked with the necessary PPEs and has hand washing facility
to get ready before entering the negative pressure room.

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 Is it mandatory to have bathroom inside the ICU isolation room?
• A bathroom is required for isolation rooms in the wards and ER
• ICU isolated patients are either bed ridden or on mechanical ventilation so a
separate bathroom is not required

 If isolation room has portable HIPA filter which is connected to a tube to the
outside and there is a monitor of negative pressure; does this fulfill the
standard?
Portable HIPA filter will not satisfy the standard and negative pressure can't be
maintained in this way.

 If the all Blood and Blood Components received from another HCF, LB.51 will
be scored as:
• NA (Not Applicable)
• 0 (Not Met)
Outsources services shall meet the following conditions:
1. Service contract/agreement/memo of understanding (as articulated in LD.21)
specifying:
• The scope of service and the validity of the agreement
• Agreement conditions (including accreditation status and/or accreditation
standards).
• Agreement review and the right to conduct audits to confirm the contracted
party compliance.
2. There is documented evidence of regular contract review and/or audits.
If all the above conditions are met, all of the technical standards related to the
outsourced services will be scored as “Not Applicable”. If there is no service
contract/agreement/memo of understanding and/or there is no documented
evidence of regular review/audits, all of the technical standards related to the
outsourced services will be scored as “Not Met”.

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PART 3 : DO & DON’T

DON’T

Hospital Generators are

provided only with a
small powder
extinguisher.

DON’T

Obstructed fire exit door

Page: 24 of 28
DON’T

Exit door with no panic

hard ware

DON’T

Uncertified fire-rated
door

Page: 25 of 28
DON’T

Improper storage.

DON’T

Evident separation
between walls and
ceiling.

Page: 26 of 28
DON’T

Emergency shut off

valves are not marked
with areas/rooms
affected.

DON’T

Medical gas pipes are

not clearly marked and
labeled for the contents
and direction of gas
flow.

Page: 27 of 28
DON’T

Emergency shut off

valves are available in
all units, but located at
the roof at different
areas just above the
room doors, where a
person needs open the
roof decorating tile to
reach the valve.
Moreover affected
areas/rooms are not
marked.

DON’T

Obstructed fire exit.

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